Psychiatric Annals

CME Article 

Generalized Anxiety Disorder in Children and Adolescents: An Update

Nazish Imran, MBBS, FRCPsych, MRCPsych; Imran Ijaz Haider, MBBS, FRCPsych, MRCPsych, DPM; Muhammad Waqar Azeem, MD, DFAACAP, DFAPA

Abstract

Generalized anxiety disorder (GAD), despite being among the most common psychopathology of children and adolescents, often goes undetected and untreated. GAD is characterized by excessive worry for more than 6 months about a variety of situations, events, or activities (especially school performance among children), inability to control the worry, and presence of at least one physical symptom. The interplay of various risk factors (genetic, environmental, and psychosocial) and protective factors is seen in youth with GAD, and comorbidity is common. GAD is associated with significant distress and disability independent of comorbid disorders. A multimodal approach that includes psychoeducation, psychological therapies (in particular cognitive-behavioral therapy), family therapy, and pharmacological treatment provides the best outcome for children and adolescents with GAD. [Psychiatr Ann. 2017;47(10):497–501.]

Abstract

Generalized anxiety disorder (GAD), despite being among the most common psychopathology of children and adolescents, often goes undetected and untreated. GAD is characterized by excessive worry for more than 6 months about a variety of situations, events, or activities (especially school performance among children), inability to control the worry, and presence of at least one physical symptom. The interplay of various risk factors (genetic, environmental, and psychosocial) and protective factors is seen in youth with GAD, and comorbidity is common. GAD is associated with significant distress and disability independent of comorbid disorders. A multimodal approach that includes psychoeducation, psychological therapies (in particular cognitive-behavioral therapy), family therapy, and pharmacological treatment provides the best outcome for children and adolescents with GAD. [Psychiatr Ann. 2017;47(10):497–501.]

Generalized anxiety disorder (GAD) is among the most common anxiety disorders in youth, with prevalence rates as high as 59% in child anxiety clinics,1 and 10% in child psychiatric clinics.2 GAD severely disrupts child functioning in various domains of life, including academic, peer and family relationships, and functioning at home.3–5 GAD is also considered a “gateway” disorder because it often predicts adult mental health problems, including anxiety and depression along with impaired quality of life.5–7 Despite the huge public health burden associated with GAD in youth, it often goes undetected and untreated.

Epidemiology

Prevalence rates vary due to differences in studied age groups, assessment tools, diagnostic criteria, and source of information (ie, self-report, parent report, or teacher report) as well as whether impairment criteria were used or not. A recently published systematic review involving 41 studies conducted in 27 countries found worldwide prevalence of any anxiety disorder to be 6.5%.8 It is difficult to have an exact prevalence rate for GAD in youth because prior to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),9 children with multiple worries would get a diagnosis of overanxious disorder. A cumulative incidence for GAD of 4.3% at age 34 years was noted in the Early Developmental Stages of Psychopathology study,10 with the main incidence period evident in adolescence. The 12-month prevalence of GAD among adolescents in the United States is estimated to be 0.9%.11 GAD, like all other anxiety disorders, is more common in women than in men, and men have a later age of onset.10 Children with GAD may also develop other anxiety disorders over time.

DSM-5 Criteria for Generalized Anxiety Disorder in Children and Adolescents

The DSM, fifth edition (DSM-5)11 recognized some differences in criteria for diagnosing young people with GAD. Table 1 lists these criteria. In addition to the criteria in Table 1, duration of symptoms needs to be at least 6 months, cause clinically significant impairment in functioning, must not be attributable to another medical condition or substance use, and should not be explained better by another mental disorder.11

Criteria for Diagnosing Young People with Generalized Anxiety Disorder

Table 1:

Criteria for Diagnosing Young People with Generalized Anxiety Disorder

Apart from schoolwork, children may also excessively worry about social interactions, family, health/safety, world events, and natural disasters.12

Etiology and Risk Factors for Generalized Anxiety Disorder in Children and Adolescents

Studies have identified a number of risk factors associated with anxiety disorders, although only a few have been specifically studied for GAD alone. These risk factors are shown in Table 2.12–18

Risk Factors for Anxiety Disorders, Including Generalized Anxiety Disorder, in Children

Table 2:

Risk Factors for Anxiety Disorders, Including Generalized Anxiety Disorder, in Children

Comorbidity

Anxiety disorders are considered to have significant comorbidity, which influences its clinical presentation and is associated with greater impairment, academic difficulties, suicide attempts, conflicts with family, and impact on use of mental health services.19 Approximately 75% of children and adolescents with GAD meet diagnostic criteria for at least one other diagnosis.20,21 The most common comorbidity is another anxiety disorder or unipolar depression.11 Rates of comorbid depression vary from 10% to 15%.5 In a study of general child and adolescent psychiatry clinic consecutive referrals in Sweden, 46% of patients had at least one anxiety disorder.22 Among anxious adolescents, homotypic comorbidity (concurrent anxiety) was observed in 43%, and heterotypic comorbidity (concurrent nonanxiety psychiatric disorders) was observed in 91%.22 Other common comorbid disorders include attention-deficit/hyperactivity disorder, oppositional defiant disorder, substance abuse, and learning and speech problems.23

Differential Diagnosis

Due to the high comorbidity of GAD, it can sometimes be difficult to make a diagnosis. Other mental health disorders or medical conditions in children can sometimes be mistaken for GAD. These disorders in children and youth are discussed in the following text.

Social Anxiety Disorder

Anticipatory anxiety for upcoming social situations in which one may be evaluated or have to perform is seen in social anxiety disorder.

Obsessive-Compulsive Disorder

Obsessions are intrusive, inappropriate, and repetitive ideas, images, and thoughts rather than the excessive abnormal worry seen in GAD.

Posttraumatic Stress Disorder

If symptoms are better explained by posttraumatic stress disorder (PTSD) then GAD is not the diagnosis, although anxiety is invariably seen in children and adolescents with PTSD.

Adjustment Disorder

Anxiety in adjustment reactions occurs in response to a specific stressor within 3 months and does not persist for more than 6 months after the stressor is removed.

Autism Spectrum Disorder

Social awkwardness and withdrawal, social skills deficits, communication deficits, repetitive behaviors, and adherence to routines help to distinguish autism spectrum disorder from GAD.

Substance-Induced Anxiety Disorder

Anxiety is seen only in the context of substance abuse. History, physical examination, or laboratory investigations in these patients provide evidence of a substance capable of producing anxiety symptoms as well as symptoms developing soon after substance intoxication or withdrawal.

Medical Conditions Associated with Anxiety

Many medical illnesses, such as pheochromocytoma and hypertyhyroidism, can cause anxiety as a direct physiological effect of the illness.

Depression

Generalized anxiety is often seen in children and youth with depression; however, clinical symptoms of depression predominate and precede the onset of anxiety symptoms.

Assessment

A diagnosis of GAD in children and adolescents is based on comprehensive assessment involving multiple informants and domains (Table 3), and formal evaluation tools (Table 4).24–28

Evaluation Essentials for Generalized Anxiety Disorder in Children and Adolescents

Table 3:

Evaluation Essentials for Generalized Anxiety Disorder in Children and Adolescents

Formal Assessment Tools for Diagnosing Generalized Anxiety Disorder in Children

Table 4:

Formal Assessment Tools for Diagnosing Generalized Anxiety Disorder in Children

Treatment

A multimodal treatment approach with psychoeducation of parents and the child about the disorder, liaison with school personnel, cognitive-behavioral therapy (CBT), family therapy, and pharmacotherapy is recommended for children with GAD.29 Many factors influence the treatment choice for individual patients, such as psychosocial stressors, risk factors, severity and impairment of the anxiety disorder and comorbid disorders, age and developmental functioning of the child, family functioning, and acceptability of the proposed treatment.

Psychological Management

Most guidelines, including the National Institute of Clinical Excellence guidelines,30 recommend psychological therapy as the first-line treatment for children and adolescents with anxiety disorders. In the treatment of anxiety disorders in children, exposure-based CBT has empirical support through the findings of several randomized controlled trials (RCTs).29 The best researched and most empirically supported manual for child CBT for anxiety is the Coping Cat31 and its adaptations.29

CBT in combination with selective serotonin reuptake inhibitors (SSRIs) has proven effective in treating symptoms of anxiety in children, and this effectiveness is greater than that of either medication or therapy alone;32,33 however, remission rates of CBT treatment vary across studies. CBT is more effective in treating (and leading to remission for) GAD as compared to social anxiety disorder.34

CBT delivered online (I-CBT) may be more cost-effective than treatment as usual, and some reports show full remission from anxiety for 30% of those receiving it, but the quality of evidence for its efficacy is low.35 When CBT is judged to be too complex for children, parental involvement can lead to a better response, especially with the behavioral component of CBT.36

Research indicates that targeted behavioral therapy is effective in reducing symptoms of GAD in children age 7 to 11 years, and can lead to a remission by the 3-month follow-up.37

Additionally, although there is a dearth of research regarding the benefits of psychodynamic psychotherapy for childhood anxiety conditions, occasional research has shown some benefit in symptom reduction for childhood anxiety as compared to other disorders.29

Family therapy can be helpful for GAD but needs further research. Nevertheless, it may prove useful in childhood anxiety disorders, given the impact of parental emotional involvement in anxiety states.29

Response to either pharmacological and psychological treatments may be moderated by external factors, such as the child's initial diagnosis, and high level of baseline symptom severity and high career burden are also associated with poor outcomes.38 Nonetheless, GAD is associated with better treatment outcomes than other anxiety disorders.38 Greater symptom severity and older age are predictors of negative outcomes in CBT or SSRI treatment alone, and in such cases the involvement of parents and adjustment of treatment intensity should be considered.29

Pharmacological Management

SSRIs are commonly prescribed for children and adolescents with anxiety and are regarded as the treatment of choice; however, although SSRIs may effectively reduce concurrent anxiety and mood symptoms on their own, they should be provided in conjunction with CBT.39,40 SSRIs are generally well-tolerated in the pediatric population. Transient side effects may include gastrointestinal symptoms, increased motor anxiety, and insomnia. It is recommended that a routine screening for bipolar disorder be conducted before the initiation of SSRI treatment.29 In pediatric GAD, fluoxetine was found to be superior to placebo, whereas fluvoxamine treatment was inferior to placebo.29

A comparison of outcomes in children and adolescents with CBT or sertraline (an SSRI) and a combination of CBT and sertraline showed an advantage for the combination of CBT and sertraline at the 6-month follow-up as opposed to either CBT or medication alone.32 Conversely, Ginsburg et al.41 reported that there were no significant differences in anxiety symptom reduction of children treated with either CBT, sertraline, or a combination.

Benzodiazepines, although a common class of anxiolytics, have not been tested in children for GAD due to concerns about dependence and side effects.33

Selective serotonin noradrenaline reuptake inhibitors (SSNRIs) demonstrate efficacy in the treatment of non-OCD anxiety conditions in children and are well-tolerated.42

Some preliminary research suggests that extended-release venlafaxine (an SSNRI) may be well-tolerated and effective for GAD in children.12

Research on tricyclic antidepressants has shown contradictory results, and thus there is no consensus regarding their use in children with GAD.28

Conclusion

GAD is a highly prevalent, impairing mental health disorder of children and adolescents that carries a substantial risk for adverse outcomes and can lead to anxiety and depression in adulthood. It is important that the symptoms are recognized and a timely assessment is performed in an interdisciplinary setting along with developmental perspective. Management of GAD requires a comprehensive multimodal approach with psychological and pharmacological treatments. Involvement of family is extremely important for positive outcomes for these children.

References

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Criteria for Diagnosing Young People with Generalized Anxiety Disorder

Excessive anxiety and worry about a variety of topics, events, or activities (in children, worry is more likely to be related to their performance in school or social activities)

Children find it difficult to control the worry

For children, the anxiety and worry are associated with one (or more) of the following six symptoms (with at least some having been present for more days than not for the past 6 months)

Restlessness or feeling keyed up or on edge

Being easily fatigued

Difficulty concentrating or mind going blank

Irritability

Muscle tension

Sleep disturbance (difficulty falling or staying asleep or restlessness, unsatisfying sleep)

Risk Factors for Anxiety Disorders, Including Generalized Anxiety Disorder, in Children

Gender: females twice as likely to suffer from GAD than males10

Age: GAD typically begins during adolescence5

Biological risk factors

Genetic factors can increase the risk of GAD in children10

Neuroticism, behavioral inhibition is associated with GAD10

Urban environment12

Exposure to violence13

Trauma14

Psychosocial stressors such as socioeconomic disadvantage15

Parental anxiety disorder: increased risk of anxiety disorder and functional impairment in children16

Neuroimaging findings: disruptions in amygdala circuits involved in emotion processing has been observed in children with GAD17

Evaluation Essentials for Generalized Anxiety Disorder in Children and Adolescents

Basic principles of evaluation

Interviewing the child/adolescent on his or her own

Interviewing a parent, caregiver, or other adult who knows the child well and can report on current and past behavior

Use of developmentally appropriate language

Awareness of developmental variations of symptomatology when assessing very young children

Awareness of high level of comorbidity in children with anxiety disorders

Essential to assess for possible co-existing mental health problems, neurodevelopmental conditions, drug and alcohol misuse

Impact on school functioning

Impact on peers and family relationships

Also need to assess

Educational history

Family history

Psychosocial assessment

Substance abuse history

Relevant physical evaluations as needed

Individual assessment of child (engagability, presence of comorbidities, child's own views of difficulties, strengths of a child)

Parental level of distress/parental anxiety and parenting practices

Formal Assessment Tools for Diagnosing Generalized Anxiety Disorder in Children

Child Behavior Checklist24

Child and Adolescent Psychiatric Assessment25

Anxiety Disorders Interview Schedule for Children and Parents26

Revised Children's Anxiety and Depression Scale27

Spence Children's Anxiety Scale28

Authors

Nazish Imran, MBBS, FRCPsych, MRCPsych, is an Associate Professor, Child & Family Psychiatry Department, King Edward Medical University/Mayo Hospital. Imran Ijaz Haider, MBBS, FRCPsych, MRCPsych, DPM, is a Professor, Department of Psychiatry & Behavioral Sciences, Fatima Memorial College of Medicine and Dentistry. Muhammad Waqar Azeem, MD, DFAACAP, DFAPA, is the Chair, Department of Psychiatry, Sidra Medical and Research Center; and a Professor of Psychiatry, Weill Cornell Medicine, Cornell University.

Address correspondence to Nazish Imran, MBBS, FRCPsych, MRCPsych, 6-C Phase 1, Defence, Lahore, Pakistan; email: nazishimrandr@gmail.com.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20170913-01

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