Anxiety disorders are one of the most common psychiatric disorders in children and adolescents, but they often go undetected or untreated. Identification and effective treatment of childhood anxiety disorders can decrease the negative impact of these disorders on academic and social functioning in youth and their persistence into adulthood.
This article reviews assessment and focuses on evidence-based treatment interventions for childhood anxiety disorders: cognitive-behavioral therapy (CBT) and SSRIs. The following anxiety disorders are discussed: separation anxiety disorder (SAD), generalized anxiety disorder (GAD), specific phobia, panic disorder, social phobia, and selective mutism. Obsessive-compulsive disorder and posttraumatic stress disorder are not covered in this article.
The prevalence of any anxiety disorder in youths ranges from 2% to 4%, with 6- and 12-month estimates between 10% to 20%, and lifetime estimates only slightly higher.1 Anxiety disorders are common in preschool children, and they follow patterns similar to those in older children. The impact of anxiety symptoms in young children may be clinically significant even if full criteria are not met.
One anxiety disorder is often comorbid with another anxiety disorder, as well as with other psychiatric disorders—especially depression and attention-deficit/hyperactivity disorder (30%). Anxiety often precedes depression; the co-occurrence of anxiety and depression increases with age and is associated with greater impairment. Furthermore, the presence of anxiety disorders in childhood increases the risk of abusing alcohol in adolescence.
Screening and assessment
During the diagnostic evaluation, clinicians need to distinguish transient and developmentally appropriate worries and fears from anxiety disorders. In addition, the impact of stressors or traumas on the development or maintenance of anxiety symptoms needs to be assessed.
Common fears among infants include loud noises, being dropped, and later, normal separation anxiety. Toddlers typically experience fear of imaginary creatures (monsters) and darkness. From age 5 to 6 years, children experience worries about physical well-being (eg, injury, kidnapping) and later, fears of natural events (storms) develop. School-aged children worry about school performance, behavioral competence, rejection by peers, health, and illness. In adolescence, worries about social competence, social evaluation, and psychological well-being are prominent.
The American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders2 recommends the following: routine screening for anxiety in childhood, gathering information from various sources about anxiety symptoms (child, parent, teacher), assessing for comorbid disorders, and evaluating severity and functional impairment. Children may be more aware of their inner distress (GAD), parents are more likely to appreciate the impact of anxiety on family life (SAD), and teachers are skilled at observing social functioning relative to same-age peers (social phobia).
Table 1 reviews the clinical presentation for each anxiety disorder and considers the anxious thoughts, physical sensations, and behavior related to children and adolescents.
Self-report measures for anxiety, such as the Multidimensional Anxiety Scale for Children (MASC)3 and Screen for Child Anxiety-Related Emotional Disorders (SCARED),4 can help clinicians screen for anxiety symptoms at baseline and monitor response to treatment. Children and parents can use visual analogues, such as a feelings thermometer, to rate severity of anxiety symptoms and impairment during the diagnostic evaluation. Younger children may prefer other visual tools for rating, such as smiley faces and upset faces.
Somatic symptoms, such as headaches, abdominal complaints, muscle tension, restlessness, and difficulty in sleeping, commonly accompany childhood anxiety disorders. Early screening for anxiety can help decrease excessive medical workups. Assessing somatic symptoms before initiating treatment can decrease later confusion with adverse effects of medication.
Treatment of children with anxiety disorders of mild severity and minimal impairment should begin with psychotherapy.2 Combining psychotherapy with medication treatment may be necessary in children with moderate to severe anxiety, when treating a comorbid disorder, or when there is a partial response to psychotherapy alone.5
To investigate monotherapies versus combined treatment, the Child/Adolescent Anxiety Multimodal Study (CAMS), a placebo-controlled trial in youths with moderate to severe SAD, GAD, and/or social phobia, compared CBT, sertraline, or placebo with combination treatment with sertraline and CBT.6 CBT (60% improved) and sertraline (55% improved) showed relatively equal efficacy and were superior to placebo (24% improved) for the treatment of childhood anxiety disorders, and the combination of CBT and sertraline (81% improved) had a response rate superior to either modality alone. All 3 of these active treatments were recommended with clinicians considering availability, family preferences, and cost in choosing a treatment.6 Unfortunately, CBT is not widely available and thus may not be a treatment option for many anxious children until more clinicians in the community and schools integrate CBT into their practice.
Family assessment can help clinicians identify possible environmental triggers and reinforcements, parenting styles (especially controlling, critical, overprotective), family responses to the child’s anxiety symptoms, parental expectations, and coping strategies modeled by parents.7 In addition, if anxiety disorders are present in either or both parents, psychoeducation and treatment for parental anxiety disorders should be considered.
1. Costello EJ, Egger HL, Angold A. Developmental epidemiology of anxiety disorders. In: Ollendick TH, March JS, eds. Phobic and Anxiety Disorders in Children and Adolescents. New York: Oxford University Press; 2004:334-380. Suggested Reading for Clinicians Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283. Suggested Reading for Parents McHolm AE, Cunningham CE, Vanier MK. Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications; 2005.
2. Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46:267-283.
3. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.
4. Birmaher B, Axelson DA, Monk K, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:415-423.
5. March JS, Ollendick TH. Integrated psychosocial and pharmacological treatment. In: Ollendick TH, March JS, eds. Phobic and Anxiety Disorders: A Clinician’s Guide to Effective Psychosocial and Pharmacological Interventions. New York: Oxford University Press; 2004:141-174.
6. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359:2753-2766.
7. Connolly SD, Suarez LM. Generalized anxiety disorder, specific phobia, panic disorder, social phobia and selective mutism. In: Dulcan MK, ed. Dulcan’s Textbook of Child and Adolescent Psychiatry. In press.
8. Compton SN, March JS, Brent D, et al. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.
9. Velting ON, Setzer NJ, Albano AM. Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents. Prof Psychol Res Pract. 2004;35:42-54.
10. Albano AM, Kendall PC. Cognitive-behavioural therapy for children and adolescents with anxiety disorders: clinical research advances. Int Rev Psychiatry. 2002;14:129-134.
11. Grover RL, Hughes AA, Bergman RL, Kingery JN. Treatment modifications based on childhood anxiety diagnosis: demonstrating the flexibility in manualized treatment. J Cognitive Psychother. 2006;20:275-286.
12. King NJ, Muris P, Ollendick TH. Childhood fears and phobias: assessment and treatment. Child Adolesc Mental Health. 2005;10:50-56.
13. Barlow DH, Craske MG. Mastery of Your Anxiety and Panic: Therapist Guide for Anxiety, Panic, and Agoraphobia. 4th ed. New York: Oxford University Press; 2007:209.
14. Beidel DC, Turner SM, Young B, Paulson A. Social effectiveness therapy for children: three-year follow-up. J Consult Clin Psychol. 2005;73:721-725.
15. Cohan SL, Chavira DA, Stein MB. Practitioner review: psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990-2005. J Child Psychol Psychiatry. 2006;47:1085-1097.
16. Seidel L, Walkup JT. Selective serotonin reup-take inhibitor use in the treatment of pediatric non–obsessive-compulsive disorder anxiety disorders. J Child Adolesc Psychopharmacol. 2006;16:171-179.
17. The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med. 2001;344:1279-1285.
18. Wagner KD, Berard R, Stein MB, et al. A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry. 2004;61:1153-1162.
19. Reinblatt SP, Riddle MA. The pharmacological management of childhood anxiety disorders: a review. Psychopharmacology (Berl). 2007;191:67-86.
20. Rynn MA, Riddle MA, Yeung PP, Kunz NR. Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. AmJ Psychiatry. 2007;164:290-300.
21. Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994;33: 1000-1006.
22. Rynn MA, Siqueland L, Rickels K. Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. Am J Psychiatry. 2001;158:2008-2014.
Connolly SD, Suarez LM. Generalized anxiety dis-order, specific phobia, panic disorder, social phobia and selective mutism. In: Dulcan MK, ed. Essentials of Child & Adolescent Psychiatry. Washington, DC: American Psychiatric Press. In press.
Ollendick TH, March JS, eds. Phobic and Anxiety Disorders in Children and Adolescents. New York: Oxford University Press; 2004.
Rapee RM, Wignall A, Hudson J, Schniering C. Treating Anxious Children and Adolescents: An Evidence-Based Approach. Oakland, CA: New Harbinger Publications; 2000.
Rapee RM, Wignall A, Spence SH, Cobham V. Helping Your Anxious Child: A Step-by-Step Guide for Parents.Oakland, CA: New Harbinger Publications; 2008.
Suggested Reading for Clinicians
Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.
Suggested Reading for Parents
McHolm AE, Cunningham CE, Vanier MK. Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications; 2005.