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Anxiety Disorders

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Introduction

The Questions and Answers that follow aim to provide an introduction to anxiety disorders for parents and other family members. Following those, we offer links to selected resources for more information and support and a list of valuable services.
More information about many topics relevant to children with anxiety disorders and many other chronic conditions and their families can be found in the left menu. Detailed information aimed at primary care doctors can be found in our Anxiety Disorders module.

What are anxiety disorders and what causes it?

Anxiety is characterized by excessive worry and fear. Anxiety disorders are common in both children and adults, including in children with other special health care needs. Children with anxiety disorders tend to be worriers and can seem irritable or easily embarrassed. Children with generalized anxiety tend to worry about multiple issues. There are also anxiety disorders characterized by fear related to more specific contexts, such as separation from a parent or caregiver, specific phobias such as fear of medical procedures, or social situations.
In order to be classified as an anxiety disorder, the anxiety must cause significant daily distress or limit normal functioning, must not be caused by a medication, substance abuse, or a medical issue (unless defined as such), and must be different from anxiety that is normal for the child’s development. Children with special health care needs (CSHCN) are at increased risk of mood disorders including anxiety and depression. [Houtrow: 2011]

What are the symptoms of anxiety disorders?

Common anxiety symptoms in children can include fear, worry, reassurance-seeking, avoidance, crying, shaking, hypervigilance, and tantrums. Physical symptoms can include racing heart, stomach aches or nausea, headaches, sleep problems, dizziness, shortness of breath, sweating, chest pain, muscle discomfort, and tingling/prickling sensation in extremities. [Bagnell: 2011] In generalized anxiety disorder, symptoms may be recurrent and present even without an apparent stressor, while in other anxiety disorders symptoms may only be present when a stressor is present. [American: 2013]

How is it diagnosed?

Feelings of anxiety and worry can be completely normal responses to stress and change. However, an anxiety disorder should be considered when symptoms persist more than a few weeks, cause significant distress and/or dysfunction in performing activities of daily living, are atypical for the child’s developmental age, and/or are out of proportion to what is generally expected for the stressor itself. Different criteria exist for diagnosing different types of anxiety disorders.
Certain conditions, such as Asthma and Seizures/Epilepsy may cause anxiety. Anxiety may be separate or related to certain other conditions such as Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder (ADHD), disruptive behavior disorders, learning disorders, and mood disorders like Depression . Multiple anxiety disorders can present in the same person. [Bagnell: 2011]

What is the prognosis?

Anxiety disorders in youth are often associated with long-term psychiatric disorders including substance abuse, depression, and other anxiety disorders. [Wehry: 2015] While many suicide prevention efforts focus on identifying youth with depression, youth affected by anxiety are also at increased risk of suicide attempts. [Wehry: 2015] Anxiety disorders can also lead to poorer health and educational outcomes, as well as financial and interpersonal difficulties. [Wehry: 2015] On the other hand, many people with anxiety disorders respond favorably to treatment with medication and/or therapy.

What is the risk for other family members or future babies?

Anxiety disorder in the parents has been associated with an increased risk of anxiety disorder in their children [Biederman: 2001], [Merikangas: 1999] and high levels of functional impairment in children with childhood anxiety disorders. [Manassis: 1998]

What treatments/therapies/medications are recommended or available?

Various professionals may be part of the treatment team in different roles including primary care provider, psychiatrist, psychologist, social worker, nurse practitioner, counselor, and school psychologist. Behavioral and other counseling therapies are available to help families and children develop skills to manage and reduce anxiety and may be sufficient as monotherapy in cases of mild-to-moderate anxiety. Medications are available for moderate-to-severe anxiety, symptoms caused by anxiety, and conditions which may be causing or increasing the risk for anxiety.

How will my child and our family be impacted?

Families will need to develop skills to help the child and family reduce stress and anxiety. Family function and stressors strongly impact adherence to both behavioral and medical therapy plans. Parents who are anxious or avoidant may need extra support and training to not reinforce those traits in their children. Parents who are overprotective, over-controlling, and overly critical may increase anxiety in some children. Insecure parent-child attachment also may increase anxiety in some children. [Connolly: 2007] Accomodations may need to be made in school to help reduce anxiety or deal with the effects of anxiety.

What are the recommendations for treating anxiety in children with autism spectrum disorder?

According to a 2016 review of psychoactive medications used to treat anxiety and depression in children with autism spectrum disorder (ASD), response to medications may differ from responses in neurotypical youth. SSRI use (citalopram, sertraline, fluoxetine) is still commonly the first line medical treatment, but there is limited evidence for SSRI use in treating anxiety in children with ASD and the family should be aware of the possibility of activation. There is reasonable evidence suggesting better control of anxiety symptoms with use of extended release guanfacine (Intuniv), atomoxetine (Strattera), and buspirone (BuSpar). Children with “high-functioning” ASD often benefit from cognitive behavioral therapy.

What are the recommendations for treating anxiety in children with ADHD?

It can be tricky to decide which to treat first, as many symptoms of ADHD and anxiety can overlap. It is often recommended to treat anxiety first, but because uncontrolled ADHD symptoms can exacerbate anxiety (such as worrying about inadequate performance in the classroom setting), and because stimulant trials are faster than SSRI trials, some practitioners may choose to treat the ADHD symptoms first. Careful clinical questioning regarding the primary source of distress and use of screening questionnaires can be helpful in determining which to treat first. If a child appears more anxious or agitated on stimulant medication, consideration should be made to treat anxiety first. Clonidine and guanfacine may be helpful in treating some symptoms of both anxiety and ADHD. See Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD) for more information.

How long should a child with anxiety disorder be treated with medications?

Many children and families are eager to stop medications as soon as they feel better and symptoms are under control. However, currently it is recommended to continue medication treatment for 6-12 months once symptoms are under control before attempting to wean medication. Some disorders, including OCD, may require lifelong pharmacologic management.

When does worry become an anxiety disorder after a stressful life event? How long is “reasonable” to allow a child to adjust to an anxiety-provoking situation such as a move without being evaluated and/or treated for an anxiety disorder?

The DSM-5 clearly outlines criteria for both duration and severity that must be met in order to diagnose an anxiety disorder. For most anxiety disorders, symptoms must be prevalent for at least 6 months, although there are some exceptions. If a child is not experiencing significant disruptions in functioning (academic, social, or otherwise), then they also may not meet severity criteria for a disorder. Many children experience temporary and transient worry after life changes such as moves or transitions. Children who experience mood or anxiety symptoms after a stressor that resolve within 6 months may be better described as having an Adjustment Disorder. Medications may not be warranted in this case, but therapy may be helpful to aid in the transition.

Resources

Information & Support

For Parents and Patients

Support

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

The Child Anxiety Network
Parent-focused information about phobias, specific anxiety disorders in children, and treatment.

National Alliance of Mental Illness (NAMI)
A national organization that provides information and resources for families and professionals, including helpline, local chapter resources, and advocacy.

General

Anxiety Disorders Resource Center (AACAP)
Information and short videos about features, diagnosis, and treatment of anxiety disorders. Includes links to Facts for Families, brief handouts that explain diagnosis, treatment options, and when and how to find treatment; American Academy of Child Adolescent Psychiatry.

What to Do When You Worry Too Much
An interactive self-help book designed to guide 6–12 year olds and their parents through the cognitive-behavioral techniques most often used in the treatment of generalized anxiety. Metaphors and humorous illustrations make difficult concepts easy to understand, while prompts to draw and write help children to master new skills related to reducing anxiety; written by Dawn Huebner, PhD.

Family Toolkit for Anxiety (Utah Academy of Child & Adolescent Psychiatry)
Information about diagnosis and help at home and school, includes complimentary treatments; info is presented alphabetically by condition, so may need to scroll to find anxiety toolkit.

Anxiety Disorders (healthychildren.org)
Defines anxiety disorders for families; sponsored by the American Academy of Pediatrics.

Emotional Problems (healthychildren.org)
Helpful information about emotional difficulties, including anxiety and associated problems; American Academy of Pediatrics.

Mental Health, Naturally by Kathi Kemper
Holistic health expert and pediatrician Dr. Kathi J. Kemper presents natural treatments used for mental health issues such as ADHD, depression, anxiety, stress, and substance abuse; available for purchase on American Academy of Pediatrics website.

Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety
Book that helps parents identify and understand anxiety in their children, outlines effective and convenient parenting techniques for reducing anxiety, and shows parents how to promote bravery for long-term confidence; by Dr. Donna Pincus - creator of The Child Anxiety Network, Associate Professor at Boston University, and the Director of the Child and Adolescent Fear and Anxiety treatment Program at Boston University.

Patient Education

Acupressure for Stress and Anxiety (Memorial Sloan Kettering Cancer Center)
Patient information about acupressure and integrative medicine.

Depression and Anxiety Fact Sheet (Utah Family Voices) (PDF Document 49 KB)
Information, tips, and resources for families.

Drugs & Supplements Related to Anxiety: Patient Information (MayoClinic)
Describes for families precautions, proper use (includes pediatric use), and side effects of drugs and supplements used for anxiety. Can also search by first letter of drug/supplement name.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Studies

Anxiety in Children (ClinicalTrials.gov)

Authors & Reviewers

Initial publication: August 2016; last update/revision: November 2016
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Mary Steinmann, MD

Page Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013. 978-0-89042-554-1

Bagnell AL.
Anxiety and separation disorders.
Pediatr Rev. 2011;32(10):440-5; quiz 446. PubMed abstract

Biederman J, Hirshfeld-Becker DR, Rosenbaum JF, Hérot C, Friedman D, Snidman N, Kagan J, Faraone SV.
Further evidence of association between behavioral inhibition and social anxiety in children.
Am J Psychiatry. 2001;158(10):1673-9. PubMed abstract

Connolly SD, Bernstein GA.
Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 2007;46(2):267-83. PubMed abstract / Full Text

Houtrow AJ, Okumura MJ, Hilton JF, Rehm RS.
Profiling health and health-related services for children with special health care needs with and without disabilities.
Acad Pediatr. 2011;11(6):508-16. PubMed abstract / Full Text

Manassis K, Hood J.
Individual and familial predictors of impairment in childhood anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 1998;37(4):428-34. PubMed abstract

Merikangas KR, Avenevoli S, Dierker L, Grillon C.
Vulnerability factors among children at risk for anxiety disorders.
Biol Psychiatry. 1999;46(11):1523-35. PubMed abstract

Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR.
Assessment and treatment of anxiety disorders in children and adolescents.
Curr Psychiatry Rep. 2015;17(7):52. PubMed abstract / Full Text