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Guidance for primary care clinicians diagnosing and managing children with anxiety disorders

Anxiety is defined as "anticipation of future threat." [American: 2022] Children with anxiety disorders tend to be worriers and can seem irritable or easily embarrassed.

Other Names

Specific disorders addressed in this module are:
Agoraphobia Selective mutism
Anxiety disorder due to another medical condition Separation anxiety disorder
Generalized anxiety disorder (GAD) Social anxiety disorder (social phobia)
Obsessive-compulsive disorder (OCD) Specific phobia
Other specified anxiety disorder Substance/medication-induced anxiety disorder
Panic disorder Unspecified anxiety disorder
Post-traumatic Stress Disorder (PTSD)

Key Points

Most common pediatric anxiety disorders
Anxiety often has its onset during childhood. The “pediatric triad of anxiety disorders” includes generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. These disorders affect similar areas of the brain, can frequently co-occur, and tend to respond similarly to medication and behavioral interventions. [Wehry: 2015] The most common anxiety disorders in younger children are separation anxiety and specific phobias. The most common anxiety disorder in adolescents is social phobia. [Bagnell: 2011]

Seek information from other caregivers
Obtaining supplementary information from other caregivers, teachers, counselors, and others who regularly interact with the child can be extremely helpful in establishing the diagnosis and a treatment plan.

Identify specific stressors
Taking a careful history and delineation of the primary source of anxiety are necessary for appropriate diagnosis and treatment. If anxiety occurs predominantly in a particular situation or setting, such as school, more intensive interventions may be focused on those settings. If post-traumatic stress disorder is suspected and abuse, neglect, or safety concerns arise that have not been previously reported or investigated, adherence to mandated reporter laws in the clinician’s area of practice is imperative.

Evaluation and treatment of underlying medical concerns
Sometimes, symptoms of anxiety, irritability, or behavioral changes are due to an underlying medical concern rather than an anxiety disorder. This should particularly be considered in CYSHCN with limited verbal or communication abilities. Conversely, some anxiety disorders present, often in younger children, with prominent somatic symptoms, such as headaches, stomachaches, or sleep disturbance, with no apparent medical cause or symptoms that are out of proportion to what would be expected for a preexisting medical condition.

Therapy alone vs. combination therapy
Cognitive behavioral therapy (CBT) and other therapy modalities are effective in treating anxiety disorders and can have long-lasting effects. Therapy alone is low-risk, well-tolerated, and often effective for mild to moderate anxiety. For patients with moderate to severe anxiety, there is evidence that combination treatment is superior to therapy or medication alone both in acute phase treatment and for longer-term benefit. [Wang: 2017] [Piacentini: 2014] [Walkup: 2008]

SSRI dosing may be higher for anxiety than for depression
Treatment of anxiety with SSRIs may require higher doses than treatment for depression does. Starting doses are the same, although, for individuals with significant worry about side effects, a lower dose may be chosen. For CYSHCN, lower doses and slow titration of medications are recommended due to a higher risk of side effects.

A medication trial must be of adequate dose and duration
Treatment duration is as important as optimal dosing. A medication should be tried for at least 4-6 weeks at an adequate dosage before considering it a failure. Therapy is a useful adjunct to medication during this time and can help the individual learn other coping mechanisms for managing anxiety.

Short-acting benzodiazepines are not recommended
Short-acting benzodiazepines should only be considered for severe anxiety (i.e., complete refusal of life activities and inability to function as a result of anxiety) and with supervision by a psychiatrist. Longer-acting formulations are preferred, and a plan to taper should be developed at initiation.

Behavioral interventions for sleep anxiety
For anxiety about going to sleep, behavioral interventions can be very helpful (see Behavioral Techniques to Improve Sleep). For example, gradually moving a child’s sleep location from the parents’ bed to the floor and eventually to the child’s bed, or systematically checking/reassuring the child with timed intervals (5, 10, 15 minutes), and coupling these with positive rewards can help many children.

Alternative medication use
Many people use “natural” medicine to manage anxiety symptoms. Ask about all over-the-counter medications, herbs, supplements, and other treatments that have been tried or are being tried. Using large doses of anything can lead to side effects and toxicity. Product quality varies among manufacturers. Herbs and Dietary Supplements Program (OSU) is an online training program for clinicians that categorizes various natural approaches to treating anxiety based on evidence and risks. Integrative Medicine for CYSHCN discusses often used alternative therapies.

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, response to medications may differ from responses in neurotypical youth. There is reasonable evidence suggesting better control of anxiety symptoms with use of extended-release guanfacine (Intuniv), atomoxetine (Strattera), and buspirone (BuSpar). SSRI use (citalopram, sertraline, fluoxetine) remains the first-line medical treatment, but there is limited evidence for SSRI use in treating anxiety in children with ASD and increased risk of activation. Children with “high-functioning” ASD often can benefit from CBT.

Treating anxiety in children with ADHD
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 help determine which to treat first. If a patient appears more anxious or agitated on stimulant medication, consideration should be made to treat anxiety first. Clonidine, guanfacine, and atomoxetine mayhelp some symptoms of both anxiety and ADHD. See Anxiety Disorders & Attention Deficit Hyperactivity Disorder (ADHD) for more information.

When does worry become an anxiety disorder after a stressful life event?
Many children experience temporary and transient worry after life changes, such as moves or transitions. Adjustment disorder can be considered for children who experience mood or anxiety symptoms after a stressor, and these generally resolve within 6 months after removal of the stressor. The DSM-5clearly outlines the times for which symptoms must persist in order to meet criteria for anxiety disorder (for most anxiety disorders, symptoms must be present 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 may not meet severity criteria for a disorder. Medications may not be warranted in this case, but brief therapy may be helpful to aid in the transition.

Re-evaluation
Periodic re-evaluation to assess for the presence of one or more anxiety disorders is reasonable since they can occur at any age and may change over time.

Practice Guidelines

Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, Ripperger-Suhler J, Rockhill C.
Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124. 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

Geller D, March J.
Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.
J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113. PubMed abstract / Full Text

Cohen JA, Bukstein O, Walter H, Benson SR, Chrisman A, Farchione TR, Hamilton J, Keable H, Kinlan J, Schoettle U, Siegel M, Stock S, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.
J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-30. PubMed abstract

Diagnosis

Anxiety disorders are differentiated from normal, developmentally appropriate fears and worries by duration and impact on function. Children with a history of neglect, abuse, or trauma may be at risk for post-traumatic stress disorder, which can have onset at any age. As with any mental health diagnosis, the patient’s cultural background should be considered, as some fears or anxieties may be consistent with normative cultural beliefs. When assessing CYSHCN, clinicians should keep in mind that anxiety disorders are more common in these children. Females tend to be more frequently affected than males for most anxiety disorders.
Ask about:
  • Prior mental health disorders and response to past treatments
  • Chronic or past acute medical conditions, noting those that can co-occur or result in anxiety
  • Prior hospitalizations, surgeries, and other medical tests and interventions that may have provoked anxiety
  • Medication history - Prescription drugs with side effects that may mimic anxiety include antiasthmatics, sympathomimetics/psychostimulants, steroids, selective serotonin reuptake inhibitors (SSRIs), antipsychotics (akathisia), pimozide (neuroleptic-induced SAD), and atypical antipsychotics. Nonprescription drugs with side effects that may mimic anxiety include diet pills, antihistamines, and cold medicines. [Connolly: 2007]

Presentations

Anxiety is a normal emotion. However, anxiety becomes problematic when reactions to situations are disproportionate to the event and are often triggered by “typical” developmental experiences, such as going to school, being away from parents, or changes in responsibilities. An important task during evaluation is to distinguish normative worries to specific developmental stages (separation from caregivers in toddlers, supernatural creatures in preschoolers, natural disasters in school-age children, and social/existential concerns in adolescents) from anxiety disorders.
Many anxiety disorders start during childhood, often between 6-12 years of age. While anxiety disorders can occur at any age, different anxiety disorders often have an onset with specific developmental phases:
  • Separation anxiety in preschool/early school-age
  • Specific phobias in school-age
  • Social anxiety in later school-age and early adolescents
  • Generalized anxiety, panic, and agoraphobia-later adolescent/young adulthood
Common symptoms of anxiety in children include hypervigilance, reactivity to novel situations, and interpretation of common situations as threatening. Children with anxiety disorders often present first to primary care with vague, often recurrent somatic symptoms, including headaches, stomachaches, nausea, dizziness, bowel/bladder urgency, tremors, and insomnia. Anxiety may or may not be apparent during interaction with the patient in the clinical setting. Tantrums, irritability, and behavior problems, including aggression, are often present, especially in younger children, and may be confused with the mood lability of bipolar disorder.
Common symptom patterns include problems with separation from caretakers, prominent worries and intolerance of uncertainty, and severe shyness or self-consciousness. Other common manifestations of anxiety include fatigue, seeking reassurance from caregivers, perfectionistic tendencies, and being excessively critical of themselves. Concentration difficulties, academic difficulties, and restlessness that may be initially misdiagnosed as ADHD.
Spontaneous improvement of symptoms during weekends and school breaks may be indicative of separation anxiety disorder. Specific phobias and separation anxiety disorder tend to have onset in early childhood. School refusal can be a behavior associated with any anxiety disorder, although specific consideration should be made for social anxiety disorder, which has onset in adolescence.
Obsessive-compulsive disorder also tends to have onset in late adolescence and early adulthood and is associated with mental and behavioral rituals that might be confused with increased goal-directed activity seen in bipolar disorder or stereotyped behaviors in autism spectrum disorder.
Watch the patient’s interaction with the parent or caregiver for indications of nervousness insecurity, or unusual attachment for the child’s developmental stage. Children may appear sullen, withdrawn, tense, fidgety, or wary of interactions with others with or without caregivers present. Children with separation anxiety may become visibly upset when parents are asked to leave the room.

Diagnostic Criteria and Classifications

Anxiety disorders share some general principles. Anxiety disorders are present for several months (typically lasting longer than 6 months), in contrast to normal or adaptive stress responses that generally last a few weeks to a few months, often in the context of a life change or stressors. The anxiety is atypical for the child’s developmental age and is out of proportion to the stressor. Anxiety disorders also impair the child’s normal function. Anxiety disorders are highly comorbid with other anxiety disorders so children may have symptoms of more than one anxiety disorder at a time. Although all anxiety disorders are characterized by excessive and persistent fear or worry, careful clinical questioning can help the clinician further characterize the type of anxiety disorder that is present.
To meet diagnostic criteria, the anxiety must cause significant daily distress or limit normal functioning; represent a distinct change from the patient’s baseline behavioral and emotional functioning; not be caused by a medication, substance abuse, or other psychiatric or medical issues (unless defined as such); and be differentiated from anxiety that is normal for the child’s developmental level. Such anxiety is also generally persistent and not a temporary, short-term reaction to a stressor. Children and youth with special health care needs (CYSHCN) are at increased risk for mood disorders, including anxiety and depression. [Houtrow: 2011]
Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are no longer classified as anxiety disorders, reflecting an evolving understanding of their neurobiology. However, because anxiety remains a prominent feature and their treatments are similar to other anxiety disorders, they are discussed in this module.
The following descriptions differentiate among specific anxiety disorders; see the [American: 2022] for authoritative diagnostic criteria (copyright prevents detailing them here).
Agoraphobia - fear of situations, such as public spaces, related to a perceived lack of potential escape should panic or embarrassment occurs. A person with panic disorder who avoids certain settings out of concern that he or she will have a panic attack and will not be able to escape may have panic disorder with agoraphobia; however, agoraphobia may occur in a person without panic attacks. In children, the most common feared situation is being outside of the home alone, often with the fear of becoming lost.
Generalized anxiety disorder - persistent, excessive worry and perception of lack of control of multiple domains of one’s life, such as home, school, and extracurricular activities. Often associated with fatigue, sleep disturbance, irritability, restlessness, concentration difficulties, and muscle tension (e.g., a child who is tense and has trouble relaxing with nighttime worrying that can make it hard to fall asleep).
Obsessive-compulsive disorder – persistent, unpleasant/unwanted thoughts or urges known as obsessions, and/or repetitive mental acts or behaviors known as compulsions that the patient carries out to obtain temporary relief from the obsessions or in accordance with irrational or overly rigid rules.
Panic disorder - recurrent, unexpected panic attacks that typically peak in minutes and last <1 hour and consist of severe anxiety and physical manifestations of autonomic activation including increased heart rate, palpitations, chest pain, difficulty breathing, sweating, tremulousness, nausea, dizziness, and other symptoms. Panic attacks can be seen in multiple psychiatric conditions, including other anxiety disorders or reactions to stress. They can mimic medical disorders, and appropriate medical evaluation of symptoms should be performed as indicated. Panic attacks should raise concern for an underlying disorder but are not considered to be mental disorders themselves. Panic disorder always includes recurrent, unexpected panic attacks accompanied by worries about having a panic attack in the future, but having panic attacks is not sufficient to diagnose panic disorder. Panic disorder is less common in younger children and when present, panic attacks more typically triggered by a specific event/trigger compared to in older children where they more commonly occur in the absence of a specific event/trigger.
Post-traumatic stress disorder – persistent anxiety that arises from exposure to a potentially life-threatening event(s) or a close family member or caregiver being exposed to a potentially life-threatening event(s). Involves subsequent nightmares, flashbacks, hypervigilant behaviors, and/or avoidance of reminders of the traumatic event(s).
Selective mutism - persistent refusal or inability to speak in certain settings (e.g., school) despite demonstrating normal language use in another setting (e.g., home) that is not due to a problem with comprehension. Selective mutism often co-occurs with other anxiety disorders, especially social anxiety disorder.
Separation anxiety – developmentally inappropriate degree of fear or worry about circumstances that could lead to separation or loss of a caregiver. Associated behaviors include reluctance to leave the caregiver, nightmares, and somatic complaints (e.g., a child who has stomach aches before going to school, but not on weekends). Children’s anxiety is often surrounding losing primary attachment figures or that something bad may happen to them.
Social anxiety disorder - fear or anxiety surrounding the possibility of judgment or possible criticism and rejection from others in social situations. In children, anxiety must occur in interactions with peers in addition to adults. Associated behaviors include avoidance of social interactions, school refusal, and refusal to perform in front of others. Performance anxiety is a type of social anxiety where fear is restricted to public speaking or performance. [Connolly: 2007]
Specific phobia - recurrent, disproportionate fear or avoidance of specific things or situations - for example, animals, natural disasters, and medical environments or procedures. Kids may have more than one specific phobia at a time. [Connolly: 2007]
Substance/medication-induced anxiety disorder – anxiety disorder due to intoxication or withdrawal from a substance (e.g., alcohol withdrawal or stimulant intoxication) or treatment side effects.
Unspecified anxiety disorder – may be used when it is clear that the child is significantly impacted by anxiety, but the clinician has not identified a more specific anxiety disorder diagnosis.

Screening & Diagnostic Testing

Screening tools help identify children and adolescents at increased risk of an anxiety disorder. While there are no American Academy of Pediatrics (AAP) screening recommendations for anxiety (only recommendations for depression and substance abuse), the American Academy of Child & Adolescent Psychiatry recommends that clinicians providing psychiatric assessment of children ask screening questions about anxiety disorders. [Connolly: 2007] There are no recommendations for routine anxiety screening in a general pediatric population. If a child presents with emotional or behavioral issues, part of the evaluation should include asking about anxiety. If there is concern for anxiety disorder, screening tools may help along with supplement history, clinical observations, and pertinent medical evaluation. The inclusion of subscales in some of these screens makes manual scoring more time-consuming. Obtaining information from multiple informants can greatly assist in the evaluation since different anxiety disorders may manifest in different settings.
Generalized Anxiety Disorder 7-Question Screen (GAD-7) - 7-item report developed to screen for generalized anxiety disorder; it can be completed as a patient self-report or parent report. Scores >10 should prompt further inquiry, and scores >16 have good specificity for generalized anxiety disorder in youth ages 12-17. [Mossman: 2017] Instructions for use and links for the screening tool in multiple languages are included at Patient Health Questionnaire (PHQ) Screeners (agree to the terms of use and select free screener from drop-down menu).
Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh)- child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders. (Total scores >=25 are consistent with increased risk of any anxiety disorder, and subscale scores further help identify risk for general anxiety disorder, separation anxiety disorder, panic disorder or significant somatic symptoms, social phobia, and significant school avoidance. Free to download or link to online Excel worksheet that calculates the score. Translations in Arabic, Chinese, Czech, Finnish, French, German, Hebrew, Italian, Spanish, Tamil (Sri Lanka), and Thai. Based on published, peer-review studies.
Spence Children’s Anxiety Scale (SCAS) (PDF Document 115 KB) - child (45 questions) and parent (39 questions) versions for ages 8-15, plus a preschool version filled out by parent (34 items) or teacher (22 items). The screen scores for overall anxiety disorder, as well as separation anxiety, social phobia, obsessive-compulsive problems, panic/agoraphobia, generalized anxiety/overanxious, and symptoms and fears of physical injury. T-scores >60 correlate with increased risk for an anxiety disorder, excluding the teacher-completed preschool scale that is for informational purposes and does not have normative data available. Based on DSM-IV, with free access to downloadable PDFs and online scoring versions. Available in many languages.
Children’s Yale–Brown Obsessive Compulsive Scales (CY-BOCS) (PDF Document 50 KB)- assesses presence and severity of obsessions and compulsions for both diagnosis of OCD and monitoring treatment response in children ages 6-17. Completed by a clinician or trained interviewer during a semi-structured interview with a child and/or parent, instructions and tips for how to ask questions and grade responses are included; free download. This is a more time-consuming scale that may be challenging to use in a primary care setting. Scroll past the Y-BOCS (adult version) to reach the CY-BOCS.
DSM-5 Online Assessment Measures (APA)- alternatively, the American Psychiatric Association offers free tools that are not yet validated for use in children, but they have acceptable test-retest reliability with parent informants in the DSM-5 field trial. [Freedman: 2013] Clinicians can use the Level 1 Cross-Cutting Symptom Measures assessment to determine areas of concern in 12 domains, then additional Level 2 assessments to assess scores for anxiety and other DSM-5 categories. There are also Disorder-Specific Severity Measures for use in youth ages 11-17 for social phobia, separation anxiety, specific phobia, and generalized anxiety disorders. The measures were developed to be administered at the initial patient interview and to monitor treatment progress. Instructions, scoring information, and interpretation guidelines are included.

Genetics & Inheritance

Although heredity seems to be a factor in many people with anxiety, the etiology of anxiety disorders is considered complex and polygenic, and no specific causal or high-risk mutations have been identified. [Smoller: 2016] [Bagnell: 2011]

Prevalence

Previous data demonstrated that anxiety disorders affect 6-20% of children and youth in the US and are the most common mental health disorders in kids. [Connolly: 2007] [Bagnell: 2011] [Wehry: 2015] About 7% of children ages 3-17 in the United States are diagnosed with anxiety, although less than 60% receive treatment. [Ghandour: 2019] Anxiety disorders are more common in females (2:1 compared to males). [American: 2013] Almost half of CYSHCN are estimated to be affected by anxiety or depression, with an estimated prevalence that is 25% greater than in typically developing children. [Houtrow: 2011] Separation anxiety disorder typically shows the greatest prevalence in child samples while social anxiety disorder is more prevalent in adolescent samples. Specific phobias are the most prevalent form of anxiety disorders. [Rapee: 2023]

Differential Diagnosis

The following conditions may have anxiety as a component or have signs and symptoms that mimic those of anxiety disorders. [Connolly: 2007] The DSM-5 Handbook of Differential Diagnosis (APA) offers differential diagnosis pathways and decision trees (available for purchase).
Adjustment disorder with depressed mood consists of depressed mood and impaired function within three months of a clearly defined stressful life event. To be diagnosed with an adjustment disorder, the patient cannot meet the full criteria for a major depressive episode.
Attention deficit hyperactivity disorder has a pattern of persistent inattentiveness, distractibility, and/or hyperactivity starting in childhood and impairing function in more than one setting (see the Portal’s Attention-Deficit/Hyperactivity Disorder (ADHD)). Concentration difficulties, academic difficulties, and restlessness that may be initially misdiagnosed as ADHD are also common symptoms of social anxiety disorder as well as generalized anxiety disorder, which tends to have onset in later adolescence.
Adjustment disorder has transient change in mood associated with life stressors, usually lasting less than 6 months and resolving spontaneously.
Asthma may feel panicky in association with difficulty breathing or excessive coughing (see the Portal's Asthma).
Autism spectrum disorder involves social avoidance, irritability, or restlessness, associated with repetitive behaviors or restricted interests, adherence to routines, and ongoing social problems starting in early childhood (see the Portal’s Autism Spectrum Disorder).
Bipolar disorder can involve restlessness, irritability, impaired sleep associated with depressive and manic episodes.
Caffeine intake can cause restless or anxious symptoms after consumption.
Central nervous system disorders, such as brain tumors can cause irritability or personality changes associated with other central nervous system abnormalities.
Delirium can include anxiety or irritability in association with other changes in awareness or behavior.
Depression can include somatic complaints, sleep difficulty, poor concentration associated with persistently depressed mood (see the Portal’s Depression). The incidence of depression in children and youth with anxiety is 4-fold that of other children. Eliciting specific mood symptoms (sadness, irritability) is vital in differentiating these diagnoses. Anxiety generally precedes the onset of depression, so carefully assess youth with anxiety for symptoms of depression.
Hyperthyroidism can cause unexpected weight loss, rapid or irregular heartbeat, sweating, and irritability.
Hypoglycemia can cause anxiety, nervousness, shakiness, hunger, confusion, and other symptoms.
Illness anxiety disorder includes excessive, enduring worry about having a particular illness despite somatic symptoms that are minimal, absent, or disproportionate to actual circumstances (classified as a somatic symptom disorder).
Lead intoxication can cause irritability associated with abdominal pain, constipation, developmental delays or learning problems, fatigue, weight loss, or hearing loss, and lead exposure (see the Portal's Childhood Lead Exposure).
Learning disabilities can include worrying about school performance in conjunction with difficulty in one or more skill areas (e.g., reading, math).
Migraine involves recurring headaches may be associated with light or sound sensitivity, nausea or vomiting, or aura (see the Portal’s Headache (Migraine & Chronic))\.
Obsessive-compulsive disorder also tends to have onset in late adolescence and early adulthood and is associated with mental and behavioral rituals that might be confused with increased goal-directed activity seen in bipolar disorder or stereotyped behaviors in autism spectrum disorder.
Pheochromocytoma can involve anxiety or racing heart associated with high blood pressure, sweating, tremors, pallor, and other symptoms (see Pheochromocytoma (MayoClinic) for symptoms and tests).
Psychotic disorders can include social withdrawal, restlessness associated with abnormal thinking and perceptions.
Seizure disorders can make an individual feel panicky at onset of seizure. Seizures are often associated with repetitive movements, loss of consciousness; they are frequently shorter than most panic attacks (see the Portal’s Seizures/Epilepsy).
Somatic symptom disorders has anxiety regarding physical symptoms or other health-related concerns may be a prominent feature.
Substance use disorders provoke anxiety precipitated by intoxication of substances (stimulants, cannabis, hallucinogens or inhalants) or associated with withdrawal (alcohol, opioids, or sedatives). See Substance Use Disorders.

Co-occurring Conditions

It is very common for an individula with an anxiety disorder to meet criteria for aditional anxiety disorders. Anxiety disorders are often comorbid with Autism Spectrum Disorder; Attention-Deficit/Hyperactivity Disorder (ADHD); disruptive behavior disorders; learning disorder; mood disorders; somatic symptom disorders; Substance Use Disorders; and tic disorders (tics may increase in anxiety-provoking situations). Multiple anxiety disorders can present in the same person. [Bagnell: 2011]

Medical Conditions Causing Anxiety Disorders

The following medical conditions are known to precede anxiety symptoms:
Endocrine - hyperthyroidism, hypoglycemia, hyperadrenocortisolism, pheochromocytoma
Cardiovascular - congestive heart failure, pulmonary embolism, arrhythmias (e.g., atrial fibrillation)
Respiratory - asthma, pneumonia, chronic obstructive pulmonary disease (COPD)
Metabolic - vitamin B12 deficiency, porphyria
Neurologic - seizure disorders, tumors, encephalitis, vestibular dysfunction

Prognosis

Anxiety disorders in childhood are often seen prior to the onset of other psychiatric disorders such as disruptive behavior disorders and depression, which have their onset in later childhood. Although anxiety disorders often persist into adulthood, they usually have a waxing and waning course with varying degrees of symptom severity among episodes. [Beesdo: 2009] Younger children tend to have recurrent episodes of 1 anxiety disorder type, but the risk of developing multiple anxiety disorders increases with age. Anxiety disorders may contribute to development of depression and substance use disorders. [Beesdo: 2009] 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] Unrecognized and undertreated anxiety disorders can also lead to poorer health and educational outcomes, as well as financial and interpersonal difficulties. [Wehry: 2015]

Many people with anxiety disorders respond favorably to treatment with medication and/or therapy, and treatment effects can last beyond the acute treatment phase. [Piacentini: 2014] Only about 1/3 of patients with anxiety disorders improve without treatment; up to 1/3 of patients may have a chronic, treatment-resistant course despite intensive treatment, especially if anxiety symptoms are severe or are accompanied by a major depressive disorder. [Durham: 2012]

Treatment & Management

Most pediatric anxiety disorders can be managed in the primary care setting, ideally in collaboration with behavioral health specialists for ongoing therapy and in consultation with child psychiatrists for diagnostic dilemmas or patients that are difficult to treat conventionally. Monitoring the impact of the anxiety disorder and response to treatment is vital including both reduction of anxiety symptoms a well as improving functional impairment

For children with mild symptoms of anxiety associated with minimal impairment, treatment should be focused on lifestyle modification and evidence-based psychotherapy. For severe symptoms of limited response to therapy, combination of medication and psychotherapy are recommended. [Walter: 2020]

Managing Anxiety in Children-Healthy Lifestyle Wheel
Adapted by Dr. Jennifer Goldman-Luthy from Dr. Kathi Kemper's book Mental Health Naturally
Lifestyle changes in the areas on the wheel (left) can be powerful in treating anxiety. The primary care clinician should offer information about cognitive behavioral therapy (CBT) and other behavioral health approaches, medications, and healthy lifestyle changes. Pharmacologic treatment typically involves gradual titration to clinical response, continued treatment for several months or a year, and then attempt to wean gradually during a low-stress time. The short-term goal is to improve function and participation in regular activities. The long-term goal is that the child develops skills to sustain function and avoid relapses, which is a primary aim of behavioral therapy.

A healthy lifestyle helps anxiety. This includes regular exercise, healthy foods, adequate sleep, meaningful relationships, community engagement, stress management and relaxation practices, a sense of purpose, fun, and spirituality. [Kathi: 2010] When treating a child for anxiety, focusing on each of these components can augment, or even in some cases, take the place of treatment with prescription medications and therapy.

Mental Health / Behavior

Cognitive behavioral therapy (CBT) is the most empirically-supported psychotherapy based on randomized controlled studies for anxiety disorders in children that has shown both short-term and long-term efficacy. It is helpful to explain to families that CBT helps children learn to recognize and gain better control over their anxiety. CBT can be similarly effective in children with high-functioning autism spectrum disorder who experience anxiety. [Earle: 2016] The CBT process uses several components, such as psychoeducation, training to better manage one’s somatic complaints, cognitive restructuring (such as rethinking negative self-talk), exposure methods (i.e., gradually getting used to an anxiety-provoking situation), and plans to prevent and manage relapses. [Connolly: 2007] CBT therapists may use workbooks for kids and parents; some families defer therapy and simply use CBT-based workbooks, such as What to Do When You Worry Too Much at home. Mindfulness-based CBT is an emerging approach that may be beneficial. [Connolly: 2007] For more in-depth information and reviews of the evidence behind CBT used for different types of pediatric anxiety, see [Connolly: 2007].

Psychodynamic psychotherapy has been used extensively, though there is less high-quality evidence supporting its effectiveness. [Connolly: 2007] This approach aims to help the patient uncover and explore unconscious thoughts that contribute to their anxiety.  Parents are routinely involved in both forms of therapy to help improve parent-child relationships and teach parents more effective skills to manage their child’s anxiety and support their therapeutic process.

Mental health, mindfulness, biofeedback, and meditation apps and games have proliferated. Clinicians and patients often consider these apps for convenience and privacy, and because it seems likely that most kids would prefer to play a game than go to therapy. However, “there is insufficient evidence to suggest that any mobile app for mental health can be used effectively with children and young people. Clinicians should be cautious about recommending mobile apps until there is sufficient evidence to support their safety and efficacy.” [Grist: 2017] Consider assessing children with anxiety for substance use with appropriate toxicology tests, particularly if their symptoms have sudden/episodic onset or if there are accompanying concerns on physical examination, such as mental status or autonomic changes.

Medications

Prescription medications are often considered in conjunction with therapy, especially those with more severe symptoms of anxiety or who fail to respond to therapy alone. Ongoing monitoring of tolerance and for side effects and drug interactions is important, as well as for comorbid conditions such as depression or other anxiety disorders. Medication can also be beneficial for kids who are unable to access therapy or who are highly anxious about starting therapy.
The treatment goals for anxiety disorders are symptom improvement and return to an adequate baseline level of functioning with tolerable side effects. A step-wise approach is advised, in which subsequent steps are taken only when a step is not effective or tolerated. Each step may require 4-6 weeks of a medication trial in order to fully assess efficacy. Many anxiety medications have significant side effects and may interact with other medications; some may lower seizure threshold. Black Box warnings related to reports of increased suicidality in children and young adults up to the age of 25 are issued with many of these medications, particularly the SSRI and serotonin and norepinephrine reuptake inhibitors (SNRIs).
Although many antidepressants have been approved by the FDA for treatment of anxiety disorders in adults, and several been studied for treatment of anxiety disorders in children and adolescents, only a few have FDA-approved indications in the pediatric population. Duloxetine (Cymbalta) is FDA-approved for treatment of GAD in children ≥7 years. For treatment of OCD, sertraline (Zoloft) is FDA-approved in children ≥6 years, fluoxetine (Prozac) is FDA-approved in children ≥7 years, clomipramine (Anafranil) is FDA-approved in children ≥10 years, and fluvoxamine (Luvox) is FDA-approved in children ≥12 years. However, there is a large body of literature, including randomized controlled trials, that supports the efficacy and tolerability of pharmacotherapeutic treatments for off-label use in treatment of childhood anxiety disorders. Therefore, off-label use of many medications is common in treatment of childhood anxiety disorders.
SSRIs remain the first-line medications for anxiety disorders. Some general guidelines when using SSRIs include starting at low doses to assess for tolerability and going up gradually. Generally, after one failed trial of a SSRI, a second SSRI trial is recommended. An adequate trial of a SSRI includes being on a therapeutic dose (fluoxetine 20-60 mg, sertraline 50-200 mg, escitalopram 10-20 mg) for an adequate duration of time (typically 4-6 weeks) or when medication is not tolerated due to side effects. Significant side effects that should be monitored include suicidal ideation, behavioral activation/agitation, induction of mania/hypomania, and serotonin syndrome. [Walter: 2020]
The following is adapted from the Pediatric Anxiety Flowchart (UACAP) (PDF Document 402 KB) with permission from the author, Travis Mickelson:
Step 1: In children with anxiety disorder, SSRIs have the best evidence for use, particularly fluoxetine (Prozac) and sertraline (Zoloft). Higher doses of SSRIs may be needed to treat anxiety than depression. Fluvoxamine (Luvox) is an SSRI that is also FDA-approved for use in children with OCD, but it is generally not used first-line due to higher risk of drug-drug interactions. Escitalopram (Lexapro) and citalopram (Celexa) are also likely effective; however, at higher doses, citalopram increases the risk of prolonged QT interval. Consider monitoring when citalopram doses above 40 mg are required. Paroxetine (Paxil) has some evidence for use in social anxiety disorder in youth. [Strawn: 2012]
  • Fluoxetine: Start 5-10 mg daily and increase every 2-4 weeks as tolerated, up to 60 mg daily.
  • Sertraline: Start 12.5-25 mg daily and increase every 2-4 weeks as tolerated, up to 200 mg daily [Earle: 2016]
Step 2: Try an alternate SSRI - switch to different SSRI if no benefit from first. Fluvoxamine (Luvox) may be helpful in severe OCD if fluoxetine and/or sertraline are ineffective or not tolerated. 
Step 3: Switch to an SNRI - Duloxetine (Cymbalta) has been FDA-approved for use in kids 7-17 with generalized anxiety disorder. Venlafaxine (Effexor) has some evidence for use in children with generalized anxiety [Strawn: 2012] or social phobia. Some moderate quality studies show good response to treatment of comorbid anxiety with venlafaxine or duloxetine in children with ASD when SSRIs are not successful. [Earle: 2016] However, for children on the autism spectrum or with other neurodevelopmental disabilities, second-line therapy is typically an alpha-2 agonist (clonidine, guanfacine), used to address hyperactivity or anxiety/hyperarousal states. Consultation with a child and adolescent psychiatrist may be appropriate after two failed medication trials for anxiety.
Step 4: Consider augmentation or alternative medications that can be used alone if serotonergic medications are not tolerated, or as adjunctive therapy for partial response to one of the above meds. Consultation with a child psychiatrist is recommended at this point if not sought previously. Note that “as needed” medications for anxiety are generally discouraged; however, they might be considered for panic disorder or procedural anxiety. The following are from the American Academy of Child and Adolescent Psychiatry Facts for Families: [American: 2017]
  • Antihistamines: They can be useful for as-needed treatment of anxiety, but the effectiveness tends to wear off with long-term use. They can cause significant sedation and other side effects, as well as decrease anxiety. They also can lower seizure threshold and interact with other medications. Examples of antihistamines include hydroxyzine (Vistaril) and diphenhydramine (Benadryl).
  • Anticonvulsants: Gabapentin (Neurontin) is used to treat certain seizure disorders and neuropathic pain, but is sometimes used for anxiety. Pregabalin (Lyrica), an anticonvulsant GABA-derivative, is better studied, but it is expensive. It is approved for use in adults with generalized anxiety disorder, but not for children.
  • Antihypertensives: Clonidine (e.g., Kapvay, Catapres) and guanfacine (e.g., Intuniv, Tenex) are alpha-agonists used for second-line treatment of ADHD and have some anxiolytic properties. This may be a good option for someone with ADHD and anxiety who experiences worsening anxiety on a stimulant.
  • Atypical anti-anxiety medications: Buspirone (Buspar) is an anxiolytic 5-HT1A agonist that takes 1-4 weeks for onset of action and is approved for generalized anxiety disorder in adults. It is not currently FDA-approved for use in children. It does not cause dependency. There is a study with positive evidence for buspirone to treat comorbid anxiety in children with autism spectrum disorder.  [Earle: 2016]
  • Atypical antipsychotics: They are used occasionally for severe anxiety and aggressive behaviors; however, there is significant risk of side effects, including weight gain, metabolic syndrome, movement disorders, and akathisia (a restless sensation that may mimic or worsen anxiety).
  • Benzodiazepines: Little evidence exists for use in pediatric anxiety disorders. [Connolly: 2007] Procedural anxiety may be treated with lorazepam (Ativan) or diazepam (Valium), although there is some reported risk of behavioral disinhibition in young children. [Nutter: 2016] They are best used short term, but can be used to bridge the starting of SSRI therapy in youth with panic disorder. Clonazepam (Klonopin) is preferred in certain cases due to longer half-life and decreased risk of rebound anxiety. Benzodiazepines are generally avoided due to risk of abuse and diversion, and they cause significant sedation. [Nutter: 2016] Of note, children with seizures often have a benzodiazepine reserved for management of status epilepticus; regular use for treatment of anxiety may result in increased tolerance to the medication.
  • Beta blockers: Propranolol has been used in adults for as-needed management of performance anxiety. [Fourneret: 2001] It also has been used to decrease aggressive behaviors and nervousness in children with neurodevelopmental disabilities. [Dulcan: 2015] Little research has been done on beta blockers for pediatric anxiety; however, there is a positive case review of propranolol use for school avoidance. [Kung: 2012]
  • Prazosin: This is an alpha-1 antagonist that may be useful for treatment of nightmares associate with posttraumatic stress disorder. [Kung: 2012]
  • Selective norepinephrine reuptake inhibitor: Medications, such as atomoxetine (Strattera), that are approved for treatment of ADHD have some evidence in decreasing anxiety as well and may be considered in someone with comorbid anxiety and ADHD. [León-Barriera: 2023]
  • Tetracyclic antidepressants: Tetracyclic antidepressants, such as mirtazapine (Remeron), can be very sedating, so should be dosed at night. Sedative effects tend to decrease with increased doses. They can be useful in treating comorbid depression and insomnia. There is some evidence for use in treating comorbid anxiety in children with autism spectrum disorder. [Earle: 2016]
  • Tricyclic antidepressants: These have significant side effects, can lower seizure threshold, and increase risk of morbidity or mortality with overdose. Due to increased side effect profile these are commonly reserved for those who have failed several other medical classes. Examples include clomipramine, imipramine, amitriptyline. Clomipramine is FDA-approved for treatment of OCD; imipramine can be useful for treatment of enuresis. There is inconclusive evidence for use in separation anxiety disorders.
Many of these medications can take 4-6 weeks to determine response. Note that some medications used to treat anxiety, such as guanfacine, clonidine, and propranolol, can affect heart rate and/or blood pressure and abrupt discontinuation should be avoided.
Often children and families are eager to stop medications as soon as they feel better and symptoms are under control. However, it is recommended to continue medication treatment for 6-12 months once symptoms are under control before attempting to wean medication. A slow medication taper may be considered during a stress-free time (such as the summer) by reducing medication every 2-4 weeks as tolerated. If symptoms return no further reduction should be made and may consider increasing back to previously beneficial dose. [Doyle: 2022]
Some disorders, including OCD or recurrent anxiety, may require lifelong pharmacologic management. Patients should be counseled that medications should not be discontinued abruptly and dosage changes should occur in partnership with the treating physician. Sudden discontinuation of an antidepressant medication can result in antidepressant discontinuation syndrome characterized by flu-like symptoms, imbalance, tremors, paresthesias, “brain zaps,” and irritability, or anxiety (for SSRIs or SNRIs) - or, cholinergic symptoms, agitation, and delirium-like symptoms (for TCAs). Hypertensive rebound is a risk of abruptly stopping alpha-2 agonists. Abrupt cessation of long-term benzodiazepine use may present with symptoms similar to acute alcohol withdrawal and may require medical management.
If a patient is taking serotonergic medications, such as SSRIs, SNRIs, or clomipramine for depression or anxiety, serotonin syndrome is a rare but serious risk that is characterized by autonomic instability, muscle rigidity, hyperreflexia, mental status changes, and hyperthermia. Serotonin syndrome usually results from serotonin agonist polypharmacy and should be considered if the above symptoms occur with increasing doses of serotonergic antidepressants or the addition of new serotonergic agents to a patient's medication regimen. Treatment ranges from supportive in mild cases to ventilation and dialysis in severe cases. [Perry: 2012]

Learning, Education, Schools

Assess the child’s anxiety symptoms in the context of their developmental age. Determine if the child’s symptoms impact social relationships, school attendance and performance, or participation at school, home, or during extracurricular activities. Classroom-based accommodations may be helpful in the treatment of anxiety in children. Speaking with a teacher or counselor may be very helpful; consent from the patient and family may be required. It may be helpful to identify an adult at the school other than the teacher (school counselor or nurse) who can help the child with anxiety management strategies if needed. If anxiety affects school participation and performance, school accommodations should be considered which could include things like decreased homework, providing space for the child to take a break and engage in anxiety management strategies, increasing time for tests or assignments, or gradual exposure to certain anxiety-provoking situations such as giving speeches.. [Connolly: 2007] While the primary care clinician cannot prescribe specific accommodations in the educational setting, a letter of support for the child’s 504 Plan with suggested interventions may be helpful for the school. See School Accommodations: IEPs & 504s.
As children mature, different types of anxiety disorders, such as social phobia, become more common. Older children and adolescents with anxiety may try to self-medicate or abuse drugs or alcohol.

Cardiology

Elevated blood pressure and mild tachycardia can occur with anxiety, but may be related to anxiety about being in a clinic; consider home monitoring if unclear.

Endocrine

Dry or moist skin may indicate thyroid concerns; however, sweating can occur during acute anxiety as well. Inspect and palpate the thyroid.

Neurology

Children with anxiety disorders should have a normal neurologic examination. Anxiety can exacerbate tics. testing may be helpful if there is concern about the differential diagnoses or medical conditions that can cause anxiety.

Social and Family Functioning

Awareness of family and peer support and relationships is useful. Bullying and cyberbullying related to digital media use is an increasing issue that may increase risk of developing depression and possibly anxiety. [Hoge: 2017] Assess for traumatic exposures including abuse, neglect, and exposure to domestic violence. Family functioning 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. Parenting styles that 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] Helpful parenting traits to encourage with parents of children with anxiety disorders include proving warmth, consistency and encouragement of autonomy. [Rapee: 2023]
Taking a history of family members with anxiety disorders can help identify how familiar the family is with anxiety disorders, as well as how the family has responded to past behavioral and medical interventions. It also alerts the clinician to significant medical or psychosocial events that may trigger stress or maladaptive anxiety response in the child or family. [Wehry: 2015] Parental anxiety disorder has been associated with increased risk of anxiety disorder in offspring [Biederman: 2001] [Merikangas: 1999] and high levels of functional impairment in children with childhood anxiety disorders. [Manassis: 1998]

Complementary and Alternative Medicine

Many people use “natural” medicine, mind-body therapies, different systems of medicine (e.g., Traditional Chinese Medicine or Ayurveda) or related modalities to manage anxiety symptoms. Research suggests that the use of biofeedback-assisted relaxation training may reduce anxiety in children and youth, hypnosis may alleviate preoperative anxiety, and other mind-body practices, such as mindfulness and yoga,can alleviate stress and improve coping skills. [McClafferty: 2016] However, many approaches lack specific evidence for use in treatment of pediatric anxiety, and even low-risk approaches must be weighed against the potential for side effects, medication interactions, time, and cost. See Complementary and Alternative Medicine (CAM).
  • Assess and encourage healthy lifestyle habits, including healthy diet, sleep, mind-body practices, and regular exercise.
  • Be sure to ask about all over-the-counter medications, herbs, supplements, and other treatments that have been previously tried or are being tried. Many herbal remedies and supplements can have significant drug-drug interactions and are not as closely monitored by the FDA as medications. Using large doses of anything can lead to side effects and toxicity, and product quality varies among manufacturers. Some commonly used herbs for anxiety are listed below; however, evidence is limited, there are potential risks associated with each, and little research on long-term use and risks of these herbs.
    • Chamomile – risk of medication interactions and allergic reactions
    • Kava – risk of serious liver damage
    • Lavender – risk of side effects and medication interactions
    • Lemon balm – risk of side effects
    • Passionflower – often combined with other products and can cause dizziness and drowsiness
    • Valerian – risk of side effects, lacks long-term safety data
  • Cannabidiol (CBD) has been the focus of increasing attention for use in treating almost every disorder under the sun, but little evidence exists currently on the efficacy and safety of its use for treatment of pediatric anxiety. Counsel families about the lack of quality data and regulation of over-the-counter CBD products to treat pediatric anxiety, and that these products can contain other psychoactive chemicals such as tetrahydrocannabinol (THC) which could potentially exacerbate anxiety. See CBD for Neurologic Conditions in Children for more information on pediatric medical use of CBD.
The National Center for Complementary and Integrative Health (NIH) has scientific information about herbs and botanicals, new research, and training related to integrative medicine. The Herb at a Glance portion of this site provides a series of brief fact sheets with basic information about specific herbs or botanicals. Herbs and Dietary Supplements Program (OSU) is an online training program for clinicians that categorizes various natural approaches to treating anxiety based on evidence and risks. The book, Mental Health, Naturally, is also a good resource for supplement use and dosing recommendations.
Nutrition/Growth/Bone
Children with anxiety disorders should have a normal neurologic examination. Anxiety can exacerbate tics. testing may be helpful if there is concern about the differential diagnoses or medical conditions that can cause anxiety.
Anxiety disorders can be associated with appetite changes, but major fluctuations in weight are uncommon. Unexpected weight gain or loss should raise concern for medical issues, mood disorders, or eating disorders. Anxiety can also be seen in eating disorders such as avoidant restrictive food intake disorder (ARFID), which may improve with treatment of underlying anxiety. The use of SSRIs can result in weight gain in some patients.
Inspect and palpate the abdomen. Anxious children may withhold stool, which can lead to co-occurring constipation or overflow incontinence.
Advise avoiding coffee and other caffeinated products, such as energy drinks, which may worsen anxiety. A well-rounded diet is the best good way to provide a balance of micronutrients. However, when families want guidance about specific nutritional supplementation, the following summary of items from the AAP published book: Mental Health, Naturally, MD, MPH, Director of the Center for Integrative Health and Wellness at Ohio State University, may be useful:
  • Multivitamins/minerals are usually well-tolerated and can help reduce anxiety and stress in some people.
  • B vitamins can help with stress; however, they may have side effects. Inositol supplements (B8) are generally safe and can be helpful for anxiety and stress.
  • Vitamin C reduces feelings of stress.
  • Suboptimal levels of Vitamin D are linked to anxiety in some patients with fibromyalgia.
  • Calcium with magnesium and zinc can reduce anxiety.
  • Low levels of magnesium are linked to anxiety. Watch for diarrhea when supplementing magnesium.
  • Iodine deficiencies can result in hypothyroidism, which can be associated with anxiety.
  • Iron deficiencies can result in increased feelings of stress and fatigue.
  • Selenium deficiencies can result in abnormal thyroid function, and correcting deficiencies can improve anxiety in some people.
  • Omega-3 fatty acids can be helpful for patients with anxiety.
  • Gamma-aminobutyric acid (GABA), an amino acid, has unclear evidence on use in anxiety.
  • D-cycloserine (DCS), an amino acid, has unclear evidence on use in anxiety.
  • Theanine is an amino acid in green tea. Decaffeinated green tea could be helpful in reducing stress and promoting calm sensations.
  • Tryptophan and 5-hydroxytryptophan (5-HTP) are amino acids thought to help with panic and anxiety, but they can interfere with SSRIs and cause a variety of side effects.
  • Deficiencies in lysine, an amino acid, are associated with increased anxiety.
  • Arginine, an amino acid, can reduce anxiety and stress; however, it has potential for significant side effects.
See Drugs, Herbs, & Supplements (MedlinePlus) for more information. Some families may be interested in Apps to Help Kids and Teens with Anxiety.

Services & Referrals

General Counseling Services (see RI providers [30])
I Refer for additional testing to elucidate a diagnosis or tease out comorbid learning or cognitive disorders. Some psychologists work as therapists. School psychologists may assist in school support plans and accommodations for children whose anxiety negatively impacts their ability to effectively participate in the educational process. Refer if therapy is needed or if help navigating social systems and coordinating services would benefit the family.

All therapists/counselors likely have expertise/experience in managing anxiety disorders.

Psychiatry/Medication Management (see RI providers [80])
Refer for assistance in diagnosis and treatment of complicated (multiple comorbidities), refractory (generally defined as more than 2 ineffective adequate antidepressant medication trials or worsening of symptoms despite treatment), or severe cases. May provide brief consultation or routine follow-up, depending on the needs and preferences of the primary care clinician and family. The patient may see a nurse practitioner or physician assistant who is supervised by a physician. Frequency of visits is usually a few times per year.

Therapy/Counseling > … (see RI providers [143])
Social workers can help families identify family issues and improve communication skills and relationships. Social workers can help with crisis intervention and utilizing resources.

ICD-10 and DSM-5 Coding

F06.4, Anxiety disorder due to a known physiologic condition

F40.0, Agoraphobia

F40.1, Social phobia

F40.2xx, Specific phobias

F41.x, Panic disorder

F41.1, Generalized anxiety disorder

F41.9, Unspecified anxiety disorder

F42.x, Obsessive-compulsive disorder

F43.1x, Post-traumatic stress disorder

F93.0, Separation anxiety disorder of childhood

F94.0, Selective mutism

The presence of “x” indicates that further modifiers are required. For example, F42 is not a billable code; it has 5 additional modifying codes:

  • F42.2, Mixed obsessional thoughts and acts
  • F42.3, Hoarding disorder
  • F42.4, Excoriation (skin-picking) disorder
  • F42.8, Other obsessive-compulsive disorder
  • F42.9, Obsessive-compulsive disorder, unspecified

Also, see ICD-10 Coding for Mental & Behavioral Disorders Due to Psychoactive Substance Use (icd10data.com) for a detailed list of codes by substance and ICD-10 Coding for Phobic Anxiety Disorders (icd10data.com) for additional codes based on specific phobic stimuli.

DSM-5 Coding

The DSM-5 billable code for GAD is 300.02 (F41. 1).

Coding for Developmental & Mental Health Screening has further coding options.

Resources

Information & Support

For Professionals

Mental Health, Naturally
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.

Dietary Supplements (NIH)
Fact sheets for health professional and consumer that give a current overview of dietary supplements: National Institutes of Health.

First-Line Management of Pediatric Mental Health Problems (AAP)
Free webinar about the primary care management of mental health problems in the pediatric population (49:13 minutes- July 2011) ; by Jane Meschan Foy, MD, FAAP / American Academy of Pediatrics.

Tools

Pediatric Anxiety Flowchart (UACAP) (PDF Document 402 KB)
One-page algorithm for assessment and treatment of pediatric anxiety; created by Dr. Travis Mickelson/Utah Academy of Child & Adolescent Psychiatry (based on DSM-IV).

Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh)
A child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders, including general anxiety disorder, separation anxiety disorder, panic disorder, and social and school phobia. Free to download, or link to on-line Excel worksheet that calculates the score. Translations in Arabic, Chinese, French, German, Italian, Spanish, Tamil (Sri Lanka), and Thai.

Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) (PDF Document 442 KB)
Assesses presence and severity of obsessions and compulsions for both diagnosis of OCD and monitoring treatment response in children ages 6-17. Completed by a clinician or trained interviewer. Instructions and tips for how to ask questions and grade responses are included in the screening materials link.

Spence Children’s Anxiety Scale (SCAS) (PDF Document 115 KB)
Child (45-question) and parent (39-question) forms for school-aged children. Scores for overall anxiety disorder plus scores for separation anxiety, social phobia, obsessive-compulsive problems, panic/agoraphobia, generalized anxiety/overanxious symptoms, and fears of physical injury. Based on DSM-IV, with free access to downloadable PDFs and online scoring versions. Available in many languages.

Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) (PDF Document 47 KB)
Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.

Online Assessment Measures (APA)
Assessments are administered at the initial patient interview and to monitor treatment progress. Instructions, scoring information, and interpretation guidelines are included - no fee required; American Psychiatric Association.

Youth Outcome Questionnaire (OQ Measures)
A 64-item report completed by the parent/guardian. It is a measure of treatment progress for children and adolescents (ages 4-17) receiving mental health intervention. It is designed to track the patient’s sense of well-being over time in order to gauge response to mental health interventions; available for purchase.

DSM-5 Handbook of Differential Diagnosis (APA)
A workbook with differential diagnosis pathways and decision trees that are practical for clinical use; for purchase from the American Psychiatric Association.

Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes a variety of resources, checklists, intake and assessment forms, and patient education materials.

Patient Health Questionnaire (PHQ) Screeners
Free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.

Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit (AAP)
Toolkit for pediatric care providers delivering comprehensive mental health care. Now in a new online format; available for a fee from American Academy of Pediatrics.

Services for Patients & Families in Rhode Island (RI)

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)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Helpful Articles

PubMed search for anxiety disorders in children, last 2 years

Hoge E, Bickham D, Cantor J.
Digital Media, Anxiety, and Depression in Children.
Pediatrics. 2017;140(Suppl 2):S76-S80. PubMed abstract

Strawn JR, Dobson ET, Giles LL.
Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety.
Curr Probl Pediatr Adolesc Health Care. 2017;47(1):3-14. PubMed abstract / Full Text

Santilhano M.
Online intervention to reduce pediatric anxiety: An evidence-based review.
J Child Adolesc Psychiatr Nurs. 2019;32(4):197-209. PubMed abstract

Doyle MM.
Anxiety Disorders in Children.
Pediatr Rev. 2022;43(11):618-630. PubMed abstract

Authors & Reviewers

Initial publication: September 2013; last update/revision: March 2024
Current Authors and Reviewers:
Author: Matthew Koster, DO, MBA
Authoring history
2020: update: Jennifer Goldman, MD, MRP, FAAPA; Mary Steinmann, MD, FAAP, FAPAR
2016: first version: Jennifer Goldman, MD, MRP, FAAPA; Mary Steinmann, MD, FAAP, FAPAR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Academy of Child & Adolescent Psychiatry.
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American Psychiatric Association.
Diagnostic And Statistical Manual Of Mental Disorders, Text Revision (DSM-5-TR).
Fifth Edition ed. American Psychiatric Association Publishing; 2022. https://doi.org/10.1176/appi.books.9780890425787

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...

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

Beesdo K, Knappe S, Pine DS.
Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V.
Psychiatr Clin North Am. 2009;32(3):483-524. PubMed abstract / Full Text

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

Cohen JA, Bukstein O, Walter H, Benson SR, Chrisman A, Farchione TR, Hamilton J, Keable H, Kinlan J, Schoettle U, Siegel M, Stock S, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.
J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-30. 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

Doyle MM.
Anxiety Disorders in Children.
Pediatr Rev. 2022;43(11):618-630. PubMed abstract

Dulcan MK, Ballard R.
Medication Information for Parents and Teachers: Propranolol—Inderal.
American Psychiatric Publishing, Inc.; (2015) http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615370283.m.... Accessed on 5/5/2020.
From Helping Parents and Teachers Understand Medications for Behavioral and Emotional Problems: A Resource Book of Medication Information Handouts, Fourth Edition. Washington, DC, American Psychiatric Publishing, 2015-subscription required.

Durham RC, Higgins C, Chambers JA, Swan JS, Dow MG.
Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups.
J Affect Disord. 2012;136(3):875-81. PubMed abstract

Earle JF.
An Introduction to the Psychopharmacology of Children and Adolescents With Autism Spectrum Disorder.
J Child Adolesc Psychiatr Nurs. 2016;29(2):62-71. PubMed abstract

Fourneret P, Desombre H, de Villard R, Revol O.
[Interest of propranolol in the treatment of school refusal anxiety: about three clinical observations].
Encephale. 2001;27(6):578-84. PubMed abstract

Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, Yager J.
The initial field trials of DSM-5: new blooms and old thorns.
Am J Psychiatry. 2013;170(1):1-5. PubMed abstract / Full Text

Geller D, March J.
Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.
J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113. PubMed abstract / Full Text

Ghandour RM, Sherman LJ, Vladutiu CJ, Ali MM, Lynch SE, Bitsko RH, Blumberg SJ.
Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.
J Pediatr. 2019;206:256-267.e3. PubMed abstract / Full Text
This article reviews data from the 2016 National Survey of Children's Health (NSCH) to report nationally representative prevalence estimates of each condition among children aged 3-17 years and receipt of treatment by a mental health professional.

Grist R, Porter J, Stallard P.
Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review.
J Med Internet Res. 2017;19(5):e176. PubMed abstract / Full Text

Hoge E, Bickham D, Cantor J.
Digital Media, Anxiety, and Depression in Children.
Pediatrics. 2017;140(Suppl 2):S76-S80. PubMed abstract

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

Kathi J. Kemper.
Mental Health, Naturally: The Family Guide to Holistic Care for a Healthy Mind and Body.
1st ed. American Academy of Pediatrics; 2010. 1581103107 http://shop.aap.org/Mental-Health-Naturally-The-Family-Guide-to-Holist...

Kung S, Espinel Z, Lapid MI.
Treatment of nightmares with prazosin: a systematic review.
Mayo Clin Proc. 2012;87(9):890-900. PubMed abstract / Full Text

León-Barriera R, Ortegon RS, Chaplin MM, Modesto-Lowe V.
Treating ADHD and Comorbid Anxiety in Children: A Guide for Clinical Practice.
Clin Pediatr (Phila). 2023;62(1):39-46. PubMed abstract

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

McClafferty H, Sibinga E, Bailey M, Culbert T, Weydert J, Brown M.
Mind-Body Therapies in Children and Youth.
Pediatrics. 2016;138(3). PubMed abstract
This AAP Section on Integrative Medicine clinical report outlines popular mind-body therapies for children and youth and examines the best-available evidence for a variety of mind-body therapies and practices, including biofeedback, clinical hypnosis, guided imagery, meditation, and yoga. The report is intended to help health care professionals guide their patients to nonpharmacologic approaches to improve concentration, help decrease pain, control discomfort, or ease anxiety; American Academy of Pediatrics.

Merikangas KR, Avenevoli S, Dierker L, Grillon C.
Vulnerability factors among children at risk for anxiety disorders.
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