Anxiety in Children

Anxiety is a common emotion that everyone experiences from time to time, but many youth experience persistent fears and worries to the point that it impacts their day-to-day functioning. It is likely that pediatricians will encounter a sizable portion of patients who fit within this category and meet criteria for an anxiety disorder. These disorders are the most common mental health conditions among youth, with an estimated 31.9% of adolescents between the ages of 13 and 18 experiencing an anxiety disorder¹.

Even more concerning is the rate of increase in childhood anxiety disorders, which has doubled over the past 30 years². There are a variety of factors that have contributed to this increase, including mounting pressure to perform well in school, social media and school shootings — to name a few. Given these factors, it is important for primary care practitioners to screen and assess anxiety disorders because they are the health professionals most likely to encounter youth who are experiencing these problems.

Screening for anxiety in children

Anxiety symptoms can manifest in a variety of ways including thoughts, emotions, sensations and behaviors. The most common symptoms are recurring fears and worries about everyday life, increased irritability, avoidance of school or friends and trouble sleeping. They may also have chronic physical complaints, such as headaches, stomachaches and fatigue. Among anxiety disorders, youth are most likely to experience generalized anxiety disorder, panic disorder, separation anxiety disorder and phobic disorders.

At Children's Hospital Colorado, we recommend using a brief screener to assess the prominent symptoms that are present in these disorders. There are numerous non-proprietary childhood anxiety screening tools available that take about 5 to 10 minutes to administer and score. Examples of helpful screeners include:

• The Screen for Child Anxiety Related Disorders (SCARED): 41 questions assessing the most common anxiety disorders in youth; includes a version for parent and child (ages 8 to 18)
• The Spence Children’s Anxiety Scale: 45 questions assessing the most common anxiety disorders in youth; includes a version for parent and child (ages 6 to 18) and a preschool scale (ages 3 to 6) for parents to complete
• Generalized Anxiety Disorder-7 (GAD-7): 7 item self-report for youth (ages 13 to 17) that assesses diagnostic symptoms of generalized anxiety disorder (GAD)

Educating parents about anxiety in children

Given the pervasiveness of pediatric anxiety disorders in youth, it is important to provide education to parents regarding ways to address anxiety symptoms when they manifest in their children. Typically, most individuals respond to symptoms of anxiety through use of experiential avoidance. Experiential avoidance is characterized by attempts to avoid thoughts, feelings, sensations and experiences that trigger feelings of anxiety. For example, if a child is anxious about taking a test at school, the most common response will be to avoid attending school on the day of the exam. In the short term, experiential avoidance results in an immediate reduction in anxiety symptoms but actually strengthens the frequency and intensity of anxious symptoms over time.

Often, parents will respond to a child's anxiety symptoms by accommodating avoidance strategies. For example, they may allow a child to stay home from school when they complain of GI symptoms before a big test. It is important to help parents understand that the most effective way to help address anxiety is to have a child engage the experience they are seeking to avoid. Parents need to be prepared for this course of action to temporarily increase distress in their child (and likely within the parent as well). But ultimately it will reduce the likelihood that a child's symptoms from their pediatric anxiety disorder will impair them. Connecting families to empirically based treatments will help provide the support needed to effectively reduce the use of experiential avoidance to cope with symptoms.

Anxiety treatment for children

A large body of research has demonstrated that there are effective treatments for anxiety disorders in children and adolescents. These include a combination of cognitive behavioral therapy (CBT) and SSRI medications. CBT for a childhood anxiety disorder focuses on restructuring thoughts about fear and worries, teaching relaxation strategies, such as breathing and muscle relaxation, and increasing exposure to feared situations. Studies have found that CBT alone results in a positive response in a majority of children, and the addition of CBT and an SSRI increases rates of positive response to treatment³. In addition to these approaches, we recommend that families work on improving daily functional activities including increasing physical activity and improving sleep hygiene.

Resources for families

Below is a list of resources related to pediatric anxiety disorders that may be helpful for providers and families:

• American Academy of Child & Adolescent Psychiatry: Anxiety Disorders Resource Center
• American Psychology Association: Anxiety Resources
• American Academy of Pediatrics: Mental Health Initiatives
• Healthychildren.org: School Avoidance: Tips for Concerned Parents

Professional references

1. National Institute of Mental Health, Prevalence of Any Anxiety Disorder Among Adolescents
2. Nuffield Foundation, Increased Level of Teenage Anxiety and Depression as Teenage Experience Changes Over Time
3. Jane Garland E, Kutcher S, Virani A, Elbe D. Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice. J Can Acad Child Adolesc Psychiatry. 2016;25(1):4–10.