Assessment and Treatment of Childhood Anxiety

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)

Intervention for pediatric anxiety disorders

The first step in the assessment and treatment of anxiety is ruling out other mental disorders, environmental exposures and physical conditions that present with anxiety disorder-like symptoms. Next, specifying the type of anxiety disorder will direct treatment. Broadly speaking, most anxiety disorders are treated by a combination of family education, psychotherapy and medications.

Therapy for childhood anxiety

A common theme for all anxiety disorders is that they arise from a perceived threat — harm, peer rejection, separation, panic, imperfection or some amalgam of concerns. Cognitive behavioral therapy (CBT) for anxiety seeks to dissipate these concerns with two basic "active ingredients": cognitive restructuring and exposure. Cognitive restructuring helps children   Research has repeatedly shown that exposures are the key driver of anxiety reduction. The more exposures conducted, the greater the clinical improvement, and the faster exposures are introduced into therapy, the more rapid a patient's improvement. Despite these compelling findings, surveys of community mental health providers indicate that a small minority who treat anxiety among youth actually practice exposure therapy. 

Medications for childhood anxiety

Several medications can help children with moderate to severe anxiety. Evidence supports the use of selective serotonin reuptake inhibitors (SSRIs) based on their efficacy and relative safety. However, they are not risk-free and can cause anxiety-like symptoms themselves, so an experienced practitioner should evaluate and monitor the use of SSRIs in children in accordance with FDA guidelines.

Medications do not cure anxiety but often reduce it. The combination of medications and psychotherapy is most effective. In fact, some promising medications in development are designed to enhance psychotherapy.

With astute intervention, most children and teens with anxiety disorders can increase their coping skills and learn strategies for success at school, home and in all their pursuits. 

Resources for pediatric anxiety

Children's Colorado is one of the largest providers of mental health services for youth in the Rocky Mountain region. We recently launched a specialty clinic, the Colorado OCD and Anxiety Program (COAP), to serve youth with moderate to severe anxiety or obsessive-compulsive disorder. Providers who would like to refer families for evaluation and treatment can call 720-777-6200 or visit the website.

The Anxiety and Depression Association of America website provides a wealth of useful resources for learning about stress, anxiety, depression, and how to locate qualified therapists.

The Society of Clinical Child and Adolescent Psychology maintains a webpage providing information for families and clinicians about evidence-based interventions for child mental health problems, including anxiety disorders. 

The American Academy of Child & Adolescent Psychiatry provides resources for clinicians and families through its Anxiety Disorders Resource Center. Offering expert guidance on identifying, managing and treating anxiety disorders in children and adolescents.

The American Psychological Association (APA) has dedicated a section of its website to Anxiety Resources, which includes information on different types of anxiety disorders, research-based treatment options and tips for coping with stress and anxiety. The APA also provides resources for clinicians, including guidelines for evidence-based practice and continuing education opportunities.

Healthychildren.org, a group powered by pediatricians, offers a comprehensive section on emotional wellness. This resource provides articles on helping children handle stress, talking with them about disasters, ways to build resilience and more. 

Citations

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