Anxiety in Children & Adolescents
Anxiety: One of the Most Common Psychiatric Disorders in Youth
One of the most common psychiatric disorders in children and adolescents are anxiety disorders; however, they usually go undiagnosed and untreated. One anxiety disorder can often be comorbid with a second, as well as with other psychiatric disorders, including depression and attention-deficit/hyperactivity disorder (ADHD).1 Anxiety often presents before depression and the co-occurrence often increases with age, associated with greater impairment of the individual and even the abuse of alcohol and drugs during adolescence.1 Therefore, the identification and effective treatment of childhood anxiety will decrease the negative impact the disorder may have on the individual. Director of the Pediatric Stress and Anxiety Disorders Clinic and Associate Professor of Clinical Psychiatry at the University of Illinois at Chicago, Sucheta Connolly, M.D. and colleagues focus on the evidence-based treatments and interventions available for children and adolescents suffering from anxiety disorders in their article “Anxiety Disorders in Children and Adolescents: Early Identification and Evidence-Based Treatment.” They focus mainly on separation anxiety disorder (SAD), generalized anxiety disorder (GAD), specific phobia, panic disorder, and social phobia.
Diagnosing Anxiety in Youth
According to Connolly and colleagues, in the event that an anxiety disorder is suspected, during a psychiatric diagnostic evaluation, the clinician must distinguish between developmentally appropriate worries and fears stemming from anxiety disorders.1 The clinician should also assess current stressors or trauma to see if they have had an impact on the development or continuance of anxiety symptoms.1 Oftentimes, it is perfectly normal for an infant to fear loud noises, being dropped, or feel normal separation anxiety from their parents/guardians. Toddlers often fear imaginary creatures and the dark. School-aged children may experience fear regarding school performance, rejection by peers, and physical wellbeing. Adolescents worry about social competence and social evaluation. All of these fears are normal; however, when they become overly feared or obsessed over, an anxiety disorder may be present.1 The American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders recommends that there are routine screenings for anxiety in childhood, gathering information from various sources including the child, their parents, and their teachers. They state that children should also be assessed for other comorbid disorders and evaluated for functional impairment before treatment is begun.2 Self-reporting measures, such as the Multidimensional Anxiety Scale for Children (MASC) and Screen for Child Anxiety-Related Emotional Disorders (SCARED) can help clinicians screen for anxiety symptoms at baseline, in order to gauge response to treatment. Younger children often use visual rating tools, such as happy and sad faces.1
Treating Youth with Anxiety
Connolly and colleagues state that the treatment of children with anxiety disorders of mild severity should begin with psychotherapy,2 while children experiencing more severe anxiety or who have a comorbid disorder should begin treatment with a combination of psychotherapy and pharmacotherapy. The Child/Adolescent Anxiety Multimodal Study (CAMS) studied youths suffering from moderate to severe SAD, GAD, and social phobia. The study compared cognitive-behavioral therapy (CBT) with sertraline or a placebo, as well as all three with a combination of CBT and sertraline.6 Results stated that CBT showed a 60 percent improvement in subjects and sertraline showed a 55 percent improvement, while the placebo showed only a 24 percent improvement.6 However, the combination of CBT and sertraline showed an 80 percent improvement, results superior to any of the other modalities.6
CBT is an effective treatment, backed by empirical support from multiple studies of the treatment of childhood anxiety. Velting and colleagues describe several of the components of CBT for childhood anxiety disorders. They state that it includes somatic management skills training, which teaches the patient self-monitoring, muscle relaxation, relaxing imagery, and diaphragmatic breathing.9 The cognitive restructuring portion teaches the child to challenge their negative thoughts and expectations while learning positive self-talk to substitute.9 With practice problem solving, the patient will generate potential solutions for anticipated challenges and generate action plans ahead of time.9 Exposure methods expose the child to feared stimuli for gradual desensitization.9 Along with these components, parents are taught to give frequent and consistent positive feedback to their child when they put forth correct effort and achieve success.1 This will increase the child’s motivation to attempt the exposure that initially will cause anxiety.1
Children and adolescents who suffer from GAD benefit greatly from CBT, as it helps them target their uncontrollable worry and the physical signs of their anxiety. The relaxation techniques, such as diaphragmatic breathing and muscle relaxation, help with their physical symptoms, while the cognitive restructuring helps them identify and challenge their anxious thoughts and worries.9 For youths with specific phobias, the systematic desensitization, which involves relaxation, is extremely helpful. They develop a fear hierarchy use real-life desensitization programs, narrative stories, and live modeling to release themselves of the fear and anxiety associated with their specific fear. Children and adolescents with SAD benefit greatly from the cognitive restructuring portion of CBT, as well, especially when examining the anxious thoughts they have when they are away from their parents and replacing them with positive thoughts.1 However, as part of the therapy, parents and school staff must not allow the child to miss school, and clinicians should equip parents with behavioral strategies to deal with and stop tantrums and irritability, as well as physical resistance.1 For children with panic disorder, CBT will include relaxation techniques, cognitive coping strategies, and gradual exposure to agoraphobic situations. Children and adolescents with social phobia will focus on social skills training and increased social opportunities in CBT.1
Many trials have proven the effectiveness of SSRIs for the treatment of childhood anxiety, and they have become the first line of treatment for anxiety in the youth population. According to Connolly and colleagues, even though the FDA has warned against the use of antidepressants in youths younger than 18, the benefit-to-risk ratio is more favorable for anxiety than they are for depression.12 Still, clinicians should monitor for depression, agitation, and suicidal ideation when the medicine is begun and when there is a change in dosage.1 SSRIs are well-tolerated medicines, with the most common adverse effects being GI symptoms, headache, increased motor activity, and insomnia.1 These effects are usually mild and temporary; however, if they are bothersome, they will usually cease when the dosage is decreased.1
According to Connolly and colleagues, the identification and effective treatment of childhood anxiety disorders can decrease the negative impact these disorders can have on youths. Regular assessments for anxiety disorders and other co-occurring disorders can help to identify them, and self-assessments, information gathering, and further evaluation can determine severity and treatment route. For youths with mild anxiety, CBT is a very effective treatment; however, for children and adolescents who suffer from more severe anxiety, a combination of CBT and an SSRI is usually used. Both CBT and SSRIs are effective treatments for anxiety, and are even more so in combination.
 Connolly, S.D. and Nanayakkara, S.D. (2009, October 8). Anxiety Disorders in Children and Adolescents: Early Identification and Evidence-Based Treatment. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/anxiety/content/article/10168/1471541
 Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46:267-283.
 March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.
 Birmaher B, Axelson DA, Monk K, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:415-423.
 March JS, Ollendick TH. Integrated psychosocial and pharmacological treatment. In: Ollendick TH, March JS, eds. Phobic and Anxiety Disorders: A Clinicians Guide to Effective Psychosocial and Pharmacological Interventions. New York: Oxford University Press; 2004:141-174.
 Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359:2753-2766.
 Compton SN, March JS, Brent D, et al. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.
 Velting ON, Setzer NJ, Albano AM. Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents. Prof Psychol Res Pract. 2004;35:42-54.
 Grover RL, Hughes AA, Bergman RL, Kingery JN. Treatment modifications based on childhood anxiety diagnosis: demonstrating the flexibility in manualized treatment. J Cognitive Psychother. 2006;20:275-286.
 King NJ, Muris P, Ollendick TH. Childhood fears and phobias: assessment and treatment. Child Adolesc Mental Health. 2005;10:50-56.
 Barlow DH, Craske MG. Mastery of Your Anxiety and Panic: Therapist Guide for Anxiety, Panic, and Agoraphobia. 4th ed. New York: Oxford University Press; 2007:209.
 Seidel L, Walkup JT. Selective serotonin reup-take inhibitor use in the treatment of pediatric nonobsessive-compulsive disorder anxiety disorders. J Child Adolesc Psychopharmacol. 2006;16:171-179. Anxiety.