Anxiety Disorders in Children

Overview & Epidemiology - Tiny Worries, Big Impact

• Most common group of psychiatric disorders in childhood & adolescence.
• Characterized by excessive, persistent fear/worry causing significant distress or functional impairment.
• Prevalence: 5-18% worldwide; Indian studies report comparable figures.
• Peak onset: Early to middle childhood (often 6-11 years).
• Gender: Girls more commonly affected than boys (ratio ~2:1).
• Etiology: Multifactorial - genetics, neurobiology, temperament (e.g., behavioral inhibition), environmental stressors.

⭐ Separation Anxiety Disorder is the most common specific anxiety disorder in children under 12 years.

Types of Disorders - Meet the Anxiety Crew

• Separation Anxiety Disorder (SAD): Age-inappropriate, excessive fear/anxiety concerning separation from attachment figures. Often school refusal, somatic complaints. Duration: ≥ 4 weeks (children/adolescents).
• Specific Phobia: Marked fear/anxiety about a specific object or situation (e.g., animals, injections, heights). Actively avoided or endured with intense fear. Duration: ≥ 6 months.
• Social Anxiety Disorder (Social Phobia): Intense fear/anxiety of social situations where individual may be scrutinized. In children, fear must occur in peer settings, not just with adults. Duration: ≥ 6 months.
• Generalized Anxiety Disorder (GAD): Excessive anxiety/worry about multiple events/activities, more days than not. Difficult to control worry. Duration: ≥ 6 months.
• Panic Disorder: Recurrent unexpected panic attacks (abrupt surge of intense fear). Followed by ≥ 1 month of persistent concern about additional attacks or maladaptive behavior change.
• Selective Mutism: Consistent failure to speak in specific social situations (e.g., school) despite speaking in other situations. Duration: ≥ 1 month (not limited to first month of school).

  ⭐ Selective Mutism often co-occurs with Social Anxiety Disorder. oka

Diagnosis & Features - Anxious Clues & Dx

• Common Anxious Clues:
  • Somatic: Frequent headaches, stomachaches, nausea, palpitations.
  • Behavioral: Irritability, excessive crying, clinginess, avoidance (school, social situations), sleep problems, constant reassurance seeking.
  • Cognitive: Persistent worries, specific phobias, difficulty concentrating, thoughts of harm/danger.
• Diagnostic Evaluation:
  • Comprehensive clinical interview (child, parents, teachers).
  • Use of standardized rating scales (e.g., SCARED, MASC).
  • Application of DSM-5 criteria (note specific duration criteria, e.g., ≥4 weeks for Separation Anxiety Disorder, ≥6 months for GAD).
  • Exclusion of medical conditions (e.g., hyperthyroidism) and other psychiatric disorders.

⭐ School refusal often signals underlying anxiety (e.g., separation anxiety, social anxiety, GAD) and requires thorough assessment, as it's a symptom, not a standalone diagnosis.

Management - Calming the Storm

• Psychotherapy: Cornerstone; first-line for mild-moderate anxiety.
  • Cognitive Behavioral Therapy (CBT):
    • Core: Psychoeducation, relaxation, cognitive restructuring, exposure.
  • Family therapy & parental training vital.
• Pharmacotherapy: For moderate-severe anxiety or poor CBT response.
  • SSRIs: First-line drugs.
    • Fluoxetine (≥8y): Start 5-10mg, target 10-20mg (max 60mg).
    • Sertraline (≥6y OCD): Start 12.5-25mg, target 50-200mg.
    • Escitalopram (≥12y MDD, off-label).
  • ⚠️ Monitor: GI upset, sleep issues, activation, suicidality (BBW).
• Combination (CBT + SSRI): Best for severe cases.

⭐ The CAMS trial showed combination (CBT + sertraline) superior to monotherapy or placebo for moderate-severe childhood anxiety.

High‑Yield Points - ⚡ Biggest Takeaways

• Separation Anxiety Disorder (SAD): Most common in young children; excessive fear of separation.
• Selective Mutism: Consistent failure to speak in specific social situations despite speaking elsewhere.
• Social Anxiety Disorder: Marked fear of social situations/scrutiny; can cause school refusal.
• First-line treatment: Cognitive Behavioral Therapy (CBT), including exposure and psychoeducation.
• Pharmacotherapy: SSRIs (fluoxetine, sertraline) if CBT fails or for severe cases.
• Comorbidities: Often coexist with other anxiety, depression, or ADHD.
• Parental involvement: Crucial for treatment success; consider family therapy.