Anxiety in children and adolescents

Overview - The Worry Bugs

• Normal developmental fears vs. pathological anxiety: excessive, persistent (≥6 months), and causing functional impairment.
• Often presents with somatic symptoms (stomachaches, headaches), irritability, and avoidance rather than verbalized worry.
• Key types: Separation Anxiety, Social Anxiety, and Generalized Anxiety Disorder (GAD).
• Characterized by catastrophic "what if" thoughts and constant reassurance seeking.

⭐ Separation anxiety is the most common anxiety disorder in children <12 years old, often manifesting as school refusal.

Anxiety Disorders - Name That Jitter

• Separation Anxiety Disorder

  • Core Fear: Separation from attachment figures.
  • Duration: ≥4 weeks in children/adolescents.
  • Presentation: Somatic symptoms (e.g., stomachaches) to avoid separation (e.g., school).

• Selective Mutism

  • Core Feature: Failure to speak in specific social situations (e.g., school) despite speaking elsewhere.
  • Duration: ≥1 month.

• Specific Phobia

  • Core Fear: A specific object or situation (e.g., needles, spiders, heights).
  • Duration: ≥6 months.

• Social Anxiety Disorder (Social Phobia)

  • Core Fear: Scrutiny or negative judgment in social/performance situations.
  • Note: In children, must occur in peer settings, not just with adults.
  • Duration: ≥6 months.

⭐ First-line treatment for pediatric anxiety disorders involves Cognitive Behavioral Therapy (CBT), often combined with SSRIs (e.g., fluoxetine, sertraline), especially for moderate-to-severe cases.

• General Management
  • Psychoeducation for child and parents is crucial.
  • CBT is the cornerstone of therapy.
  • SSRIs are first-line pharmacotherapy.

Diagnosis - Spotting the Signs

• Core Feature: Excessive, impairing worry. Duration is key: >6 months for GAD, but only >4 weeks for Separation & Social Anxiety.
• Presentation Varies by Age:
  • Younger Children: Somatic complaints (stomachaches, headaches), irritability, tantrums, school refusal.
  • Adolescents: More classic adult symptoms (restlessness, fatigue) plus social withdrawal, substance use.
• Screening Tools: Use validated scales like SCARED (Screen for Child Anxiety Related Disorders).
• Rule Out: Always exclude medical causes (e.g., hyperthyroidism) and substance use before diagnosing.

⭐ School refusal is a major red flag. While common in Separation Anxiety Disorder, it can also be the primary sign of Social Anxiety or a specific phobia related to school.

Treatment - Taming the Trembles

• Psychotherapy: The Foundation

  • Cognitive Behavioral Therapy (CBT) is the first-line and most effective treatment.
    • Involves psychoeducation, relaxation techniques, cognitive restructuring, and exposure-based strategies.
  • Parental involvement and family therapy are key to reinforcing skills at home.

• Pharmacotherapy: For Moderate-to-Severe Cases

  • SSRIs are the first-line medication, typically used with CBT.
    • Approved: Fluoxetine, Sertraline, Fluvoxamine.
    • ⚠️ FDA Black Box Warning: ↑ risk of suicidal ideation/behavior in individuals <25 years. Requires close monitoring.

⭐ The Child/Adolescent Anxiety Multimodal Study (CAMS) found that combination therapy (Sertraline + CBT) yielded the highest response rate (81%) for pediatric anxiety disorders.

High‑Yield Points - ⚡ Biggest Takeaways

• Separation anxiety disorder is the most common anxiety disorder in children < 12 years old.
• Selective mutism involves a consistent failure to speak in specific social situations and is often linked to social anxiety.
• First-line treatment for mild-to-moderate cases is Cognitive Behavioral Therapy (CBT).
• For moderate-to-severe anxiety, SSRIs (fluoxetine, sertraline) are the preferred first-line medication.
• School refusal is a common presentation for various childhood anxiety disorders, not a diagnosis itself.
• Distinguish from normal anxiety by assessing severity, duration (≥ 4 weeks for SAD), and functional impairment.