When Fear Becomes a Problem: Anxiety Disorders in Children and Adolescents

Every child gets scared or anxious sometimes. It’s normal for kids to be afraid of the dark, shy around new people, or nervous before a big test. It becomes an issue when fear and anxiety cause distress or interfere with everyday activities. Anxiety disorders in childhood and adolescence often cause adverse outcomes socially, academically, and personally. If left untreated by a professional, stress can lead to depression and an increased mortality rate later in life.

What are Pediatric Anxiety Disorders?

Fear and anxiety are normally healthy emotions. If potential harm is nearby, they prime the mind and body to deal with danger. However, these feelings become disordered when the intensity, duration, or frequency is disproportionate to the threat. Childhood anxiety disorders are conditions where dysfunctional fear or anxiety cause extreme distress and hinder a child’s or teen’s functioning.

Five Common Types of Anxiety Disorders in Children and Teens

Generalized Anxiety Disorder:  It’s normal for kids to be anxious about things sometimes. However, a persistent state of heightened apprehension is unhealthy. Children with generalized anxiety disorder worry excessively about many different things such as social acceptance, school performance, or future events.

Separation Anxiety Disorder: Most toddlers get upset when separated from their parents in unfamiliar surroundings. Separation anxiety is no longer age-appropriate when it persists beyond two years of age and causes significant distress.

Social Anxiety Disorder: Shy children may initially withdraw in new situations. Social anxiety, on the other hand, is constantly present even in familiar settings. This persistent fear of social scrutiny causes distress and inhibits children from participating in social or academic activities.

Panic Disorder: A sudden surge of fear causes a child to scream, sob, and hyperventilate. Panic attacks can come on spontaneously. Panic disorder happens when these attacks occur at least once a week. This is more commonly seen in adolescents than in younger children. 

Specific Phobias: Fear of the dark, monsters, and bugs are common in young children. The problem arises when unreasonably intense terror interferes with functioning. These phobias provoke anxiety and avoidance of the feared stimulus.

Prevalence Among Children and Adolescents

Anxiety disorders are the most common behavioral health conditions in childhood and adolescence, affecting approximately 7 percent of those ages 3 to 17. Certain types of anxiety disorders are found more often in young children than in teens. For example, separation anxiety rarely extends beyond puberty. In contrast, social and general anxiety are more common during the teenage years. Specific phobias tend to emerge early—often between the ages of 5 and 8—and can continue into adulthood.

Causes of Anxiety Disorder

A combination of genetic and environmental factors play a role in the development of childhood anxiety disorders. For example, children who have dysfunction of the limbic system are predisposed to anxiety disorders. The limbic cortex begins development early in embryonic stage, and dysfunction is typically genetic in nature. However, head trauma can also cause damage to this part of the brain.

Stress levels at home also influence pediatric anxiety disorder. Children have difficulty controlling their emotions to begin with, and being around an anxious parent only serves to heighten their fears. Therefore, simultaneously treating parental and pediatric anxiety is helpful in many cases. 

Signs and Symptoms 

Anxiety is an internal emotion. The fear that dominates a child’s thoughts may go unnoticed by parents and caregivers. It’s especially easy to overlook worries that only manifest in specific situations. Pinning down anxiety disorders is difficult due to the complex range of signs and symptoms, such as:

  • Sleeping problems
  • Trouble in school
  • Stomachaches 
  • Headaches 
  • Fatigue
  • Nail-biting 
  • Emotional outbursts
  • Difficulty sitting still
  • Clinging to caregivers 
  • Avoiding certain situations

Screening and Diagnosis 

Children often don’t disclose their anxious thoughts and feelings to caregivers. As a result, pediatric anxiety disorders often go undiagnosed and untreated. Screening tools and questionnaires can help pediatricians flag signs and symptoms of anxiety disorders. For example, the Screen for Anxiety Related Emotional Disorders (SCARED) is a questionnaire that focuses on four domains: panic, separation, school phobia, and generalized anxiety. 

For a more comprehensive psychiatric screening, the Diagnostic Interview Schedule for Children (DISC) assesses 34 common psychiatric diagnoses. It has six modules, each with all the information needed to identify and diagnose disorders. The anxiety module of the DISC screens for all kinds of anxiety disorders, including rarer ones such as selective mutism and agoraphobia. Routine screening for anxiety symptoms should include information from multiple informants such as the child, parents, and teachers. 

Treating Children with Anxiety Disorder 

Most children and teens need professional care to manage their fear and anxiety, and integration is an essential aspect of pediatric behavioral health. It’s important for parents, teachers, caregivers, clinicians, and pediatricians to all work together on behalf of the child. Before and during treatment, this management team monitors symptoms and adjusts therapy as needed. The team develops a treatment plan based on symptoms, severity, and age. For mild cases, cognitive-behavioral therapy (CBT) may be all that the child needs. However, medication in combination with therapy is warranted in moderate to severe cases or for comorbid conditions. 

Child-focused Cognitive-Behavioral Therapy

Child-focused CBT is part of a whole-child approach to treatment. The patient learns adaptive strategies to help manage anxiety. This includes education, somatic management, cognitive restructuring, exposure therapy, and relapse prevention. 

  • Education: Educating children, parents, and caregivers is always an essential aspect of addressing a child’s needs.
  • Somatic Management: Children learn specific skills such as relaxation techniques, deep breathing, and self-monitoring.
  • Cognitive Restructuring: The therapist teaches a child techniques for modifying negative self-talk and challenging unreasonable dread.
  • Exposure Methods: Gradual imagery and in-situ exposure to the feared stimulus can desensitize the child.
  • Relapse Prevention: Regular follow-up sessions are an important aspect of maintaining the child’s well-being. 

Monitoring Outcomes and Adapting Treatment

There is no one-size-fits-all solution when it comes to pediatric anxiety disorders. Instead, multimodal and adaptable interventions provide the flexibility needed for children and families to receive comprehensive care. Child-forced CBT isn’t effective in all cases. Medications such as SSRIs can help anxious children who do not respond well to other types of therapy. 

Other forms of evidence-based therapy include psychodynamic psychotherapy and family therapy. Child and Adolescent Anxiety Psychodynamic Psychotherapy (CAPP) helps children 8 years and older understand and articulate their symptoms and underlying psychological conflicts. Moreover, family therapy is warranted when childhood anxiety is found in combination with parental stress. Electronic health records (EHRs) offer innovative ways to monitor treatment and collaborate with the management team. Easy-to-read dashboards help clinicians notice patterns and red flags.

Closing Thoughts

While fear and nervousness are normal emotions in many situations, anxiety disorders take apprehension and dread to unhealthy levels. When left untreated, anxiety disorders can lead to negative outcomes in childhood and later in life. By working together, clinicians, parents, and pediatricians can determine the best course of care for the individual child.

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