Anxiety Disorders in Children and Adolescents

Children and teens have anxiety in their lives, just as adults do, and they can suffer from anxiety disorders in much the same way. Stressful life events, such as starting school, moving, or the loss of a parent, can trigger the onset of an anxiety disorder, but a specific stressor need not be the precursor to the development of a disorder.

Research has shown that if left untreated, children with anxiety disorders are at higher risk to perform poorly in school, to have less developed social skills and to be more vulnerable to substance abuse.

While children can develop any of the recognized anxiety disorders, some are more common in childhood than others. Some disorders tend to be specific to age development. Separation Anxiety Disorder and Specific Phobias are more common in younger children, about ages 6-9 years old. Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) are more common in middle childhood and adolescence. Panic Disorder can occur in adolescence as well. As with adults, depression is very common in children, especially among teenagers.

Although children experience the symptoms of anxiety in much the same way as adults do, children display and react to those symptoms differently. This can lead to difficulties in diagnosis. It can also be difficult to determine whether a child's behavior is "just a phase," or whether it constitutes a disorder.

Topics for Understanding Anxiety Disorders in Kids:

• Social Anxiety Disorder
• School Refusal/Avoidance
• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobias
• Generalized Anxiety Disorder
• Panic Disorder
• Finding Help for Your Child
• Anxiety Medication and Kids

Social Anxiety Disorder (SAD)

Social anxiety disorder is characterized by an intense fear of social and performance situations. The most commonly feared situations include initiating conversations, unstructured peer activities, performing in front of others, speaking up in class, and inviting others to get together. Avoidance of these situations significantly interferes with the quality of youngsters' lives, often impairing their school performance and attendance, as well as their ability to socialize with peers and to develop and maintain relationships.

The onset of SAD peaks in adolescence when establishing and managing friendships independently is a crucial part of healthy development. If untreated, it can persist into adulthood and increase the risk for later depression or alcohol abuse.

Parents and teachers may not be aware of the warning signs of social anxiety, or may not consider extreme shyness as a problem warranting professional attention.

Some signs to recognize are:

• Hesitance, passivity and discomfort when in the spotlight
• Avoidance or refusal to initiate conversations, perform in front of others, invite friends to get together, call others on the telephone for homework or other information, or order food in restaurants
• Avoidance of eye contact and speaks very softly or mumbles
• Minimal interaction and conversation with peers
• Appearing isolated and on the fringes of the group
• Sitting alone in the library or cafeteria, or hanging back from the group at team meetings
• Overly concerned with negative evaluation, humiliation or embarrassment
• Difficulty with public speaking, reading aloud, or being called on in class

When faced with feared situations, the child can suffer anxiety symptoms, including:

• sweating
• racing heart
• stomach ache
• dizziness
• crying
• tantrums
• freezing
• avoidance or intense dread of feared situations

In addition, childhood SAD can show up in a number of other ways:

• School Refusal/Avoidance
• Separation Anxiety Disorder
• Selective Mutism

Tips to Help Your Socially Anxious Child or Student

For Parents:

• Expose your child to different social situations, e.g., play groups, birthday parties, after school activities, where the child will have more chances to interact with his/her peers.
• Don't speak for your child, but encourage him or her to speak up, e.g., when ordering food in a restaurant.
• Praise or offer rewards to your child for speaking up. For example, offer to take the child to the movies if he/she will ask for the tickets at the box office.
• Lead by example. Teach your child how to handle social situations by allowing him/her to see how you handle the situation.

For Teachers:

• Change your classroom procedures to get the child more involved.
• Explain to the student why you are doing this, that you want to help them feel more comfortable in class, and not trying to make them feel embarrassed.
• Remind them that speaking out in class will get easier with practice.
• Do not single the child out, but call on all students for answers.
• Incorporate public speaking into your curriculum, if possible. This will help all of your students develop confidence in speaking in front of others.

These tips were adapted from Triumph Over Shyness, by Murray B. Stein, M.D., and John R. Walker, Ph.D.

School Refusal/Avoidance

A child experiencing more than just "school jitters" usually refuses to go to school on a regular basis, or has problems staying in school once there. This should not be confused with truant children who avoid school because of antisocial behavior or delinquency.

School refusal is often a symptom of a deeper problem and if not treated can have a negative impact on socialization skills, self-confidence, coping skills and, of course, education. Anxiety-based school refusal affects 2-5% of school-age children. It is common at times of transition, for example, graduating from elementary school to middle school and from middle school to high school. Anxieties tend to differ among age groups, but the most common stressors are:

• separation anxiety
• concerns about academic performance
• anxieties about making friends
• fear of a teacher or bully.

The most common ages for school refusal are between five and six, and between ten and eleven. Children who suffer from school refusal tend to be average, or above average in intelligence.

Their stress may come out in the form of physical symptoms, such as:

• headaches
• stomachaches
• nausea
• diarrhea

In addition to physical symptoms, there can be behavioral symptoms, which can manifest as:

• tantrums
• inflexibility
• separation anxiety
• avoidance
• defiance

Older children not only experience the stress that goes along with transition from one school to the next, but there is added academic pressure in the higher grades as students begin to see their futures unfolding before them. These stresses may manifest themselves in an extreme preoccupation with appearance, sleeplessness, or rebellion. As with younger children, it is important to keep the child in school, although they may fight it. Missing school reinforces anxiety, rather than alleviating it.

Common School Fears:

• Being separated from caregivers;
• Riding on the bus;
• Eating in the cafeteria;
• Using the school bathroom;
• Being called on in class;
• Changing for gym;
• Interacting with other children or teachers;
• Being picked on by peers or older children.

Separation Anxiety Disorder

Many children experience separation anxiety between 18 months and three years of age, when it is normal for a child to feel some anxiety when a parent leaves the room or goes out of sight. Usually he/she can be distracted from these feelings. Crying when first being left at daycare or pre-school is also common, and the crying subsides when the child becomes engaged in his/her surroundings.

Usually four year olds are able to leave their parents. If not, the problem could be Separation Anxiety Disorder, which affects approximately 4% of children. With Separation Anxiety Disorder, a child experiences extreme anxiety when away from home or separated from parents or caregivers. In this case, the desire to be in contact with missed persons is excessive, extreme homesickness and feelings of misery at not being with loved ones are common. While separated, it is not uncommon for these children to have fears regarding the health and safety of their parents.

Children suffering from Separation Anxiety Disorder may:

• Try to avoid going places by themselves;
• Refuse to go to school or camp;
• Be reluctant or refuse to participate in sleepovers;
• Follow a parent around;
• Demand that someone stay with them at bedtime, or "appear" in their parent's bedroom during the night;
• Awake from nightmares about being separated from loved ones.

Onset of Separation Anxiety Disorder can occur any time before age 18, but it is most common in children between the ages of seven and nine.

Selective Mutism

Children who refuse to speak in situations where speech is expected or necessary, to the extent that their refusal interferes with school and making friends, may be suffering from Selective Mutism, thought to be a severe form of Social Anxiety Disorder.

Onset of Selective Mutism is usually before five years of age, but it often comes to a head when the child enters school. The average age of diagnosis is between 4-8 years old, but these children probably exhibited "extreme shyness" at a much earlier age. For Selective Mutism to be diagnosed, the behavior must persist for at least one month. These children can be very talkative, even boisterous when at home, or in a place where they feel comfortable.

Children suffering from Selective Mutism may:

• Stand motionless and expressionless, turn his/her head, chew or twirl hair, avoid eye contact or withdraw into a corner.
• Become anxious before entering an uncomfortable situation, common symptoms of anxiety before social events include: stomachaches, headaches, and other physical ailments.
• Children suffering from Selective Mutism will often display additional signs of severe anxiety: separation anxiety, frequent tantrums and crying, moodiness, inflexibility, sleep problems and extreme shyness.

These can show up as early as infancy.

Specific Phobias

A specific phobia is defined as the intense, irrational fear of a specific object, such as a dog, or a situation, such as flying. Fears of animals, situations and natural occurrences are common in childhood, and often go away. A phobia is diagnosed if the fear persists for at least 6 months and interferes with a child's daily routine. An example of this is a child who refuses to play outdoors for fear of encountering a dog. Common childhood phobias include:

• Animals
• Storms
• Heights
• Water
• Blood
• The Dark
• Medical procedures

Unlike adults with specific phobias, children do not usually recognize that their fear is irrational or out of proportion to the situation, and they may not articulate their fears. Children will avoid situations or things that they fear, or endure them with anxious feelings, which can manifest as:

• Crying
• Tantrums
• Freezing
• Clinging
• Avoidance
• Headache
• Stomachache

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder usually affects children between the ages of six and eleven. It is characterized by excessive worry and anxiety over a variety of things, including, but not limited to:

• Grades
• Performance in sports
• Punctuality
• Family issues
• Earthquakes
• Health

The affected child cannot control his/her worry and it interferes with normal activities. Physical symptoms of GAD include:

• Restlessness
• Fatigue/Inability to sleep
• Difficulty concentrating
• Irritability
• Muscle tension

Children with GAD tend to be very hard on themselves, striving for perfection, sometimes redoing tasks repeatedly. They may also seek constant approval or reassurance from others.

Panic Disorder

Panic Disorder is diagnosed when a child suffers at least two unexpected Panic Attacks, followed by at least 1 month of concern over having another attack, losing control, or "going crazy." The most common age of onset for Panic Disorder is the early to mid twenties. It is not common in young children, but can begin in adolescence.

A Panic Attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms:

• a feeling of imminent danger or doom;
• the need to escape;
• palpitations;
• sweating;
• trembling;
• shortness of breath or a smothering feeling;
• a feeling of choking;
• chest pain or discomfort;
• nausea or abdominal discomfort;
• dizziness or lightheadedness;
• a sense of things being unreal, depersonalization;
• a fear of losing control or "going crazy"
• a fear of dying;
• tingling sensations;
• chills or hot flushes.

Children, like adults, often become apprehensive when in situations or places where they have previously had attacks, and may begin to avoid these situations and places. Agoraphobia can develop when the child begins to avoid situations in which he/she has had a panic attack previously, or situations and places from which the child feels that he/she would not be able to escape if experiencing a Panic Attack.

Finding Help for Your Child

Taking your child to the doctor for a mental health problem is as important as visiting the doctor for an ear infection or broken arm. But knowing when and where to seek mental health care can be difficult. Here are some tips for parents to make the process easier.

When Is It Time To Seek Help?

Many physical and emotional signs suggest a possible mental health problem. Any problem that is personally bothersome warrants evaluation. Further investigation may be necessary when a child seems out of step with peers or exhibits changes or problems in any of the following areas:

• Eating/appetite
• Sleeping
• School work
• Activity level
• Mood
• Relationships with family or friends
• Aggressive behavior
• Return to behavior typical of a younger child
• Developmental milestones such as speech and language.

How Do I Find Treatment?

Parents should consider the following checklist of questions to ask and issues to consider when deciding on a professional and a type of treatment.

• Professional's credentials and training: Consider the training of the professional and inquire as to his/her experience or expertise with the problem. If the professional is licensed in your state, make sure the professional has the appropriate credentials.
• Experience: Select professionals with experience with children and expertise with the particular problem of concern.
• Involvement: What role will you, the parent, have in your child's treatment? Make sure you are comfortable and understand how parents are involved.
• Type and format of treatment: How often will your child need to see a professional? What is the length of treatment? Parents and children should understand the scope of the treatment, the procedures used and the frequency and duration of the sessions.
• Cost/insurance policy: Know your health insurance coverage for mental health. Ask about acceptance of insurance when you talk to professionals. It is the parents' responsibility to know their own financial resources and any insurance requirements and limitations.
• Location/ease of accessibility: Treatment must balance convenience with availability of the professional.

How Do You Choose the Right Professional?

It is important to feel comfortable with the treating professional. Having confidence in the person is essential for establishing a positive working relationship. However, if the parents or child feel uncomfortable after a few sessions, this should be discussed in order to assess the source of the problem. Is the difficulty due to embarrassment about discussing the problem? Is the child resistant due to being angry with the parents for suggesting treatment? Or is it incompatible styles between the professional and the client?

What Is the Parent's Role in Treatment?

The initial session or two is usually used to evaluate the problem. You may be asked to provide information about family medical history, home environment, the child's physical and emotional development, and friendships. You should expect to discuss the assessment and outline a plan of treatment.

Parents should be informed about the treatment plan. Elements should include:

• Their role in treatment;
• The preferred method of communication with the professional;
• A schedule for feedback and updates;
• Coordination with outside resources or professionals;
• Strategies for helping their child participate in treatment; and
• Alternative treatments, risks and goals.

(*NOTE: Using EEG Neurofeedback, Sensory Integration Training, Auditory Integration Training, Sound Therapy and Hypnotherapy treatment plans that are customized for each patient's individual needs, The Attention & Achievement Center has had tremendous success treating both children and adults with anxiety and panic disorders.)

Successful therapy requires an investment of time and energy. The therapist may act as a guide, instructor, and confidante. The parents and child must also participate and take responsibility for putting the learning into practice. It is important for everyone involved to monitor change and progress.

Anxiety Medication and Kids

The use of medication is just one of the many treatment options available to manage the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medication without knowing which ones are appropriate, how it will affect their child, and if and when it is safe to use.

To help address these concerns, ADAA has gotten some answers to these and other frequently asked questions about treating anxiety disorders in children with medication.

1. Which medications are typically used to treat anxiety disorders in children?

The selective serotonin reuptake inhibitors (SSRIs) are currently the medications of choice for the treatment of both childhood and adult anxiety disorders. This group of medications includes fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).

Tricyclic antidepressants (e.g. imipramine) and benzodiazepines (e.g. lorazepam) are less commonly used in the treatment of childhood anxiety disorders. Other medications have been used to treat anxiety disorders in adults but require further study in children and adolescents.

Approval by the Food and Drug Administration (FDA) of the use of SSRIs in youth with anxiety disorders is currently limited to the use of Prozac, Zoloft and Luvox for the treatment of pediatric Obsessive-Compulsive Disorder. However, SSRIs are commonly used in clinical practice to treat youth with anxiety disorders, based upon several studies that report improvement in symptoms and medication safety in children with anxiety and depressive disorders.

Clinical studies, in turn, provide the necessary information for the FDA to determine whether medications will be approved. Unfortunately, studies of the use of medications in children often lag behind studies of adults; more research is definitely needed in this area. Discuss with your physician the benefits and risks of the use of all medications, whether FDA approved or not.

2. Are SSRIs safe for my child?

There are now several studies reporting the safety of SSRIs in the acute treatment of children with anxiety and depressive disorders. Additional studies are needed to assess the efficacy and safety of SSRIs when these medications are used to treat youth for longer periods of time. Parents should discuss duration of medication treatment with their child's physician, including length of the initial treatment period.

Concerns of medication safety are understandable. Risks associated with medication use, however, must also be weighed with risks of not treating anxiety disorders. For example, children with anxiety disorders frequently experience (often silently and secretively) significant discomfort and distress associated with their anxiety. Symptoms may negatively impact important developmental experiences such as learning and socialization, with risk of both short-term and longer-term functional difficulties.

3. How long will my child need to take medicine?

Current recommendations suggest that initial treatment of childhood anxiety disorders with an SSRI should be continued for approximately one year. Medication treatment may be recommended beyond this period if symptoms persist or reoccur. Symptoms and treatment response should be reassessed at regular intervals. Starting a child on an SSRI does not mean that he/she will be on the medication for life.

4. What are the most common side-effects of SSRIs?

The SSRIs are generally tolerated very well, with minimal or no side-effects. The most commonly reported side-effects include headache, stomachache or nausea, sleep changes, and jitteriness or agitation. It is important for your doctor to determine if any of these physical symptoms are present before starting the medication.

Physical symptoms could be related to an underlying medical problem, or reflect symptoms of anxiety (e.g. headache or stomachache) that may actually improve with treatment of the anxiety disorder. Your child's physician should review symptoms of possible side-effects with you and your child prior to starting an SSRI, and at subsequent follow-up visits.

5. What do I do if my child develops side-effects?

Medication side-effects are often mild and transient, and frequently do not require medication discontinuation. Call your doctor with any questions or concerns regarding possible side-effects during the course of treatment. If side-effects are more distressing or enduring, the dose of the medication may need to be adjusted and/or the medication may need to be stopped. Some children have side-effects to one SSRI, but not to others, so that a trial of a different SSRI may be needed if side-effects develop to the initial medication.

6. How can I tell if the medication is working?

Treatment monitoring begins with a thorough assessment and understanding of your child's anxiety symptoms. There are different types of childhood anxiety disorders, and hence, different types of symptoms. For example, separation anxiety disorder symptoms include avoidance of separation from caregivers or home, e.g. school refusal, "shadowing" parents around the house, or avoiding social get-togethers such as peer birthday parties or overnight camps.

Generalized anxiety disorder, characterized by multiple areas of worry, is often accompanied by symptoms of tenseness, sleep difficulties and irritability. The child's treatment plan should include specific "target symptoms" that the child is experiencing; these target symptoms can then be followed for assessment of treatment response. Symptom rating scales may be used by your child's health care professional as an additional measure of treatment response.

Finally, other adults, such as parents or teachers, are also important sources of information about your child's symptoms.

7. How long will it take for the medication to work?

Initiation of treatment with an SSRI will not produce an immediate decrease in your child's symptoms of anxiety. Improvement in your child's symptoms may begin to occur after a week or more of treatment, although an initial treatment trial of four to six weeks is needed to assess clinical response. It is also very important that your child take the SSRI on a daily basis, at approximately the same time each day (i.e. not on an "as needed" basis), in order to achieve stable and effective medication levels.

8. Will my child become addicted to these medications? Will the medications change my child's personality?

There is no evidence that the SSRIs are addictive. If medications are discontinued abruptly, symptoms such as dizziness, nausea, headache, and behavioral changes may occur. Medication dosages should not be changed, and medications should not be discontinued unless directed by the child's physician.

Treatment with SSRIs should not change your child's personality. Conversely, anxiety disorders may cloud features of your child's personality due to the impact of the anxiety symptoms and associated distress. If prominent changes in your child's behavior and demeanor do occur, parents should check with their physician about possible medication-related side-effects.

9. What if my child refuses to take the medication?

Children should not be forced to take medications, nor should the medications be disguised or inaccurately described. It is important to try to find out why the child does not want to take the medicine. For example, does the child have difficulty swallowing pills? Does the child fear that something may happen to him/her if he/she takes the medicine? Is the child concerned of possible embarrassment if others learn that he/she is taking a medication for anxiety?

Educating and involving your child in the discussion of his/her anxiety disorder is very important. Discussion should include review of symptoms that cause difficulties. Treatments should also be discussed, at a developmentally appropriate level, emphasizing the goal of symptom improvement. If the child refuses to take a medication, an initial treatment course of psychosocial interventions such as cognitive behavioral therapy should be considered, with subsequent review of medication use if symptoms do not improve.

10. Can SSRIs be used with other medications, including over-the-counter medicines for common illnesses such as a cold or the flu?

Check with your physician before adding or changing any of your child's medications to avoid potential medication interactions.

11. Are there other treatments available if I don't want to put my child on medication?

Cognitive behavioral therapy (CBT) is the most widely studied and commonly used form of psychotherapy to treat childhood anxiety disorders. CBT incorporates a variety of approaches designed to change maladaptive thoughts/beliefs and behaviors associated with anxiety disorders. Other psychosocial interventions should also be considered for children with anxiety disorders including the possibility of school support, family therapy, and assessment of potential environmental stressors contributing to the child's difficulties.

The use of psychosocial interventions, including CBT, should be considered for all children with anxiety disorders, whether they are being treated with medications or not. Parents should actively discuss treatment options with their child's health care provider.

This information was taken from an interview with Marcia J. Slattery, M.D., M.H.S., a child and adolescent psychiatrist at the Mayo Clinic who specializes in the clinical care and research of children with anxiety disorders. The interview appears in the September/October 2003 issue of ADAA's newsletter, Reporter.

(*NOTE: Using EEG Neurofeedback, Sensory Integration Training, Auditory Integration Training, Sound Therapy and Hypnotherapy treatment plans that are customized for each patient's individual needs, The Attention & Achievement Center has had tremendous success treating both children and adults with anxiety and panic disorders.)

For additional information, call the
Attention & Achievement Center at 925-280-9100

Disclaimer: The information presented here is for educational purposes only. It is not intended to replace the expert and professional advice of your physician, psychologist, or therapist. Always seek help from qualified professionals in the field of your interest. Our treatments are considered complimentary or alternative to traditional pharmacology and are not licensed or endorsed by the State of California, nor are we licensed healing arts practitioners by the State.