Anxiety disorders are one of the most common mental health conditions in children and adolescents. While everyone may have occasional moments of feeling anxious or worried, an anxiety disorder is a medical condition that causes people to feel persistently, uncontrollably worried over an extended period of time. The disorder may result in significant distress in a number of settings, such as school, peer relationships, and home life, and it may dramatically affect people's lives by limiting their ability to engage in a variety of activities.
Anxiety that occurs in multiple settings, involving excessive apprehension about a number of situations on most days is known as a generalized anxiety disorder. Generalized anxiety disorder (sometimes known as GAD) affects approximately three to four percent of children. Other anxiety disorders, which are triggered by more specific situations, include:
- social phobia or social anxiety - fear of meeting new people or of embarrassing oneself in social situations
- specific phobia - fear of a particular object (for example, spider) or situation (for example, airplane travel)
- separation anxiety disorder - fear of separating from home or primary caregiver
- panic disorder - unpredictable and repeated panic attacks unrelated to surrounding circumstances
- obsessive-compulsive disorder - uncontrollable, repetitive, thoughts and fears, often accompanied by repetitive behaviors intended to prevent the fears from being realized
- selective mutism - persistent failure to speak in specific social situations (despite the physical ability to speak in other situations), most likely due to severe social anxiety
The tendency to develop any anxiety disorder involves complex genetic and environmental factors, and it is possible for one person to have more than one anxiety disorder. top
What Does Generalized Anxiety Disorder Look Like in Children and Adolescents?
Children with generalized anxiety disorder are often preoccupied with
worries about their success in activities and their ability to obtain
the approval of others. These children may have persistent thoughts of
self-doubt that they are unable to control, and they constantly criticize
themselves. Children may be preoccupied with being on time to events
and insist on doing a task "perfectly." In contrast to the ordinary,
occasional worries or fears experienced in childhood, generalized anxiety
disorder persists for at least six months and affects children throughout
the day (at home, at school, and with friends).
Children may appear inflexible or excessively worried about conforming to rules, or they may not be able to enjoy hobbies or other recreational activities. Some children may appear shy when, in fact, they are preoccupied with significant worries. Even if children are aware that their worries are more intense than is warranted by a situation, they may not be able to stop the worry. A trained clinician (such as a child psychiatrist, child psychologist or pediatric neurologist) should integrate information from home, school, and the clinical visit to make a diagnosis. top
At home, children with generalized anxiety disorder may have a combination of the symptoms listed below.
- Excessive worry and anxiety about a variety of matters on most days for at least 6 months. Children may worry about school tasks, interactions with peers, being on time, and following rules. Worry about receiving approval is common. Children may worry about future activities, new experiences, or many other matters.
- Frequent self-doubt and self-critical comments
- Inability to stop the worry despite parental reassurance
- Physical problems, including headaches, stomach ache, fatigue, and muscle tensions
- Signs of persistent anxiety, including restlessness, feeling "on edge," difficulty concentrating or relaxing, or mind going blank
- Irritability, which often increases with increased worry
- Sleep problems, which may include waking up early, waking up feeling unrested, or trouble falling asleep or staying asleep
- Experimentation with alcohol or drugs as a way to reduce suffering. Drugs and alcohol can themselves produce or worsen anxiety.
- Depression or thoughts of not wanting to be alive in some situations if children believe there is no hope of reducing their symptoms top
At school, a child with generalized anxiety disorder may have a combination of the symptoms listed below.
- Excessive worry and anxiety about a variety of matters
- Repeated seeking of teacher approval
- An inability to explain the worries. Children may not understand why they are so anxious.
- Inability to stop the worry. Despite adult reassurance, the worries continue.
- Difficulty transitioning from home to school. Children may develop difficulty entering school in the morning if they associate more worries with school. This may lead to late arrival times, long and tearful morning drop-offs, or tearful episodes at school.
- Refusal or reluctance to attend school. Anxiety may lead a child to insist on staying at home.
- Avoidance of academic and peer activities
- Self-criticism and low self-esteem
- Difficulty concentrating due to persistent worry, which may affect a variety of school activities, from following directions and completing assignments to paying attention
- Other conditions, such as attention deficit hyperactivity disorder (ADHD), may also be present, compounding learning difficulties. Having one mental health condition does not "inoculate" the child from having other conditions as well.
- Other anxiety disorders, such as social phobia, separation anxiety, or panic disorder. Anxiety disorders may not be recognized both because children may try to hide symptoms and because their symptoms are experienced internally and may not be easily seen.
- Learning disorders may co-exist and should not be overlooked in this population. A child's difficulties in school should not be presumed to be due entirely to anxiety. If the child still has academic difficulty after symptoms are treated, an educational evaluation for a learning disorder should be considered. A child's repeated reluctance to attend school may be an indicator of an undiagnosed learning disability.
- Side effects from medications. Medications may have cognitive or behavioral effects or physically uncomfortable side effects that interfere with school performance. After a child begins receiving medical treatment for symptoms, any mood changes or new behaviors should be discussed with parents, as they can reflect medication side effects. top
At the Doctor's Office
A child's symptoms of generalized anxiety may be evident during an office visit when a child is reluctant to meet the clinician. This feature alone does not indicate a child has anxiety, since children routinely are nervous during office visits.
Clinicians may benefit from talking with parents, school staff, and other important caregivers to evaluate a child's functioning in each area to determine the underlying cause of the child's symptoms. Clinicians may encounter some of the following challenges in diagnosing and treating a child or adolescent with generalized anxiety.
- Symptoms vary over time and their appearance changes as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis.
- Other anxiety disorders may look like generalized anxiety disorder (see introductory section, "What Is Anxiety?")
- Symptoms of mood disorders, such as depression and bipolar disorder, and behavior disorders, such as attention deficit hyperactivity disorder, can resemble the symptoms of anxiety . Depression is often identified in these children.
- Certain medical conditions can cause anxiety . These conditions include hyperthyroidism, hyperparathyroidism, hypoglycemia, cardiac disorders, seizure disorders, gastrointestinal problems, and vestibular or inner-ear disorders. Relevant laboratory tests and physical examinations may be helpful when a child has anxiety.
- Caffeine and other substances, such as stimulants, can produce anxiety . Consequently, evaluation for caffeine use and other substance use, especially with adolescents, is important.
- Physical complaints such as stomach aches, headaches, and dizziness often occur in children with anxiety. The clinician must determine whether these complaints warrant further medical investigation.
- Children may have difficulty talking about their worries . Phrasing questions with particular sensitivity and compassion may allow a more complete picture of symptoms to emerge.
- Children may be unaware, or unwilling to admit , that their feelings or behavior may indicate symptoms of a disorder
- Families may need to be coached about what they can reasonably expect from their child. Children who suffer from any anxiety disorder will benefit if their family understands that therapy and medicines may reduce, but may not cure, symptoms. top
How is Generalized Anxiety Disorder Treated?
Generalized anxiety disorder is treatable through ongoing interventions provided by a child's medical practitioners, therapists, school staff, and family. These treatments include psychological interventions (counseling), biological interventions (medicines), and interventions at home and at school to reduce sources of stress for the child. Open, collaborative communication between a child's family, school, and treatment professionals optimizes the care and quality of life for the child with anxiety. top
Psychological Interventions (Counseling)
Counseling can help children with anxiety, and everyone around them, to understand that their symptoms are caused by a disorder with complex genetic and environmental origins--not by flawed attitude or personality. Counseling also can reduce the impact of symptoms on daily life. Relaxation training can teach the child how to reduce both the worries and the accompanying physical symptoms. A variety of psychological interventions can be helpful, and parents should discuss their child's particular needs with their clinician to determine which psychological treatments could be most beneficial for their child.
- Individual psychotherapy is generally recommended as the first line of treatment for children and adolescents with generalized anxiety disorder. Children with anxiety may carry a sense of failure, as if the disorder was their fault. Individual psychotherapy can help reduce symptoms, and can help young people to become aware of and address their feelings of failure and self-blame.
- Cognitive Behavior Therapy (CBT) can teach young people new skills to reduce anxiety. In CBT, a child or adolescent is helped to become aware of and to describe anxiety-laden thought patterns. A trained clinician guides the child to think of new, more positive patterns of thinking. The young person is then given a chance to practice using these new thought patterns outside the clinical visit, and to discuss his or her experiences with the clinician afterwards. These methods are based upon well-researched practices that have helped many children and adolescents.
- Parent guidance sessions can help parents to manage their child's illness, identify effective parenting skills, learn how to function as a family despite the illness, and to address complex feelings that can arise when raising a child with a psychiatric disorder. Family therapy may be beneficial when issues are affecting the family as a whole.
- Group psychotherapy can be valuable to a child by providing a safe place to talk with other children who face adversity or allowing a child to practice social skills or symptom-combating skills in a carefully structured setting.
- School-based counseling can be effective in helping a child with anxiety navigate the social, behavioral, and academic demands of the school setting. top
Biological Interventions (Medicines)
While psychotherapy may be sufficient to treat some children with anxiety, other children's symptoms do not improve significantly with psychotherapy alone. These children may benefit from medications.
The U.S. Food and Drug Administration (FDA) has not approved specific medications for the treatment of generalized anxiety disorder in children and adolescents. However, medications approved by the FDA for other uses and age groups are prescribed for young people with generalized anxiety disorder. The FDA allows doctors to use their best judgment to prescribe medication for conditions for which the medication has not specifically been approved.
The antidepressants Celexa, Lexapro, Luvox, Paxil, Prozac (fluoxetine), and Zoloft are commonly prescribed to treat the symptoms of anxiety. These medicines belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI's.
In most cases these medicines begin to be effective in reducing symptoms after the child or adolescent has taken them for at least 2-4 weeks. Fully 12 weeks may be required in order to determine whether the medication is going to be effective for a particular individual. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.
There is no "best" medicine to treat generalized anxiety disorder, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child's life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.
The following cautions should be observed when any child or adolescent is treated with antidepressants.
- Benefits and risks should be evaluated . Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov . Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.
- Careful monitoring is recommended for any child receiving medication. Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant. Frequent follow-up (weekly for the first month) is now advocated by the FDA for children starting an antidepressant.
- Some children who have generalized anxiety disorder may also have bipolar disorder. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms . While antidepressants do not "cause" bipolar disorder, they can unmask or worsen manic symptoms.
Helpful information about specific medications can be found at www.medlineplus.gov (click on "Drug Information") and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD. top
Interventions at Home
At home, as well as at school, providing a sympathetic and tolerant environment and making some adaptations may be helpful to aid a child or adolescent with anxiety.
- Understand the illness . Understanding the nature of anxiety and how it is experienced by the child will help parents sympathize with a child's struggles.
- Listen to the child's feelings . Isolation can foster low self-esteem and depression in children struggling with anxiety. The simple experience of being listened to empathically, without receiving advice, may have a powerful and helpful effect.
- Keep calm when a child becomes anxious about an event or matter . If a child sees a parent is able to remain calm, the child can model the parent's attitude.
- Reassure the child and gently note that he or she survived prior situations that caused anxiety.
- Teach relaxation techniques , including deep breathing, counting to 10, or visualizing a soothing place. Teaching children how to relax can empower them to develop mastery over symptoms and improve a sense of control over their body.
- Plan for transitions . Getting to school in the morning or preparing for bed in the evening may be complicated by fears and anxieties. Anticipating and planning for these transition times may be helpful for family members.
- Support the child's quick return to school , in the case of school refusal. The best way to reduce anxiety about school is to address specific causes of anxiety and help the child return to school as quickly as possible. A shorter school day may help until symptoms improve. Children's symptoms are more likely to decrease when they discover that they can survive the anxiety. Long absences are likely to cause higher levels of anxiety upon returning.
- Encourage the child's participation in activities that may provide a reprieve from worries
- Praise the child's efforts to address symptoms. Young people often feel that they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised.
- Encourage the child to help develop interventions . Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve. top
Interventions at School
There are many ways that schools can help a child with generalized anxiety disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following:
- Establish check-ins on arrival to facilitate transition into school
- Accommodate late arrival due to difficulty with transitions
- Because transitions may be particularly difficult for these children, allow extra time for moving to another activity or location . When a child with anxiety refuses to follow directions, for example, the reason may be symptoms of anxiety rather than intentional oppositionality.
- If the child is avoiding school , determine the cause of the child's reluctance and address it, initiate a plan to for him or her to return to school as quickly as possible. It may help ease anxiety if the child attends for a shorter school day temporarily.
- Identify a "safe" place where the child may go to reduce anxiety during stressful periods. Developing guidelines for appropriate use of the safe place will help both the student and staff.
- Develop relaxation techniques to help reduce anxiety at school. Employing the techniques developed at home can be useful.
- Provide alternative activities to distract the child from physical symptoms . Calming activities may be helpful.
- Encourage small group interactions to develop increased areas of competency
- Provide assistance with peer interactions . An adult's help may be very beneficial for both the child and his or her peers.
- Encourage the child to help develop interventions . Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
- Reward a child's efforts . Every good effort deserves to be praised.
- Please click on School-Based Interventions for a more complete list of school accommodations for children with anxiety.
Flexibility and a supportive environment are essential for a student with generalized anxiety disorder to achieve success in school. School faculty and parents together may be able to identify patterns of difficulty and develop remedies to reduce a child's challenges at these times. top
Many online resources and books are available to help parents, clinicians, and educators learn more about children and adolescents with generalized anxiety disorder. Click here for a wide selection of resources. top
Information provided above on generalized anxiety disorder draws from sources including:
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders , 4th Edition. Washington, DC: American Psychiatric Association, 1994
Bostic, JQ and Bagnell, A. "School Consultation." In Comprehensive Textbook of Psychiatry, 8th Edition . Kaplan, BJ and Sadock, VA. Philadelphia: Lippincott Williams and Wilkins, 2004
Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition . Washington, DC: American Psychiatric Association, 1999 top