Anxiety in Children and Adolescents

Up to one in three children and adolescents experience clinically significant anxiety, and it is often under-recognized and under-treated. It is particularly important for primary care providers to be aware of the symptoms of anxiety in pediatric patients, because patients typically present first in this setting. Often the presenting complaint is a physical symptom, rather than “anxiety”.

First, it is important to determine what makes anxiety clinically significant. Anxiety is an expected, normal, transient response to stress and can be helpful with the warning of danger or coping with the stress. Clinically significant anxiety is an excessive response to external stress or related to an unidentifiable trigger. It is persistent rather than transient. It causes functional impairment, by exceeding the patient’s ability to cope with the stress and/or leading to avoidance behaviors.

General symptoms of anxiety in children include many worries about things before they happen, constant worries or concerns about family, school, friends or activities, fears or embarrassment or making mistakes, low self-esteem and lack of self-confidence. There are often somatic complaints as well, like stomachaches, headaches, and sleep disturbance, as well as a desire to avoid school and friends.

Specific symptoms of separation anxiety include constant thoughts and intense fears about the safety of parents and caregivers, refusing to go to school, frequent stomachaches and other physical complaints, extreme worries about sleeping away from home, being overly clingy, panic or tantrums at times of separation from parents, trouble sleeping or nightmares, and refusing to sleep without parents.

Specific symptoms of a phobia include extreme fear about a specific thing or situation (ex. dogs, insects, needles) and the fears cause significant distress and interfere with usual activities (ex. child refuses to go to the park because of a fear of seeing a dog).

Specific symptoms of social anxiety include fears of meeting or talking to people, avoidance of social situations despite a desire to attend, and few friends outside the family.

Anxiety disorders have a high rate of co-morbidity with other psychiatric disorders, primarily mood disorders, ADHD and other disruptive behavior disorders, and substance use disorders. It is therefore important to assess for these co-morbidities. To complicate things further, there can be some overlap with the specific symptoms of anxiety and other psychiatric disorders. For example, patients with Generalized Anxiety Disorder may “obsess” about daily worries, patients with Autism Spectrum Disorders have rituals, and patients with Major Depressive Disorder may ruminate or “obsess” over negative self-thoughts, but it does not mean that these patients also have Obsessive-Compulsive Disorder.

Early awareness and treatment of anxiety can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, substance misuse, and feelings of low self-esteem. It is important for primary care providers to be comfortable with assessing for anxiety in pediatric patients and linking families to appropriate resources when needed. Further information about treatment of anxiety symptoms in young patients will be addressed in a future e-weekly publication.

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