Anxiety Disorders

Despite the high prevalence and early onset, pediatric anxiety disorders remain under-recognized and under-treated. This lack of recognition can also lead to inappropriate treatment when anxiety-related impairments (such as social avoidance, off-task behavior, or dysphoria) are misattributed to other conditions (such as autism spectrum disorder (ASD), ADHD, or depression, respectively).  

Epidemiology & Risk Factors


Analysis of the National Comorbidity Survey-Adolescent Supplement (conducted from 2000-2004 in 10,000 adolescents) revealed a lifetime prevalence of any anxiety disorder of 31.9%, with severe impairment in 8.3%.  Specific phobia had the highest prevalence (19.3%) of the individual anxiety disorders, followed by social anxiety (9.1%), separation anxiety (7.6%), agoraphobia (2.4%), panic disorder (2.3%), and generalized anxiety disorder (2.2%). 

Most anxiety disorders have their onset in childhood or adolescence.  All anxiety disorders more frequently occur among females than among males. Although sex differences may occur in childhood they increase with age, reaching ratios of 2:1 to 3:1 in adolescence. 

Risk factors

Anxiety disorders are moderately heritable but highly complex and polygenic.  Few genetic risk loci have been identified. 

Other risk factors for anxiety disorders include female sex, low income, temperamental factors including behavioral inhibition (a consistent tendency to display fear and withdrawal in unfamiliar situations), parenting styles including overprotection or rejection, and adverse life events including abuse, illness, loss of a parent or other traumatic exposures.

Comorbidity & Differential Diagnosis

Anxiety disorders commonly co-occur with other anxiety disorders and with ADHD, depression, bipolar disorder and with trauma and stress related disorders.  

Differential diagnosis

Other psychiatric disorders (any of which may co-occur with anxiety)

ADHD (inattention and/or restlessness), depression, autism (social avoidance may appear as social phobia), early psychotic disorder with social withdrawal

Medical conditions and drugs

Hypothyroidism, anemia, asthma, lead intoxication, hypoglycemia, arrythmias, pain

Beta agonists, sympathomimetics, glucocorticoids, SSRIs, antipsychotics (akathisia), diet pills, cold medications, bath salts and other illicit substances


Longitudinal studies indicate that among children or adolescents with an anxiety disorder at baseline, only 10-13% will have no mental health disorder at 10-year follow up.  Many will have the same or another anxiety disorder, and many more will develop a depressive disorder or a substance use disorder. 

People with anxiety disorders are at increased risk for suicide and for cardiovascular adverse events and death.

Characteristics Common to All Anxiety Disorders

  • Hypervigilance
  • Reactivity to novel situations
  • Biased interpretation of experiences as threatening
  • Avoidance as primary coping strategy
  • Catastrophic reactions
  • Parental accommodation: can shape family life
  • Midline physical symptoms

Anxious people are constantly scanning the environment for threats, and systematically read threats into the human and non-human environment.  fMRI studies show fear reactions in the brains of anxious children observing neutral faces at nearly the same rate as when observing threatening faces.  Anxious children may see car accidents, abductions, diseases, loss, and humiliation around every corner, much of their waking life.

Children often will not verbalize these fears, or they not even be aware that they are fears.  The physical symptoms of anxiety may manifest without the child linking them to fearful thoughts and feelings.  These symptoms are adrenaline-based and tend to appear as recurrent midline complaints, as shown here.

Other symptoms

  • Problems with falling asleep and middle of the night awakening 
  • Eating problems –over eating and under eating
  • Excessive need for reassurance 
  • Inattention and poor performance at school 
  • Explosive outbursts
  • Avoidance of outside and interpersonal activities – school, parties, camp, sleepovers, safe strangers

Anxiety can affect all the major systems.  Children with anxiety may have trouble getting to sleep or with nighttime awakening.  They may anxiously overeat or be too nervous to eat much at all.  They tend to seek constant reassurance without ever really being reassured.  Anxiety may interfere with concentration and be confused with the inattentive symptoms of ADHD.  Anxious children can be quite irritable and prone to explosive outbursts.  They may cut themselves off from activities which make them anxious, reducing their opportunities to develop social competencies.

Childhood Age of Onset of the Anxiety Disorders

Mental health disorders tend to appear in a predictable way in population of children over time.  Anxiety disorders tend to emerge relatively early in childhood, generally at younger ages than do the mood disorders.  Understanding the chronologic and developmental periods in which children and adolescents are at risk for the various disorders of mental health, especially in children whose family history puts them at higher risk for these disorders, allows you to anticipate and potentially prevent or mitigate the effect of these disorders.

The individual anxiety disorders tend to appear at times consistent with normative developmental fears that are not resolved. While most young children go through a stage of stranger anxiety, but then learn to easily separate from their parents, children with separation anxiety disorder have persistent worries that their parent will be lost to them if out of their sight.  Older children go through stages of fears of the dark and of scary creatures, fear of death or dying, or fears around illness, safety, or disaster.  In most children these fears resolve, but in generalized anxiety disorder, they are magnified and persistent.  Most adolescents have worries about peer rejection, or simply fitting in, but those with social phobia are functionally impaired by this fear.  Panic disorder tends to emerge in young adulthood, often accompanying fears around managing adult life.

Screening & Assessment

A list of public domain anxiety-specific screening and assessment instruments can be found on our screening page. None of them are perfect for use in outpatient pediatrics. The SCARED includes subscales that can help identify the particular anxiety disorder a child might have. The GAD-7, as implied by the name, is specific to generalized anxiety disorder and is commonly used in adults. The PROMIS measures are brief, general, and may be useful as initial screening measures as well as for tracking response to treatment over a broad age range.

The natural question when using a screening instrument is, "what score indicates a positive screen?" Another question is, "what constitutes mild, moderate, or severe anxiety?" The answers are not straightforward. The instruments shown have been validated over the indicated age range. Mean scores differ in healthy children over the age ranges, so the cutoffs differ as well.  In clinical practice, approximate cut-offs combined with clinical assessment are appropriate.

Anxiety severity may be better defined in terms of functional impairment than by using specific score cutoffs. Shown here is a way to categorize anxiety severity by its impact on functioning and on somatic distress.


The anxiety disorders are highly treatable.  The seminal study in the treatment of pediatric anxiety was the NIMH-funded Child-Adolescent Anxiety Multimodal Study (CAMS) (Walkup et al NEJM 2008) which randomized 488 children aged 7 to 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy (CBT), sertraline (up to 200 mg/day), a combination of sertraline and CBT, or placebo drug for 12 weeks.  Here are the response rates:

CAMS Study Arm CBT Sertraline CBT + sertraline placebo
Response rate (%) at 12 weeks 59.7 54.9 80.7 23.7

This and other studies lead to the following recommendations:

  • If anxiety is mild to moderate or of recent onset, Cognitive Behavioral Therapy (CBT) is first line treatment.
  • If anxiety is moderate to severe, combined treatment with CBT with a selective serotonin reuptake inhibitor (SSRI) is superior to either treatment alone.  
  • The goal of treatment is remission, when the child experiences no or few anxiety symptoms and anxiety is not interfering with functioning.
  • If symptom remission is not achieved with the first SSRI, it is appropriate to use a second and even a third SSRI.  A treatment algorithm is shown below.

Our review of anxiety and related disorders has emphasized the roles of CBT and SSRIs in the treatment of anxiety.  This is a simplification; there are other therapy types and other medications used, but CBT and SSRIs are the first line treatments for anxiety disorders in children and adolescents.  The table below indicates which disorders respond best to medication and/or therapy and which are best addressed with therapy alone. 

Separation Anxiety Disorder X X
Generalized Anxiety Disorder X X
Social Phobia X X
Specific Phobia X  
Adjustment Disorder with Anxiety X  
Obsessive Compulsive Disorder X X
Panic Disorder X X
Selective Mutism X  
Post Traumatic Stress Disorder X  

Adjunctive Treatment

Aerobic exercise and yoga have both shown effectiveness in the treatment of anxiety disorders.

Complementary and alternative treatments

Preliminary evidence suggests that the following may be safe and effective in the treatment of anxiety disorders in adults.  Evidence for use in children is minimal or none.

  • Lavender oil (Silexan)
  • l-theanine
  • CBD

The Course of Treatment in Pediatrics

Anxiety disorders tend to present early in childhood although they are easily overlooked.  Anticipatory guidance tailored to the individual child with a family history of anxiety or who displays behavioral inhibition can include promoting self-efficacy, developmentally appropriate risk-taking and bravery.  Early screening can help identify children with symptoms and impairment consistent with an anxiety disorder. 

Identified and treated early, many anxiety disorders can be treated by community therapists with pharmacologic management, generally an SSRI, in the pediatric clinic. 

If the patient achieves symptom remission, they should continue the SSRI for about a year, stopping at a time of stability.  Ongoing surveillance for relapse, recurrence, or emergence of another anxiety disorder is essential. 

Does my patient still need this medication? Discontinuing SSRIs


Resources for Patients & Families

AACAP Parent's Guide to Medications for Anxiety

Anxiety Canada

Resources for Clinicians

Anxiety: Pediatric Mental Health Minute Series (American Academy of Pediatrics)


Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. In Psychiatr Clin North Am (Vol. 32, Issue 3, pp. 483–524).

Koyuncu, A., Ertekin, E., Deveci, E., Ertekin, B. A., Yuksel, C., Celebi, F., Binbay, Z., Demir, E. Y., & Tukel, R. (2015). Age of onset in social anxiety disorder: Relation to clinical variables and major depression comorbidity. In Ann Clin Psychiatry (Vol. 27, Issue 2, pp. 84–89).

Schat, A., van Noorden, M. S., Noom, M. J., Giltay, E. J., van der Wee, N. J., de Graaf, R., Ten Have, M., Vermeiren, R. R., & Zitman, F. G. (2016). A cluster analysis of early onset in common anxiety disorders. In J Anxiety Disord (Vol. 44, pp. 1–8).

Tsang, T. W., Kohn, M. R., Efron, D., Clarke, S. D., Clark, C. R., Lamb, C., & Williams, L. M. (2015). Anxiety in young people with ADHD: clinical and self-report outcomes. In J Atten Disord (Vol. 19, Issue 1, pp. 18–26).

Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. In N Engl J Med (Vol. 359, Issue 26, pp. 2753–2766).