Chapter 88. Anxiety

Fear is an emotional response that is a normal part of development and essential to human survival. It is both protective and adaptive. In times of danger or anticipated risk, the sympathetic nervous system is activated and prepares the body to fight or flee the dangerous situation. Fear is short lived, which makes it different from mood states such as anxiety. Anxiety is often thought of as a secondary emotion in response to a primary emotional reaction (eg, fear). For example, people become anxious if they are fearful about a specific event, object, or situation and anticipate negative outcomes. Anxiety requires more cognitive capacities than fear. The fight-flight response may be activated when anxiety and fear appear even when there is no real danger but negative outcomes are anticipated. Such anticipatory fear, when persistent and pervasive, extends beyond normative levels of fear and anxiety and can be debilitating.

The focus of fear and anxiety changes over time as children explore their world and encounter new situations and stimuli. During infancy, fear is usually expressed as crying and limb reactivity to loud noises and novel stimuli. As infants begin to discriminate known faces from unfamiliar ones, stranger anxiety emerges (usually by 7–9 months of age). During this stage, the infant becomes very reactive (crying, muscle tension, flailing limbs, etc) to unfamiliar people. Simultaneously, bonds with primary attachment figures are typically being strengthened, and eventually separation anxiety becomes predominant (ie, child may cry when parent or other primary attachment figure is away even in the presence of other familiar adults). Separation fears are common between 1 and 3 years of age and gradually resolve by age 5 with experience that parents return after separations and a newfound awareness that objects continue to exist even when you cannot see them. From about 4 to 7 years of age, as children continue to become acquainted with their surroundings and more imaginative in their thinking, fears of new and unfamiliar situations as well as real and imagined dangers (eg, spiders, monsters, ghosts, the dark, dogs) become more prominent.

With increased learning and exposure to information obtained at school, children’s fears often become more reality based. For example, fears of fires, storms, natural disasters, kidnapping, illness, plane crashes, and crime are common during this stage. Preadolescence and adolescence are characterized by increasing autonomy and individuation from parents as well as greater emphasis on peer relationships. Social comparisons, peer status, and social acceptance become increasingly important during this time, resulting in more social fears. Abstract thinking also becomes more developed during adolescence, which allows the teenager to worry about many hypothetical situations as well as issues regarding self-identity, morality, and the future. Substantial deviations from this developmental sequence may signify the presence of problematic anxiety.

Fears and anxiety are manifested in various ways. Some children may appear visibly nervous. Others may hide their feelings, freeze in a situation, or express their anxiety as anger or frustration. While many children experience anxieties and worries at some point in their lifetime, most do not have clinical disorder. Normative and problematic anxiety can be distinguished in various ways (see eTable 88.1); ultimately, however, it is often the degree of interference and distress that determines whether a child has a clinical anxiety disorder. Specific types of anxiety disorders are distinguished by hallmark features (see Table 88-1).

Anxiety disorders can be described with reference to 3 realms: physiological, behavioral, and cognitive. Physiological reactions to feared stimuli include increased heart rate, respiratory rate, blood pressure, sweating, flushing, nausea, diarrhea, tingling sensations, abdominal problems, dry mouth, lightheadedness, dizziness, muscle tension, tremors, and chest pain. Behavioral signs of anxiety typically include avoidance, social withdrawal, irritability, angry outbursts, crying, clinginess, insomnia, nightmares, distractibility, hypervigilance, and cautiousness. Cognitively, children with anxiety often have an attentional bias toward threat-related information with a tendency to fear the worst and exaggerate risks.

Continua of Anxiety: from Fears and Worries to Anxiety Disorders

Clinginess to Separation Anxiety Disorder

Many children feel anxious when separated from their parents or other caregivers. Separation anxiety is most common between 1 and 3 years of age and mostly resolved by age 5. Thereafter, separation anxieties would be expected only occasionally, such as when starting a new school year or going away to camp; typically, however, these fears are very temporary, usually lasting 2 to 3 days for most children and 2 to 3 weeks for others. Children with separation anxiety disorder worry about being away from their parents during school, at bedtime, or even when their parents are in a different room. Often, they worry that something bad will happen to them or to their parents while they are separated. Impairment may include numerous missed opportunities (eg, camp, sleepovers, social activities), school avoidance, and sleep problems. As a rule of thumb, if separation fears persist longer than 1 month without any signs of improvement and are severe enough to cause some type of impairment, then a clinical disorder might be suspected.

Shyness to Social Anxiety Disorder

Shyness is a common childhood trait and should not be considered a clinical disorder unless it is persistent, excessive, and causes some type of impairment. Behavioral inhibition,1,2 a temperamental characteristic similar to shyness, is a stable trait in approximately one third of infants. Children with an inhibited temperament have been found to be timid with novel or unfamiliar people, objects, and situations, while uninhibited children spontaneously approach these stimuli. These behavioral differences are accompanied by physiological differences, including increased heart rate and heart rate variability, pupillary dilation during cognitive tasks, vocal cord tension when speaking under moderate stress, and salivary cortisol levels among the behaviorally inhibited children. When behavioral inhibition is persistent and stable, a child is at increased risk for anxiety disorders, specifically social anxiety disorder.3

The hallmark feature of social anxiety disorder is the excessive concern about negative evaluation and embarrassment in front of others. This persistent fear is accompanied by increased physiologic arousal and avoidance of social situations like parties, meeting new children, starting a conversation, speaking in class, and giving speeches. Parents often describe children with social anxiety as being overly sensitive to criticism and rejection as well as nonassertive with peers. Common types of impairment include lack of friends, loneliness, poor school performance related to lack of participation, school refusal, and low self-esteem. This disorder is discussed in more detail in Chapter 72 since it tends to emerge between the ages of 11 and 19 years.

Selective mutism is similar to a social anxiety disorder. Children with selective mutism are reticent to speak in certain situations, and they consistently fail to speak in 1 or more social settings (eg, school) despite speaking normally in other settings (eg, home). They do not warm up after a brief period and start speaking, although they may engage in nonverbal gestures. Selective mutism can lead to various problems in school (eg, not answering questions, not requesting to go to the bathroom), difficulty making friends, family arguments (eg, child will not speak when requested to speak), and caregiver strain.

Routine Worries to Generalized Anxiety Disorder

All children have occasional worries; however, when the worries become excessive and uncontrollable, they are no longer considered normative. Children with generalized anxiety tend to worry much more than other children their age, and they are unable to stop worrying. They may worry about their grades, homework, friends, their health, the health of others, things going on in the world, and family matters, among other things. Such children worry even when there is no realistic reason to be concerned. Insomnia, difficulty concentrating, fatigue, and irritability are common complaints among children with generalized anxiety disorder. Other forms of impairment may include a general inability to enjoy life because of constant worries, difficulty maintaining friendships, school problems related to concentration difficulties, and, occasionally, medical problems. For a more detailed discussion of the diagnosis and treatment of generalized anxiety disorders see Chapter 72.

Fears to Phobias

Fears are common during childhood and generally dissipate over time and with experience (direct experience and reassuring information from others). Fears that are considered phobias persist despite experience and reassurance and are associated with intense distress or avoidance of the phobic object or situation. The DSM-IV TR divides specific phobias into 5 categories: animal, such as fear of spiders (arachnophobia); natural environment, such as fear of lightning and thunderstorms (astraphobia); situational, such as fear of enclosed spaces (claustrophobia); blood-injection-injury, such as fear of needles (trypanophobia); and other, such as fear of school (scolionophobia). The onset of a specific phobia is usually in childhood or adolescence. The lifetime prevalence of a specific phobia is 12.5%; the 12-month prevalence is 8.7%.3a The etiology may be trauma; for example, being bitten by a dog may result in an irrational fear of dogs. Phobias may be acquired socially, as in fear of foreigners, or xenophobia. Specific phobias may also be rooted in biologic or genetic susceptibility toward anxiety. The treatment of specific phobia is nonpharmacologic. Cognitive behavior therapy with graduated exposure to the source of fear is the preferred treatment.

Habits to Obsessive Compulsive Disorder

Habits and rituals are common during childhood. For example, children may have certain ways of arranging their toys, want to wear a favorite shirt, or have various bedtime rituals that they enjoy. The obsessions and compulsions that make up obsessive-compulsive disorder, however, are more involuntary, less enjoyable, and somewhat bizarre and nonsensical in nature. Obsessions come in varying forms, including fears of contamination, need for order or symmetry, pathological doubting, and recurrent aggressive or horrific images. Common compulsive behaviors include washing, checking, counting, ordering, asking for reassurance, and repeating words or actions. Often, children engage in compulsions to neutralize the unwanted thoughts. For example, a child may think, “Everything must be lined up perfectly, or something bad will happen to my mother,” and therefore engage in excessive ordering rituals to prevent the bad event. Compulsions are more dominant in younger children, while obsessions in this age group tend to be more vague (eg, “I had to wash my hands because I just didn’t feel right”). Obsessions and/or compulsions must consume at least 1 hour per day and cause marked distress and/or significant impairment to be classified as obsessive-compulsive disorder. Like most of the anxiety disorders, obsessionality exists on a continuum where it is possible for a child to have traits even if he or she does not have the disorder. For further discussion see Chapter 72.

Panic Attacks to Panic Disorder

Panic attacks include symptoms (usually 4 or more at the same time) such as a racing heart, sweating, shaking, shortness of breath, feelings of choking, chest pain, chills, nausea, dizziness, fear of losing control or going crazy, and fear of dying. Children with or without an anxiety disorder can have panic attacks. For example, children with social anxiety disorder often have panic attacks in public speaking situations but do not necessarily have panic disorder. Similarly, a child without an anxiety disorder may have an occasional panic attack in a given situation but not have panic disorder. The hallmark feature of panic disorder is a recurrent pattern of unexpected panic attacks that come out of the blue and do not have a specific trigger. Panic disorder is associated with subsequent worry about having another panic attack or a change in behavior because of worries about having another panic attack. The presence of a behavior change related to the panic attacks often results in the additional diagnosis of agoraphobia in which a child avoids certain places (eg, malls, crowded places, being in a car) for fear that they may have a panic attack and not be able to escape or get help. Panic disorder usually begins in late adolescence and is uncommon among young children.

Stressful Experience to Posttraumatic Stress Disorder

Approximately 15% to 35% of children will experience a traumatic event in their lives; however, most will not develop a stress disorder on account of this. Children with posttraumatic stress disorder (PTSD) experienced a traumatic event (eg, varying forms of abuse, a tragic accident, fire, earthquake or other natural disaster, violent crimes, seeing somebody else being hurt) that was upsetting, frightening, life threatening, and outside the realm of a normal childhood experience. In response, the child reacted with intense fear, helplessness, or horror. A child with PTSD experiences flashbacks or recurrent images in the forms of dreams or memories as well as avoidance of stimuli associated with the trauma. Younger children may exhibit these behaviors in their play or in their drawings. Various forms of physiological arousal also become prominent after the trauma, including irritability, difficulty concentrating, hypervigilance, difficulty with sleep, and an exaggerated startle response. Related to PTSD is acute stress disorder, which also occurs specifically in response to a traumatic event but is different in that the symptoms must occur within 4 weeks of the trauma and resolve within those 4 weeks. For further discussion see Chapter 72.

Differential Diagnosis

Anxiety symptoms are seen in patients with other medical and behavioral conditions, including substance abuse disorder, autistic spectrum disorders, attention deficit hyperactivity disorder (ADHD), and adjustment disorder.

Symptoms of anxiety such as chest pain, insomnia, dizziness, headaches, shortness of breath, nausea, palpitations, and numbness may mimic medical illnesses such as cardiac disease (eg, mitral valve prolapse in an adolescent and arrhythmias), hypoglycemia, pheochromocytoma, vestibular dysfunctions, hypercortisolism, growth hormone deficiency, thyroid disorders (hyperthyroidism and hypothyroidism), pulmonary problems, and seizure disorders. It may be challenging for clinicians to recognize anxiety disorders. Diagnostic accuracy can be facilitated by considering the context, frequency, and duration of the child’s anxiety symptoms as well as atypical features such as age of onset, course, and absence of a family history of anxiety.

Substance-Induced Anxiety Disorder

Use of central nervous system stimulants like cocaine, amphetamines, or caffeine or withdrawal from central nervous system depressants (eg, alcohol, benzodiazepines, marijuana) can produce anxiety-related symptoms such as panic attacks, phobias, obsessions, or compulsions. In this case, a diagnosis of an anxiety disorder should be given only if the symptoms persist long after the effects of intoxication or withdrawal have resolved.

Autistic Spectrum Disorders

Children with autistic spectrum disorders (ASDs) (see Chapter 92) have difficulties in social relationships and communication. Children with social anxiety disorder (or selective mutism) may also demonstrate these behaviors; however, social-anxious children usually are capable of and interested in forming friendships but may be unable to do so because of their anxiety. In contrast, a child with an ASD is often unable to form attachments and/or lacks interest in social relationships. Children with an anxiety disorder are usually able to speak appropriately in situations where they are comfortable, whereas children with ASDs often have speech anomalies across situations or are unable to speak at all. The repetitive behaviors that are found in ASDs can seem similar to the compulsions of obsessive-compulsive disorder. However, compulsions in obsessive-compulsive disorder are usually more complex and performed to neutralize an obsession. Children with ASDs often do not experience the behaviors as senseless and annoying or fear the consequences of not performing the behavior.

Anxiety usually predates depression and is often associated with the onset of depression (see Chapter 93). For example, a socially anxious child who does not have friends and cannot engage in social activities may experience feelings of loneliness and low self-esteem and subsequently become withdrawn and depressed. Where there is anxiety, a clinician should also ask about depression, and vice versa. Children with attention deficit hyperactivity disorder (see Chapter 92) are often distracted by extraneous stimuli (eg, random noises, other kids, trying to get homework done to move on to something more fun), whereas children with anxiety disorders are distracted by worries and fears (eg, thoughts like “What if I say the wrong answer,” “What if my work is not good enough”) or by rituals, compulsions, or flashbacks.

Attention deficit hyperactivity disorder usually has an earlier age of onset, so if a school-aged child or adolescent suddenly displays concentration and attention problems that were not there before, anxiety may be more likely. However, if a child has both attention difficulties and chronic anxieties (worries, fears, etc), both disorders may coexist.

Adjustment Disorder

In an adjustment disorder, the stressor can be of any severity (eg, romantic break-up, going to a new school, argument with a friend), and emotional or behavioral impairment occurs in response to a stressor (within 3 months of its onset). There is significant impairment greater than expected, and criteria for other diagnoses (eg, major depression, social anxiety) are not met. Adjustment disorders can be diagnosed with mood, anxiety, and/or conduct features.

In community samples of nonreferred children, prevalence rates of anxiety typically range from 10.7% to 17.3%, and rates are usually higher in girls and younger children. In pediatric primary care settings, 1-year prevalence rates of anxiety disorders among children ages 7 to 11 range from 6.6% to 10.5% based on parent and child reports respectively.4,5 More recently, the prevalence rate of any child anxiety disorder in a primary care setting was 15%: 1.1% for obsessive-compulsive disorder, 2.6% for separation anxiety disorder, 3.2% for generalized anxiety disorder, 6.8% for social anxiety disorder, 0.7% for selective mutism, and 10% for specific phobias.5

Childhood anxiety is associated with loneliness, educational underachievement, and low self-esteem.9-10 Also, anxiety may intensify the impact of co-occurring disorders such as ADHD, making treatment more complex. In addition, child anxiety disorders are often associated with gastrointestinal problems, asthma, and headaches,11-12 potentially increasing physician visits and costs.

Genetic and Biological Influences

Family history studies that have examined anxiety in children of adults with anxiety disorders and parents of children with anxiety disorders have found rates of anxiety disorders in family members to be higher than in the general population. Twin, sibling, and adoption studies show that genetics explain approximately one third of the variance associated with child anxiety disorders.13 In a study that delineated types of anxiety related behaviors and included 4564 pairs of 4-year-old twins, contributions for general distress, separation anxiety, and fear were modest, while the contributions for obsessive-compulsive behaviors and shyness/inhibition were substantial (heritability estimate was 62%). Specific genes implicated in anxiety include serotonin and dopamine genes; however, it is likely that multiple genes are involved. Vulnerability to anxiety likely exists along a continuum, and quantitative assessments of dispositional characteristics (eg, temperamental characteristics such as neuroticism, anxiety sensitivity, and behavioral inhibition) may be most informative when trying to understand genetic transmission.14

Environmental Influences

While studies have been somewhat consistent in demonstrating that child anxiety is heritable, shared and nonshared environmental factors also have significant influences in explaining child anxiety. Shared influences include those factors that make family members similar to each other, while nonshared environment includes those factors that make an individual unique (eg, recent stressful life events, friendships, school performance, danger events). A child may be predisposed to anxiety, while the environmental (shared and nonshared) factors facilitate the actual expression of the disorder. This is further supported by the finding that children who have a parent with an anxiety disorder are at risk for developing an anxiety disorder but not necessarily the same disorder as the parent.13 Conditioning experiences, modeling, family environment, and parenting styles often play a significant role in shaping the phenotype of an anxiety disorder.

Conditioning Experiences

Behavioral models suggest that fears may be acquired through classical conditioning and subsequent higher-order conditioning leading to stimulus generalization. For example, a child bit by a big dog may first develop a fear of similar big dogs, and this fear may then generalize to all dogs and/or animals in general. Retrospective data from adults suggest that approximately 40% to 60% can recall an event, usually referred to as a traumatic conditioning event, that precipitated the onset of social fears and specific phobias.15-16

Modeling

Social learning theory proposes that fears can be acquired through modeling and vicarious learning experiences. When a child is presented with an ambiguous story and the child and parent are asked to describe what they would do in the various scenarios, anxious children choose more avoidant solutions than initially chosen after discussing the scenarios and getting advice from their parents.17 In comparison to adults with agoraphobia, adults with social anxiety disorder recall that their parents had greater concerns about the opinions of others, sought to isolate them as children, and deemphasized family sociability.18 Cumulatively, these learning experiences may lead to few social opportunities and limited rehearsal of social skill sets. Additionally, parental modeling may occur when parents express their own anxiety and fears in the presence of the child without an effective coping strategy or when they demonstrate a cognitive style of constant worries, warnings, and “what if” questions. Children may also observe their parents using avoidance when confronted with a fearful or anxiety-provoking situation (eg, parent with social anxiety who does not answer the telephone to avoid social interaction or pretends to be sick to avoid going to a party) and subsequently imitate these behaviors. Anxious and fearful behaviors may be learned as early as infancy.

Family Environment and Parenting Styles

Parenting styles may also influence the manifestation of anxiety symptoms. Anxious and controlling parenting styles may foster dependency and child insecurities about competency, which may facilitate the development of various anxious beliefs about self, others, and the world. At least 2 comprehensive reviews have linked overcontrolling parenting behavior and parental negativity to child anxiety.19-20 However, the relationship between child anxiety and absence of warmth and acceptance within the family has been less often supported. Given the cross-sectional and often retrospective nature of these findings, causality cannot be inferred. However, it seems prudent that interventions and advice be informed by such findings.

The use of brief screening questions may increase quality of communication between clinicians and parents about children’s behaviors and facilitate detection. The Screen for Child Anxiety-Related Emotional Disorders (SCARED)21 is a 5-item questionnaire useful to screen for generalized anxiety disorder, separation anxiety disorder, panic disorder, social anxiety disorder, and school phobia (see Table 88-2).

When the screening test is positive, a clinician should gather additional information about severity and impairment, including a medical and developmental history, family history of anxiety and depression, school history, social history, and any changes in the past year. Basic questions should be asked concerning the situations in which the anxiety occurs, how often it happens, what the child is afraid might happen in the situation, how the family manages the anxiety when it occurs, and severity of anxiety. Also, information should be gathered regarding anxiety-related impairment at school (eg, number of absent or tardy days, impaired academic performance, school refusal), with friends (eg, trouble making or keeping friends), with family (arguments or restricted activities because of child’s anxiety), and child’s or parent’s own distress about the anxiety. If anxiety appears to be chronic, pervasive, and associated with significant impairment, a referral to a mental health provider should be considered. In cases of mild to moderate anxiety, the child’s primary care clinician can initiate a treatment plan.

For children with persistent anxiety, evidence-based treatment options are cognitive behavior therapy and pharmacotherapy. While data are not available to support the sequencing of treatment options or combined approaches, typically a psychological intervention is initiated first, followed by pharmacotherapy when necessary. Exceptions to this rule include instances of severe and debilitating anxiety, the inability to participate in psychotherapy without the use of medication, and/or serious depression or suicidality.

Psychological Interventions

Cognitive behavior therapy and behavior therapy programs are effective with response rates of 60% to 70%.22 Both interventions usually span 12 to 20 sessions and exist in individual and group formats. Many of the gains from psychosocial interventions are maintained at least 1 year after treatment. Cognitive behavior therapy has the most empirical support, and its basic components include (1) relaxation exercises, (2) cognitive restructuring, (3) exposure to feared situations, and (4) reinforcement. Children learn about anxiety and its causes, how to monitor their anxiety, skills to relax, ways to change anxious thinking, and strategies to gradually confront feared situations. Reward systems are often used to reinforce children’s efforts and accomplishments.

Pediatrician-Based Guidance

For children with mild to moderate levels of anxiety, clinicians can offer practical advice based on cognitive behavior therapy principles (see eTable 88.2) such as educating children and families about fear and anxiety symptoms, including the protective characteristics of these responses. Simple relaxation techniques, such as diaphragmatic breathing and guided imagery, usually can be taught in 5 minutes. Guided imagery might include suggestions for the youth to think about a favorite place and imagine that place in vivid detail, including attention to sight, smell, and sound, during an anxiety provoking experience. Patients can be instructed to imagine a favorite hero or cartoon character helping them to confront their fears. Families can be advised to set up a hierarchy whereby the child is asked to gradually confront his or her fears or worries beginning with the least anxiety-provoking to most anxiety-provoking situation. For a child with social anxiety, graduated exposure exercises might include saying hi to a classmate, ordering food at a restaurant, raising his or her hand in class, going over to a friend’s house for an afternoon, joining a club, and so forth. Each step is practiced until the child feels comfortable, and then the next step is approached. The use of praise and rewards can also be useful in developing a new skill or confronting a difficult situation. Guidance directed at expanding the child’s thinking repertoire to include alternative outcomes and explanations (both neutral and positive) rather than the usual negative/fearful anticipated outcomes can be helpful. Clinicians can also encourage parents to try to model appropriate ways to confront fearful situations and to monitor their own anxious thinking.

Pharmacotherapy

Selective serotonin reuptake inhibitors (SSRI) have been demonstrated to have the most benefits and fewest side effects in school-aged children and adolescents with anxiety disorders. Randomized controlled studies of fluoxetine and fluvoxamine for youth with anxiety disorders show response rates ranging from 61% to 76%.23-24 In a study of paroxetine for children with social anxiety disorder (N = 319), 75% of children were considered responders compared to 38% of those in the placebo group. No children had serious side effects, and the medication was well tolerated.25 Suicidal ideation and suicidal behaviors occurred in 4% of adolescents treated with SSRI medications, compared to 2% who received a placebo. No suicides occurred in these studies. Although clinical trials support the use of an SSRI in the pediatric age group, they should be prescribed conservatively, especially in school-aged children.

Benzodiazepines (eg, alprazolam, clonazepam, lorazepam) are usually not first-line pharmacological treatment because of the side-effect profile, which includes sedation, cognitive impairment, and the potential for abuse and dependence; however, they can be useful to regulate sleep or when an immediate calming effect is necessary. Tricyclic antidepressants were prescribed in the past to treat child anxiety disorders. Currently, their use is more limited because of an unfavorable side-effect profile. The benefits and side effects of antianxiety medications are listed in Table 88-3.

Follow-Up

When a pediatrician is responsible for managing treatment for anxiety, biweekly visits are useful for the first 1 to 2 months, followed by monthly visits. Families and children should be reminded that SSRI medications take 4 to 6 weeks before any change might be noticed. Practical advice and encouragement (as described previously) should be used to enhance the child’s progress and to optimize the benefit from the medication. For example, a socially anxious child who has been treated with medication but does not attempt to engage in social interactions will not experience much improvement. It is often useful to correspond with teachers and mental health professionals to synchronize treatment plans and maximize the child’s response to pharmacological interventions.

Treatment Resources

Parenting guides about the treatment of anxiety, particularly those based on principles of cognitive behavior therapy, may be useful.

• Anxiety Disorders Association for British Columbia: www.anxietybc.com
• Anxiety Disorders Association of America: www.adaa.org