Up to 30% of youths will develop anxiety disorders; how you can help
Carol CohenWeitzman, M.D., FAAP and CarolynBridgemohan, M.D., FAAP
Focus on Subspecialties
Children with anxiety often present first to their primary care clinician, who is
in an ideal position to screen for, evaluate and treat these concerns. Many mild symptoms
can be managed with brief office-based interventions and may not require referral
for counseling or medication.
Learning to manage anxiety is critical for healthy development. However, 25%-30% of
children and adolescents will develop anxiety disorders during their lifetime.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, lists six types of anxiety disorders in children. Most children present with a combination
of symptoms across several anxiety types, most commonly separation anxiety, social
anxiety and generalized anxiety.
Problematic anxiety typically is driven by fear of the unknown. “What if” drives the
anxious child to ruminate on anticipated negative events and outcomes and to avoid
fear-triggering situations. Anxiety can produce a toxic cycle of maladaptive thoughts
and feelings often with subsequent avoidant behaviors to reduce uncomfortable feelings.
Children with anxiety typically experience a range of concerns, including problems
with school performance, social withdrawal or panic attacks. Others have somatic complaints
such as recurrent headaches or stomachaches. Children with anxiety are at higher risk
for mood disorders, attention and learning problems, being bullied and substance use.
Early identification of anxiety is critical to prevent progression to more severe
symptoms. However, in children who experienced higher anxiety when younger, symptoms
often re-emerge or different anxiety symptoms appear at later developmental stages
and times of transition.
Several brief checklists are available to screen pediatric patients for anxiety. The
screens have parent and child versions, can be completed in five to 10 minutes and
scored in under five minutes. Examples include:
The Spence Children’s Anxiety Scale for children ages 6-18, www.scaswebsite.com. There also is a preschool scale for children ages 3-6 years.
Treatment is similar regardless of anxiety type and includes: 1) educating parents
and children about the anxiety triad, which describes the relationship between thoughts,
feelings and behaviors, 2) reducing parental accommodation of a child’s efforts to
avoid anxiety-provoking situations, 3) helping parents support their child to tolerate
and manage anxiety, 4) helping the child develop coping skills and 5) exposing and
desensitizing the child to anxiety triggers in a stepwise, tolerable way.
Education. Initial management should focus on explaining the function of anxiety, the anxiety
triad and how avoidance results in maximum symptoms with each exposure, while persisting
through anxiety results in a lower level of symptoms with subsequent exposures. Diagrams
can be helpful in making the connection between thoughts, feelings and behaviors.
Coaching parents. Help parents recognize accommodative behaviors that maintain a child’s avoidance
by encouraging them to keep a log that tracks the child’s behavior and the parental
response (e.g., allowing the child to stay home when she has a stomachache before
a big test).
Coaching children. Teach the child to replace unrealistic, negative thinking with more realistic thoughts
(e.g., changing “I’m going to die if I say the wrong answer” to “I’ll feel embarrassed,
but I’ll be OK”); recognize the link between physical symptoms and emotional state;
and change avoidant behavior to “brave behavior.”
During office visits, demonstrate how to use coping techniques such as relaxation,
deep breathing and guided imagery. These strategies can be demonstrated in a few minutes.
Use “props” such as pictures of the anxiety triad and visual aids that illustrate
calming and coping strategies.
To build self-efficacy, have children develop a list of things that make them feel
better. Older children can keep a log of symptoms, the situation and how they responded
in feelings and actions.
Provide a list of books and apps on anxiety management and mindfulness.
For the minority of children with more severe symptoms, cognitive behavioral therapy
and medications may be required. Consider referral to a subspecialist when symptoms
worsen despite intervention, if the child is avoiding school or other activities,
or has co-morbid depression, severe panic attacks or suicidality.
Dr. Weitzman is chair of the AAP Section on Developmental and Behavioral Pediatrics
Executive Committee, and Dr. Bridgemohan is the program chair for the section.