Anxiety disorders comprise the most prevalent mental health disorders among children and adults. Psychotherapy and pharmacotherapy are effective in improving clinical impairments from anxiety disorders and maintaining these improvements. This article discusses how to obtain a suitable diagnosis for anxiety disorders in youth for implementing appropriate treatments, focusing on the evidence base for pharmacologic treatment. Clinical guidelines are discussed, including Food and Drug Administration indications and off-label use of medications, and considerations for special populations and youth with comorbidities are highlighted. Findings suggest moderate effectiveness of medication, particularly selective serotonin reuptake inhibitors, in the treatment of anxiety disorders in youth.
Anxiety is an adaptive response to danger that helps promote safety by facilitating avoidance of perceived threats. Children and adolescents have common fears and worries, which are often normal and typically follow predictable developmental periods (eg, fear of storms in toddlerhood, urges to avoid leaving home when starting school). However, anxiety can be functionally impairing when it becomes excessive and enduring or occurs outside the expected developmental timeline, in which case a clinical diagnosis and treatment are warranted. In youth with anxiety, exposure to a trigger (such as a feared object or separation from an attachment figure) results in anxious reactivity, often with thoughts of catastrophic consequences. This distress typically elicits escape urges that, when followed, bring about immediate relief of anxiety (such as leaving class, washing hands). The relief is often so rewarding that the escape behavior rapidly becomes habitual, and subsequent stressors may lead to similar escape behavior, resulting in increasingly impaired functioning. Treatment requires breaking the cycle of avoidance behaviors by reducing the reinforcement associated with avoidance and gradually empowering children and youth to tolerate anxiety in the face of potentially stressful challenges. Pharmacologic interventions are believed to confer clinical benefit by reducing the degree of anxious reactivity and thereby increase the range of opportunities for children to relearn more adaptive responses to stressful stimuli. Emerging evidence also points to subtle neurotrophic changes induced by selective serotonin reuptake inhibitors (SSRIs) that may contribute to clinical effectiveness through enhanced neuroplasticity.
Anxiety disorders are highly prevalent, and cross-sectional screens of pediatric outpatients find 20% score more than the identified clinical cutoffs for one or more anxiety disorders. Even among community samples of preschool children, almost 10% are found to have an anxiety disorder using Diagnostic and statistical manual of mental disorders fourth edition criteria. Anxiety disorders occur at similar rates among young boys and girls, but gradually become more common in females, with a 2:1 to 3:1 female preponderance by adolescence. Longitudinal studies of community samples have also shown that once a child is diagnosed with an anxiety disorder, that child is at increased future risk for recurrence of the same disorder, as well as for the subsequent development of depressive disorders and additional anxiety disorders.
Functional neuroimaging studies of anxiety disorders in children and adolescents reveal functional impairments in brain regions that modulate emotion and fear. The basic components of this circuitry are believed to be preserved across species, and include regions in the amygdala involved in fear conditioning and responses, in the hippocampus for contextual processing, and in prefrontal cortical regions in modulation of fear and extinction of fear responses. In general, the amygdala is believed to be responsible for rapid interpretation of danger, and stress-induced hormones and other neurotransmitters operate on the amygdala to strengthen memories associated with fearful stimuli, thus improving adaptive responses to threats in our environment. Although prefrontal regions typically serve to modulate this amygdala responsivity, children and adults with anxiety disorders show a deficiency in this dampening of fear responses by prefrontal cortical circuits.
Assessment and diagnosis of anxiety
Assessment for anxiety disorders typically starts with pediatricians or other primary care providers, often by initially addressing behavioral concerns or physical complaints such as headaches or stomachaches, which are particularly common at younger ages. In addition to anxiety, associated symptoms include fatigue, muscle tension, malaise, dry mouth, or a poorly defined sense of discomfort, palpitations, syncope, chest pain, shortness of breath, dizziness, paresthesias, numbness, trembling, memory loss, difficulty concentrating, vague gastrointestinal symptoms, and urinary frequency. Obtaining a timeline of physical, psychological, and behavioral symptoms of concern, preferably elicited from both the child and parents, is also recommended. A broad review focused on psychosocial stress and developmental course is also recommended, and for older children, a review of substance use, including energy drinks, caffeine, inhalants, methamphetamines, and stimulant diet pills. Evaluation for anxiety disorders should also include a review of past medical history, including previous trauma that may have precipitated posttraumatic stress disorder (PTSD), family history of psychiatric illnesses, and substance abuse.
General screening measures are available for providers to help identify children at risk for psychosocial difficulties and to add important clinical information beyond what may be obtained through a medical history. Youth self-reports may be an important tool because of the internalizing nature of anxiety disorders and because affected children may not be forthcoming with their symptoms during direct questioning. Screening tools tailored to developmental level are available, and clinical judgment is required in interpreting the results.
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