Anxiety Disorders in Children and Adolescents

An overview of other anxiety disorders common in children.

By Saint Louis Behavioral Medicine Institute

Many people believe that children do not have anxiety problems. All the signs of a problem may be there, but the child is expressing distress in a way that is hard for an adult to recognize. Children will demonstrate their anxiety in a number of ways. The younger a child, the less their ability to identify anxiety or fear. Behavioral expression is usually seen when a child feels fear and anxiety and cannot find relief.

Children who are anxious experience physical symptoms in the presence of or in anticipation of a feared situation:

* rapid heartbeat, dizziness, shortness of breath or difficulty breathing,
* muscle tension, stomach upset, diarrhea, headache
* hyper or hypo activity, difficulty sleeping,
* selective mutism, avoidance of feared situations or objects, temper tantrums

They also experience scary thoughts and they often express their anxiety behaviorally by avoiding situations that make them uncomfortable.

Children and teens suffer from anxiety as well as adults. Starting school, moving, sudden separation or loss of a parent, pet, or loved family member can trigger the onset of an anxiety disorder. Several stressors can also trigger an anxiety disorder.

Separation Anxiety Disorder and Specific Phobia are more common in children, around 6-9 years of age. Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SAD) and Panic Disorder (PD) are seen in middle childhood and adolescence. Depression has a high rate of comorbidity in children, and especially among teenagers.

Children display and react to anxiety symptoms differently which often leads to difficulties in diagnosis. Anxiety symptoms in children often display as medical symptoms which lead many parents and children to see their medical physicians for symptom treatment when symptoms first occur. Unlike adults with specific phobias, children do not usually recognize that their fear is irrational or out of proportion to the situation, and they may not articulate their fears. Children will avoid situations or things that they fear, or endure them with anxious feelings, which can manifest as:

Intestinal symptoms such as:

* diarrhea, nausea, stomachache
* Muscle tension, insomnia, headache, dizziness
* Crying or Tantrums
* Avoidance
* Freezing or Clinging

The following are descriptions of the Anxiety Disorders that affect Children and adolescents:

Social Anxiety Disorder (SAD)

SAD can be seen in preschool and grade school children. It is usually diagnosed in early teens. If not treated, SAD can persist into adulthood, and can place a child at risk for alcohol abuse, depression, and difficulty with relationships.

Children suffering with SAD exhibit:

* Fears at least one social situation (such as recess, group activities such as birthday parties) or a performance situation (reading aloud in front of a group).
* Fears and avoids social interactions with schoolmates

Experiences anxiety/fear/anger symptoms prior to, or at the thought of a scheduled social event and has physical symptoms of intestinal upsets such as nausea, stomachache, diarrhea, or headache, racing heart, dizziness.

Behavioral symptoms can include:

* defiance
* anger
* inflexibility
* tantrums

These symptoms can interfere with daily activities and relationships.
School Refusal/Avoidance

SAD can be associated with:

* School Refusal/Avoidance
* Separation Anxiety
* Selective Mutism

School Refusal is not just "school jitters" or truancy. The child usually refuses to go to school on a regular basis, or has problems staying through the day.

School refusal is a symptom of a deeper problem and if not treated has a negative impact on self-confidence, social skills and learning. Anxiety-based school refusal affects 2-5% of school-age children. It is often seen at times of transition.

Ages five and six, and ten and eleven are commonly affected.

Older children also experience added academic pressure in higher grades.

Fears can involve:

* Being bullied, picked on by older kids
* Group activities such as gym class, eating in the cafeteria
* Using the bathroom
* Being singled out in class to read or give an answer
* Interacting with others where attention is focused on them

Separation Anxiety Disorder

Separation anxiety between 18 months and three years of age and is considered normal. Usually s/he can be distracted. Crying subsides when the child becomes engaged in their surroundings.

Separation Anxiety Disorder affects approximately 4% of children over the age of 4. Onset is most common between 7-9 years of age. A child suffering from Separation Anxiety Disorder experiences extreme anxiety when away from home or separated from parents or caregivers. Feelings of extreme homesickness and misery are experienced. It is not uncommon for these children to have fears of the health and safety of their parents.

Children suffering from Separation Anxiety Disorder can exhibit:

* Avoidance or refusal to go places alone
* School refusal
* Refuse sleepovers or camp
* Demand parent be around
* Have nightmares when separated from loved ones.
* Appear in parents bedroom in middle of the night.

Selective Mutism

Selective Mutism is a severe form of Social Anxiety Disorder. Children with selective mutism suffering from social anxiety fail to speak in situations where speech is expected or necessary. It often becomes severe when the child enters school. The average age of diagnosis is 4-8 years old. Children often exhibited "extreme shyness" at an earlier age. Selective mutism must persist for at least one month is a diagnostic criteria. Often, these children can be very talkative, even boisterous in a place where they feel comfortable.

Children suffering from Selective Mutism may:

* Stand motionless and expressionless (try to be "invisible")
* Avoid eye contact or withdraw out of sight
* Exhibit Separation Anxiety
* Exhibit anxiety symptoms, both physical and behavioral before social events
* Exhibit frequent tantrums, inflexibility, sleep problems and extreme shyness.

These symptoms can be seen in infancy.

Specific Phobias

A specific phobia is defined as an intense, irrational fear of a specific object, or a situation. Fears are common in childhood and often go away. A phobia is diagnosed if fear persists for at least 6 months and interferes with daily life. Childhood phobias can include:

* Animals, "monsters", cartoon characters
* Storms, loud noises
* Heights, elevators
* Pools, bathtubs
* Night time or the dark
* Needles, or medical procedures, blood

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder can affect children between six and eleven years old. It is characterized by excessive worry and anxiety over a variety of things such as performance, family, health, natural disasters, etc.
The affected child cannot control his/her worry and it interferes with normal activities.

Symptoms are characterized as:

* Muscle tension and inability to relax: restlessness
* Fatigue, sleep difficulty
* Difficulty concentrating, muscle aches
* Irritability

Children with GAD tend to be hypercritical of themselves and strive for perfection. They may require constant reassurance and approval.

Panic Disorder with or without Agoraphobia

Adolescents can experience the same symptoms as seen in adults and follows the same adult diagnostic criteria. Panic Disorder is diagnosed when a child suffers at least two unexpected Panic Attacks, followed by at least 1 month of concern over having another attack, losing control, or "going crazy." The most common age of onset for Panic Disorder is the early to mid twenties. It can begin in adolescence, and is less common in children

A Panic Attack is defined as the abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes.

Children often become apprehensive when in situations or places where they have previously had attacks. Agoraphobia can develop when a child begins to avoid situations in which a panic attack previously occurred, or avoids places which s/he feels would not be able to escape if experiencing a Panic Attack. Children can also avoid places or situations in which they fear a symptom attack will occur. Symptoms can include: nausea, headache, dizziness, palpitations, fainting.

Treatment Options may Include combinations:

* Cognitive Behavior Therapy
* Exposure Response Prevention
* Family Education
* Group Therapy
* Individual Therapy
* Medication

Saint Louis Behavioral Medicine Institute, Universal Health Services an academic affiliate of Saint Louis University Health Sciences Center is an established mental health care resource for St. Louis, MO. Visit their website at