Children's Hospital Colorado
Pediatric Mental Health Institute
Pediatric Mental Health Institute

Assessment and Treatment of Childhood Anxiety

Most children and teens experience anxiety to some degree — usually about some dreaded event like a test or performance. Anxiety becomes disordered when such apprehension is persistent, distressing and impairing. When the anxiety becomes severe enough, it can negatively impact academic and social functioning.

In one large epidemiologic study, the National Comorbidity Study – Adolescent Supplement, one third of adolescents met criteria for an anxiety disorder, with about a tenth being severely affected. Due to the ad and childhood, pediatricians confront anxiety in children on a daily basis. Despite being so widespread and impairing, anxiety disorders are often difficult to detect and pediatric anxiety treatment guidelines are not well-known.

Detecting anxiety in pediatric patients

Parents and children may not mention concerns because they may be embarrassing and not clearly disruptive. Children and teens may only complain of anxiety-related physical symptoms, such as stomach aches or headaches. A careful history revealing clear triggers helps in identifying the anxious origin of such complaints, such as stomach aches that reliably occur in the morning before school.

Another issue is that anxious youth may only express irritability or disruptive behavior. Well-crafted screening practices can help, along with a reliable referral network for further evaluation. For example, the Pediatric Symptom Checklist is a well-validated childhood anxiety assessment tool that covers quite a bit of ground and is freely available in a number of languages.

Pediatric and adolescent anxiety treatment

The first step in the assessment and treatment of anxiety is ruling out other mental disorders, environmental exposures and physical conditions that present with anxiety disorder-like symptoms. Next, specifying the type of anxiety disorder will direct treatment. Broadly speaking, most anxiety disorders are treated by a combination of family education, psychotherapy and medications.

Therapy for childhood anxiety

A common theme for all anxiety disorders is that they arise from a perceived threat — harm, peer rejection, separation, panic, imperfection or some amalgam of concerns. Psychotherapy for anxiety seeks to dissipate these concerns with two basic "active ingredients": cognitive restructuring and exposure. Cognitive restructuring helps children 'reappraise' whatever they dread. For example, a therapist might help a young athlete interpret pre-game jitters as excitement rather than anxiety. Exposure is just what it sounds like: confronting the fear. However, this is done in a therapeutic environment to prevent increasing the anxiety.

Medications for childhood anxiety

Several medications can help children with moderate to severe anxiety. Evidence supports the use of selective serotonin reuptake inhibitors (SSRIs) based on their efficacy and relative safety. However, they are not risk-free and can cause anxiety-like symptoms themselves, so an experienced practitioner should evaluate and monitor the use of SSRIs in children in accordance with FDA guidelines.

Medications do not cure anxiety, but often reduce it. The combination of medications and psychotherapy is most effective. In fact, some promising medications in development are designed to enhance psychotherapy.

With astute intervention, most children and teens with anxiety disorders can increase their coping skills and learn strategies for success at school, home and in all their pursuits.

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