Anxiety disorders in children

Some degree of anxiety is a normal aspect of child development. For example, most 1- to 2-year-olds are afraid of separation from their mother, especially in unfamiliar places. Fear of the dark, monsters, bugs, and spiders is common in 3- to 4-year-olds. Shy children may have a first reaction to new situations with fear or rejection. Fear of injury and death is common in older children. Older children and adolescents often become anxious when presenting a book to a class. Such difficulties should not be considered manifestations of a disorder. However, if these otherwise normal manifestations of anxiety become so pronounced that normal functioning is significantly disrupted or the child experiences severe stress, an anxiety disorder should be considered.

Epidemiology

At various points in childhood, approximately 10-15% of children suffer from an anxiety disorder (e.g., generalized anxiety disorder, separation anxiety, social phobia; obsessive-compulsive disorder; specific phobias; acute and post-traumatic stress disorder). What all anxiety disorders have in common is a state of fear, worry, or anxiety that significantly disrupts the child's lifestyle and is out of proportion to the circumstances that caused it.

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Causes of anxiety disorders in a child

The cause of anxiety disorders has a genetic basis, but is significantly modified by psychosocial experience; the mode of inheritance is polygenic, and only a small number of specific genes have been described to date. Anxious parents tend to have anxious children, which has the potential to make the child's problems worse than they otherwise would be. Even a normal child has difficulty remaining calm and collected in the presence of anxious parents, and for a child genetically predisposed to anxiety this is much more problematic. In 30% of cases, the effect of treating anxiety disorders is achieved by treating the parents in combination with treating the child.

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Symptoms of anxiety disorders in a child

Probably the most common manifestation is refusal to go to school. "School denial" has largely been superseded by the term "school phobia." True fear of school is extremely rare. Most children who refuse to go to school probably have separation anxiety, social phobia, panic disorder, or a combination of these. Refusal to go to school is also sometimes seen in children with specific phobias.

Some children complain directly of anxiety, describing it as worrying about something, such as “I’m afraid I’ll never see you again” (separation anxiety) or “I’m afraid the kids will laugh at me” (social phobia). At the same time, most children describe discomfort as somatic complaints: “I can’t go to school because my stomach hurts.” Such complaints can lead to some confusion, since the child is often telling the truth. Upset stomach, nausea, and headaches often develop in children with anxiety disorders.

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Diagnostics of anxiety disorders in a child

Diagnosis varies depending on the specific anxiety disorder.

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Treatment of anxiety disorders in a child

Anxiety disorders in children are treated using behavioral therapy (exposure to the anxiety-provoking factor and response prevention), sometimes in combination with medication. In behavioral therapy, the child is systematically placed in an anxiety-provoking situation, gradually changing in intensity. By helping the child stay in the anxiety-provoking situation (response prevention), therapy allows the child to gradually become less susceptible to such situations, and anxiety decreases. Behavioral therapy is most effective when an experienced therapist familiar with child development individualizes these principles.

In mild cases, behavioral therapy alone is usually sufficient, but medication may be needed in more severe cases or if an experienced therapist specializing in pediatric behavioral therapy is not available. Selective serotonin reuptake inhibitors (SSRIs) are usually the first choice when medication is needed.

Most children tolerate SSRI therapy without complications. Occasionally, gastric discomfort, diarrhea, or insomnia may occur. Some children experience behavioral side effects, including agitation and disinhibition. A small proportion of children do not tolerate SSRIs, in which case serotonergic tricyclic antidepressants such as clomipramine or imipramine are acceptable alternatives; both are given at a starting dose of 25 mg orally at bedtime, which is often sufficient. If higher doses are necessary, serum drug levels and ECGs should be monitored. Blood levels should not exceed 225 ng/mL, as higher levels are often associated with an increased risk of side effects for a relatively small increase in therapeutic effect. Because drug absorption and metabolism vary widely, the doses required to achieve therapeutic levels vary widely. In some cases, dividing the dose into two or three doses may be necessary to reduce side effects.

SSRIs Used in Older Children and Adolescents

Preparation	Starting dose	Maintenance dose	Comments
Citalopram	20 mg once	40 mg once daily	Escitalopram analogue
Escitalopram	10 mg once	20 mg once daily	The most selective of the SSRIs
Fluoxen	10 mg once	40 mg once daily	Long half-life; most stimulating SSRI; drug accumulation may occur in some patients
Fluvoxamine	50 mg once	100 mg twice daily	May increase levels of caffeine and other xanthines
Paroxetine	10 mg once	50 mg once daily	Has the most pronounced sedative effect of all SSRIs; withdrawal symptoms may occur in some patients
Sertraline	25 mg once	50 mg once daily	FDA approved for obsessive-compulsive disorder in children under 6 years of age

¹ Behavioural side effects such as disinhibition and agitation may occur. They are usually mild to moderate in severity; reducing the dose or changing to a similar drug is usually sufficient to manage behavioural side effects. Rarely, severe side effects such as aggression and suicidal behaviour may occur. These side effects are idiosyncratic and may occur with any antidepressant and at any time during treatment. Children and adolescents treated with these drugs should therefore be monitored closely.

The dosage range is approximate. There is considerable variability in both therapeutic effect and adverse reactions; the starting dose is exceeded only if necessary. This table does not replace complete information on the use of the drugs.

Forecast

The prognosis depends on the severity, availability of competent treatment, and the child's ability to recover. In most cases, children struggle with anxiety symptoms well into adulthood and beyond. However, with early treatment, many children learn how to control their fear.

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