PsyDactic - Child and Adolescent Psychiatry Board Study Edition

021 - Anxiety Disorders of Childhood

• T. Ryan O'Leary, MD • Episode 21

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In this episode Dr. O'Leary delves into the complex world of Pediatric Anxiety Disorders. Learn about Separation Anxiety Disorder, Selective Mutism, Specific Phobias, Social Anxiety Disorder, Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder. Through clinical vignettes and DSM-5-TR criteria, this episode explores the nuances of diagnosis and when typical childhood anxiety crosses into a disorder. Dr. O'Leary also covers prevalence, etiology, and evidence-based treatments including Cognitive Behavioral Therapy (CBT) and pharmacotherapy like SSRIs. Key takeaways include the importance of accurate diagnosis, understanding child-specific presentations, and the nuances of medication use in children. This is essential listening for anyone interested in child and adolescent mental health, or studying for psychiatry board exams.

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com


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This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Pediatric Anxiety Disorders - Script

    Actual recording will differ


Welcome to PsyDactic Child and Adolescent Psychiatry Edition.  I am your host Dr. O’Leary, a fellow in Child and Adolescent Psychiatry in the National Capital region.  I started this podcast feed to help me study for my board exams and I hope it helps you as well, but anyone interested in human development or mental health may enjoy this content.  I need to let you know that everything that I say here should be considered to be my own opinion even if I am quoting or referencing someone or some institution.  Additionally, I have been learning how to use A.I. to assist me with the content creation and research.  Specifically, for this episode I used Gemini’s Deep Research tool to produce a detailed overview of Pediatric Anxiety Disorders and then consolidated that information into a podcast script that includes my own content merged with the A.I. content.  I use my own background knowledge as well as spot checking of the facts to make sure that the A.I. isn’t just making stuff up.  Like humans, A.I. makes mistakes, but I have found it recently to be at least or even more reliable than human produced content.


Previous episodes have also used A.I.-generated-hosts to deliver the content, but I find that I learn the content better if I host the podcast myself, so for topics like anxiety disorders that will make up between 7-9% of the ABPH board content, I want to be more intimately involved with producing the content.



In this episode, I am covering Separation Anxiety Disorder (SAD), Selective Mutism (SM), Specific Phobia (SP), Social Anxiety Disorder (SAD/SoP), Panic Disorder (PD), Agoraphobia, and Generalized Anxiety Disorder (GAD). But first, let's make this more practical. I’m going to present some clinical vignettes, and I want you to think about the most likely diagnosis. Let's start with Maureen.


(Sound Effect)


An 8-year-old girl, Maureen, is brought to the clinic by her mother due to a six-week history of refusing to attend school. Each morning, Maureen cries, clings to her mother, and complains of severe stomachaches and nausea. She repeatedly tells her mother, "I'm scared something terrible will happen" while she is away from her mother and she may never see her again.  Maureen also has significant difficulty sleeping alone, often needing someone to stay in her room until she falls asleep and gets up in the middle of the night to get in bed with her parents.  When she finds herself alone in a room at home she frequently calls out to her mom and goes to look for her. She has always had difficulty sleeping alone, but the school avoidance and frequent reassurance seeking started shortly after her mother had a brief, uneventful hospitalization for a minor surgical procedure. Maureen’s grades have started to decline, and she has stopped attending friends' birthday parties and after-school activities she previously enjoyed.



So, what do you think? The answer here is (C) Separation Anxiety Disorder. Maureen exhibits excessive fear of separation from her mother, school refusal due to this fear, worries about harm to her mother, sleep difficulties when not near her mother, and physical symptoms related to the separation. All this lasting for more than 4 weeks.  This isn't GAD's diffuse worry, Social Anxiety's fear of scrutiny, or a Specific Phobia of school itself.




Next, let's look at Lily.


A 5-year-old girl, Lily, is in her first year of kindergarten. Her parents describe her as a "chatterbox" at home, where she is talkative, expressive, and playful with her parents and older sibling. However, her kindergarten teacher reports that Lily has barely spoken in the classroom or to any school staff since starting school 3 months ago. She appears to understand instructions, follows classroom routines, and willingly participates in non-verbal activities such as drawing and puzzles. When asked direct questions by the teacher or peers, Lily typically looks down, remains silent, or communicates with simple gestures like nodding or shaking her head. Her parents confirm her language skills at home are age-appropriate, and she had no prior speech or language delays.  There is one teacher with home she has whispered to a couple of times.


(Pause)


 The diagnosis for Lily is (C) Selective Mutism. She speaks at home but fails consistently to speak at school for more than a month. This isn’t a language disorder or autism; she communicates fine in other settings.




Anxiety is a normal part of childhood. Think about the developmentally appropriate separation anxiety in toddlers or a young child's fear of the dark.  In fact, if a child did not display some separation anxiety, we would wonder if there was something developmentally wrong.  But when does it cross the line into a disorder? In general pathological anxiety in children and adolescents is marked by its severity, persistence—often six months or more for many disorders, though shorter for some like Separation Anxiety Disorder in kids—and the significant dysfunction or impairment it causes in their daily lives, whether at school, with friends, or at home.

Pediatric anxiety disorders are the most common psychiatric conditions in youth, affecting roughly 1 in 12 children overall and this increases to an estimated 1 in 4 adolescents.  These aren't just "phases" of development that they'll likely outgrow without any help. Untreated anxiety is often chronic, persisting into adulthood and increasing the risk for other conditions like depression and substance use disorders.  Sometimes, anxiety in children mimics other conditions. A child might be inattentive, restless, irritable, or have frequent stomachaches or headaches.  This can lead to misdiagnosis, perhaps as ADHD or ODD, if the underlying anxiety isn't recognized.  That's why accurate diagnosis and timely, evidence-based treatment are so critical.



 Alright, let's get into the nitty-gritty: the DSM-5-TR diagnostic criteria.

First up, Separation Anxiety Disorder

The core feature here is developmentally inappropriate and excessive fear or anxiety about separation from attachment figures. To diagnose SAD, you need at least three of eight specific symptoms. These include recurrent distress around separation, persistent worry about losing or harm to attachment figures, worry about events leading to separation (like getting lost or kidnapped), reluctance or refusal to go out or to school due to separation fears, fear of being alone, reluctance to sleep away from home or without an attachment figure nearby, nightmares about separation, and repeated physical complaints like headaches or stomachaches when separation is anticipated or occurs.


A key child-specific point: the duration must be at least 4 weeks in children and adolescents, compared to 6 months for adults. And of course, this has to cause clinically significant distress or impairment.  I doubt a parent would be asking you to evaluate a child with 3 of 8 of these symptoms if it wasn’t causing distress, but just in case you incidentally found out that they meet 3 of the 8 criteria and there is no reported impairment, then you should be giving the diagnosis.  This logic carries forward all diagnoses that require impairment.


Next, Selective Mutism 

This is characterized by a consistent failure to speak in specific social situations where speaking is expected, like at school, even though the child speaks in other situations, like at home. This isn't due to a lack of language knowledge, for example when learning a second language, or a communication disorder (see episode 13 for a rundown on that). The disturbance must last at least 1 month (and not just the first month of school) and interfere with educational achievement or social communication. Onset is typically before age 5, though it often comes to clinical attention when school starts because before this, some kids (especially those who were 3-4 during the COVID pandemic), had not had a lot of opportunity to present. These kids might use frequent nonverbal communication like gestures or writing.


Then we have Specific Phobia

This involves a marked, persistent, and excessive fear or anxiety about a specific object or situation (called a stimulus) – think animals, heights, needles, flying, etc. The phobic stimulus almost always provokes immediate fear, is actively avoided or endured with intense anxiety, and the fear is out of proportion to the actual danger. This must last for 6 months or more and cause significant distress or impairment.  My son, for example, loves to fish, but is somehow terrified to hold a wiggling earthworm.  A non-wiggling worm is ok, but a wiggling one is terrifying to him.  Even though earthworms are harmless, it causes significant distress, but his impairment is really limited to putting bait on a hook, so I’m ambivalent about calling it a disorder because we don’t fish for a living.  However, it does interrupt the fun of fishing.


Anyway, the phobias we treat are generally going to have more severe consequences.  For kids, the fear or anxiety can be expressed as crying, tantrums, freezing, or clinging.  Importantly, the DSM-5-TR removed the requirement that the individual (including children) must recognize their fear as excessive.


Now for Social Anxiety Disorder (or Social Phobia), or SAD.  You know what, I am not going to call it “sad” or S A D because that is just sad.  Social anxiety is a marked fear or anxiety about one or more social situations where the individual is exposed to possible scrutiny by others – like conversations, meeting new people, being observed eating, or performing.  The core fear is acting in a way or showing anxiety symptoms that will be negatively evaluated (humiliating, embarrassing, leading to rejection).  These situations almost always provoke fear, are avoided or endured with intense anxiety, the fear is out of proportion.  It also needs to be present for 6 months or more, and causes significant distress or impairment.  This means a single incident of refusal to do something, like speak in front of the class, does not meet criteria.  


Crucially for children, the anxiety must occur in peer settings, not just with adults.  And like with specific phobias, their anxiety can manifest as crying, tantrums, freezing, clinging, or failing to speak.  For kids who have been diagnosed with Selective Mutism, there is something close to a 90% chance that they also have social anxiety disorder, so be on the lookout for this comorbidity.


It's also important to remember that for both Specific Phobia and Social Anxiety Disorder, behavioral expressions in children—tantrums, clinging—can easily be misread as defiance rather than anxiety.  A thorough history is key.

Moving on to Panic Disorder 

The essential feature is recurrent unexpected panic attacks. If a kid knows that they hate public speaking and has a panic attack prior to every instance, this is not a panic attack that counts for panic disorder. A panic attack is an abrupt surge of intense fear or discomfort peaking within minutes, with at least 4 of 13 symptoms like palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills or heat, paresthesias, derealization/depersonalization, fear of losing control or "going crazy," or fear of dying.  That is a lot of things, but you only need to have 4 of them reported. For the disorder, at least one attack must be followed by 1 month or more of persistent concern about more attacks or their consequences, or a significant maladaptive change in behavior related to the attacks. 


Younger children don’t tend to report cognitive symptoms like a fear of losing control and tend to focus more on the physical sensations. The APA has a Severity Measure for Panic Disorder for kids aged 11-17. (https://www.psychiatry.org/getmedia/bdf5a1a6-1357-4bb6-9c37-0ca93d7e062e/APA-DSM5TR-SeverityMeasureForPanicDisorderChildAge11To17.pdf) 


Next is Agoraphobia

This involves marked fear or anxiety about two or more of five situations: using public transport, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside the home alone. The individual fears these because escape might be difficult or help unavailable if panic-like or other incapacitating/embarrassing symptoms occur. These situations almost always provoke fear, are actively avoided or endured with intense anxiety, the fear is out of proportion, lasts 6 months or more, and causes significant distress/impairment.


A key DSM-5 change was decoupling Agoraphobia from Panic Disorder; it's now a distinct diagnosis and this can get tricky.  The key difference is the reason to avoid certain situations or leaving the home.  If there is a generalized fear of public use spaces or open spaces, this is agoraphobia.  If the reason is exclusively because of fear of a random panic attack, that is panic disorder.  You can have agoraphobia and specify that there are panic attacks present.  In children, the feared incapacitating symptoms might include disorientation or getting lost, not just panic.


Finally, Generalized Anxiety Disorder.

The core is excessive anxiety and worry about a number of events or activities, occurring more days than not for at least 6 months. The individual finds it hard to control the worry. The anxiety and worry are associated with symptoms like restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, or sleep disturbance.


Here’s a critical child-specific point: only one of these associated symptoms plus impairment is required for children, versus three for adults.  Children with GAD often worry about competence, safety, or future events and can be perfectionistic.  Somatic complaints are also common.  While this "one symptom rule" can aid detection, it also means clinicians must be rigorous in confirming excessive, uncontrollable worry and functional impairment to avoid over-pathologizing normal childhood experiences.


Now, let's turn to epidemiology. Anxiety disorders are highly prevalent, with global estimates around 6.5% to 8.3% in children and up to 25% in adolescents age 13-18 depending on who is measuring.  Females are more commonly affected, often at a 2:1 to 3:1 ratio. Etiology is multifactorial, involving genetic predispositions (like behavioral inhibition) and environmental factors (stressful life events, parenting styles, socioeconomic status).  If you are interested in how environmental factors contribute to anxiety, listen to or read The Anxious Generation, a book by Jonathan Haidt (thats h-a-i-d-t) as he attempts to explain why anxiety disorders have been on the rise for the past couple of decades.  

Comorbidity is very common, both with other anxiety disorders and with conditions like depression, ADHD, bipolar, and disruptive behavior disorders. 7

Let's quickly touch on specifics for each:

  • Separation Anxiety Disorder: Prevalence around 4.1% in community samples, one of the earliest onsets at around 6 years. Risk factors include family history of anxiety/depression and overprotective parenting. Highly comorbid with GAD, specific phobias, and depression.
  • Selective Mutism (SM): Rare, estimates are generally less than 1%. Onset before age 5, often noticed at school entry. Behavioral inhibition and family history of shyness are strong risk factors.  Extremely high comorbidity with Social Anxiety Disorder (often over 80-97%).
  • Specific Phobia (SP): Lifetime prevalence 3-15% globally, around 20% in US adolescents. Onset typically 7-11 years. Risk factors include female gender, behavioral inhibition, and direct or vicarious negative experiences with the phobic stimulus.  Phobias of needles, flying, and bugs are super common. High comorbidity with other anxiety and mood disorders.
  • Social Anxiety Disorder: Social Anxiety Disorder has an estimated global prevalence of 4.7% in children, 8.3% in adolescents, and 17% in youth.  Social anxiety appears to increase with age then level off in young adulthood and then persist. Median onset around 13 years. Behavioral inhibition and fear of negative evaluation are key risk factors; child maltreatment and peer victimization also play a role.  Obviously bullying is going to have an effect on whether normal social anxiety becomes intolerable. Comorbid with other anxiety disorders, depression, and substance use. Difficulties in peer relations can be both a risk factor and a consequence for SAD/SoP and GAD, creating a negative feedback loop.
  • Panic Disorder (PD): Uncommon before age 14 (less than a half of a percent), but jumps to around 1 or 2% in US adolescents. More common in females by about 3:1 ratio.  Very high comorbidity with other anxiety and mood disorders and panic symptoms are also common in PTSD.
  • Agoraphobia: Uncommon in young children, lifetime prevalence in US adolescents around 2-ish%. Generally onset after 20 years of age and prevalence continues to increase with age. More common in females; risk factors include panic disorder, neuroticism, and anxiety sensitivity. High comorbidity with other anxiety and depressive disorders.
  • Generalized Anxiety Disorder (GAD): Prevalence between 2.2% to 4.6% in youth.  Median onset late adolescence (16-18 years). More prevalent in adolescent females. Significant genetic contribution; temperamental traits like behavioral inhibition and negative affectivity are risk factors, as are environmental factors like parental psychopathology and stress. High comorbidity with other anxiety disorders and depression.


I think it is a good time for a couple more vignettes

Vignette: Social Anxiety Disorder

Scenario: A 14-year-old boy, David, is referred for social withdrawal and worsening academic performance in the 4th quarter of 8th grade.  Parents report he has never been a social butterfly, but this year increasingly avoids school dances, parties, and the cafeteria, preferring to bring his own lunch and eat in a more quiet place. He has skipped his humanities class recently and failed to tell parents about a project he was supposed to present last week.  They report that once about a month ago, they had to pick him up from school following a panic attack he had when he remembered that he left his lunch at home.

Question: Given this limited information, what is the most likely diagnosis for David:

(A) Generalized Anxiety Disorder

(B) Separation Anxiety Disorder

(C) Social Anxiety Disorder

(D) Agoraphobia

(F) Panic Disorder

(Pause for 5-7 seconds)

 With this information, I am most suspecting (C) Social Anxiety Disorder, but it is not a slam dunk.  David's core fear appears to be social situations involving peers or having to present in front of peers. He shows avoidance and distress in these situations. We haven’t been given information about broad worry or for separation fears, which are usually present in younger children.  My next question might be “How often do you think about whether or not you might have a panic attack?” or “How does he appear when taking public transportation or going to a park?”


Vignette: Agoraphobia

Scenario: For 8 months, a 15-year-old boy, Ben, has refused to accompany his family to crowded places (like restaurants, theaters, concerts) and has skipped school when required to take the public buses. He is not sure what he is afraid of, but sometimes has fantasies of a public shooter or the guy next to him will have a heart attack, during which he will be trapped by a gathering crowd or trampled when trying to escape from the shooter.  He thinks that the probability of these events is far higher than it actually is. He's has had panic symptoms which tended to build within him during the expectation of having to go somewhere outside of the home.  For example, his parents had to coax him into the car because he did not want to go to the medical clinic, insisting he was fine.


Question: The most likely diagnosis for Ben is which of the following:

(A) Panic Disorder with Agoraphobia

(B) Specific Phobia, Situational Type

(C) Social Anxiety Disorder

(D) Agoraphobia

(Pause for 5-7 seconds)

Ben is meeting criteria for (D) Agoraphobia. He fears and avoids multiple agoraphobic specific situations (crowds, public transport, enclosed places) due to thoughts that escape might be difficult if something bad happens.  His fears of what might happen are not specific to a single situation.  It’s broader than a Specific Phobia of crowds or buses.  This has lasted over 6 months with impairment. Since he hasn't had unexpected panic attacks, and DSM-5 allows Agoraphobia as a standalone diagnosis, this fits best.


Let's shift gears to treatment. The mainstays for pediatric anxiety of all types are various forms of Cognitive Behavioral Therapy (CBT) and pharmacotherapy, particularly SSRIs SNRIs.  Combination therapy is often best for moderate to severe cases. 

Cognitive Behavioral Therapy (CBT) is a first-line psychosocial treatment.  Core components include psychoeducation, somatic arousal management (like relaxation techniques), cognitive restructuring (challenging anxious thoughts), problem-solving, and critically, exposure therapy – gradual confrontation with feared stimuli.  Parental involvement is really key here.  Many parents cannot stand seeing their child in distress and will have reinforced their fears by allowing them to avoid situations.  This is super common.  Many kids with anxiety will learn to cope with it if there is no other choice, but if a caregiver becomes anxious about their anxiety, this is extraordinarily reinforcing.

Several influential studies support CBT. A 2017 meta-analysis by Wang and colleagues found CBT significantly improved anxiety symptoms and remission rates compared to no treatment and even beat fluoxetine head to head, suggesting that CBT was more effective than some SSRIs and overall CBT has lower dropout rates in studies and fewer side effects.  However, the side effects of SSRIs in studies of anxiety disorders are generally mild.


The Child/Adolescent Anxiety Multimodal Study (CAMS) was a landmark trial.  Acutely, at 12 weeks, the combination of CBT and sertraline (COMB) had the highest response rate (80.7%), significantly better than CBT alone (59.7%) or sertraline alone (54.9%). All active treatments beat placebo (23.7%). This low placebo response was important at the time because it demonstrated that "watchful waiting" often isn't enough. Long-term, at 36 weeks, most acute responders (about 80%) maintained their gains. While CBT and sertraline monotherapy outcomes improved and converged with COMB with peaked early with regard to remission rates based on CGI-S severity, the COMB group maintained an edge for achieving full diagnostic remission for any anxiety disorder at weeks.


For Specific Phobias, exposure is key.  You are not going to medicate these away. The ASPECT trial published in 2022 looked at One Session Treatment (OST) versus multi-session CBT for specific phobias.  Children aged 7-16 years with specific phobia were randomized to receive OST or CBT and they found similar efficacy for both.


Now for Pharmacotherapy. SSRIs are generally used first-line. SNRIs like venlafaxine and duloxetine are often used second-line.  If you are looking for FDA approved medication specifically for generalized anxiety, duloxetine and escitalopram are the only meds specifically approved in kids.  For OCD we have approvals for lexapro (escitalopram), fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox), but if you are relying on FDA approved medications specifically for generalized anxiety in children, you don’t have many choices.  It would make a good test question, but is not as useful in clinical practice.


A network analysis by Dobson, Bloch, and Strawn in 2019 included 22 RCTs with a total of 24 treatment arms including 2,623 patients. Selective serotonin reuptake inhibitors (SSRIs) as a class were superior in reducing anxiety.  Serotonin-norepinephrine reuptake inhibitor (SNRI) and α₂ agonist treatment separated from placebo. The likelihood of treatment response was about double for SSRIs compared to SNRIs.


SSRIs potentially have earlier onset and greater efficacy than SNRIs for core pediatric anxiety disorders. 


Remember the FDA black box warning for all antidepressants regarding increased risk of suicidal thoughts and behavior in children, adolescents, and young adults under 25, so close monitoring is essential.


So, what is FDA-approved for pediatric anxiety?

  • Duloxetine (Cymbalta), an SNRI, is approved for GAD in ages 7 and older. 67
  • Escitalopram (Lexapro), an SSRI, was approved in May 2023 for GAD in ages 7 and older. 13 

For OCD, which is anxiety-related:

  • Fluoxetine (Prozac) for OCD (ages 7+) and MDD (ages 8+). 80
  • Sertraline (Zoloft) for OCD (ages 6+). 11
  • Fluvoxamine (Luvox) for OCD (ages 8+). 67
  • Clomipramine (Anafranil), a TCA, for OCD (ages 10+). 67 

No medications are specifically FDA-approved for pediatric Separation Anxiety Disorder, Social Anxiety Disorder, Specific Phobia, Panic Disorder, Agoraphobia, or Selective Mutism. SSRIs are commonly used off-label for these.


This brings us to a crucial point for your boards and practice: medications that are effective in adults but have different efficacy or safety profiles in children. Kids are not just small adults! Neurodevelopmental differences in brain structure, receptor sensitivity, and drug metabolism play huge roles. Methodological challenges in pediatric trials, like higher placebo response rates, can also complicate findings.

Let's look at a few key classes:

  • Benzodiazepines: While effective for short-term adult anxiety, RCTs in pediatric anxiety disorders (not procedural anxiety) have largely failed to show superiority over placebo. Risks in children include dependence, withdrawal, and paradoxical reactions like agitation or aggression.  So, generally not recommended for pediatric anxiety disorders.
  • Tricyclic Antidepressants (TCAs) (excluding clomipramine for OCD): Effective for some adult anxiety, but evidence in pediatric anxiety (non-OCD) is sparse. 
  • Buspirone: FDA-approved for adult GAD. However, two large RCTs in pediatric GAD failed to show superiority over placebo, though these trials might have been underpowered. It was generally well-tolerated in kids, but with higher dropout due to adverse events. Not currently recommended due to lack of proven efficacy.
  • Hydroxyzine: An antihistamine with some anxiolytic effects in adult GAD. There's a lack of robust RCT evidence for its use as a primary treatment for DSM-defined pediatric anxiety disorders. Sedation is a prominent side effect in children and I have seen this effect in practice, so I rarely use it. It might have a limited role for acute distress or procedural anxiety, but not as a primary ongoing treatment.


Thank you for hanging out with me today. Today we reviewed pediatric anxiety disorders, which are very common, impairing, and require a developmentally-informed approach at every stage – from diagnosis using DSM-5-TR criteria with its child-specific nuances, and selecting evidence-based treatments like CBT and SSRIs which also have many considerations based on age.  In general for moderate to severe anxiety, combination therapy often yields the largest and most durable results.  And always be mindful that medications like benzodiazepines, most TCAs, buspirone, and hydroxyzine which have recognized utility in adults, generally lack robust efficacy or have less favorable risk-benefit profiles in children.

Until next time, I am Dr. O’Leary and this has been an episode of PsyDactic - Child and Adolescent Psychiatry Edition.

(Outro Music Fades Out)


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