Anxiety

  1. Definitions
    1. Variations
    2. Problems
    3. Disorders
  2. Key Points
  3. Assessment
  4. Differential Diagnosis and Comorbidity
  5. Management
  6. Appendices
    1. Further Information for the Physician
    2. Temperament
  7. Further Reading
  8. Citations

Definitions

According to the Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version (M. Wolraich (Ed.) 1996) , the following are the definitions for Anxiety variations and problems.

Variations

V65.49 Anxious Variation

Fears and worries are experienced that are appropriate for developmental age and do not affect normal development.

Transient anxious responses to stressful events occur in otherwise healthy child and they do not affect normal development.

Problems

V40.2 Anxiety Problem

An anxiety problem involves excessive worry or fearfulness that causes distress in the child. However, the behaviors are not sufficiently intense to qualify for an anxiety disorder or adjustment disorder with anxious mood.

Disorders

309.21 Separation Anxiety Disorder

  1. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
    1. recurrent excessive distress when separation from home or major attachment figured occurs or is anticipated
    2. persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
    3. persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
    4. persistent reluctance or refusal to go to school or elsewhere because of fear of separation
    5. persistently and excessively fearful or reluctant to be alone or without major attachment figured at home or without significant adults in other settings
    6. persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
    7. repeated nightmares involving the theme of separation
    8. repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
  2. The duration of the disturbance is at least 4 weeks.
  3. The onset if before age 18 years.
  4. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.
Specify if:
Early Onset: if onset occurs before age 6 years

Separation Anxiety Disorder (DC: 0-3R and Associated CHADIS Criteria)

Normal text is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005, pp. 21-23). Italisized text conveys information about the CHADIS items assessing the DC: 0-3R criteria. Please note that per DC: 0-3R guidelines, anxiety disorders are only diagnosed in children 24 months and older. The only exception is Anxiety Disorder NOS, which can be diagnosed in CHADIS as young as age 4 months.

The diagnosis of Separation Anxiety Disorder requires that ALL FIVE of the following criteria be met:

  1. The child experiences developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the child is attached. At least some of the time, the child cannot control the anxiety. The anxiety is evidenced by THREE (OR MORE) of the following:
    1. Recurrent, excessive distress when separation from home or major attachment figures occurs or is anticipated. ("Does your child get extremely upset about being separated or about the idea of being separated from you or another important adult?" --Often or Almost Always)
    2. Persistent, excessive worry that an untoward event (e.g., getting lost or being kidnapped) will lead to separation from a major attachment figure ("Does your child worry that something bad will happen to you or another important adult in his/her life?" --Often or Almost Always)
    3. Persistent reluctance or refusal to go to child care, school, or elsewhere out of fear of separation. ("Does your child get very upset or refuse to go to daycare, school, or other places without you?"--Often or Almost Always)
    4. Persistent or excessive fear or reluctance to be alone or without major attachment figures at home or without significant adults in other settings. ("Does your child have trouble being separate from you within your house (for example, when you are in another room)?"--Often or Almost Always)
    5. Persistent reluctance or refusal to go to sleep without the presence of a major attachment figure ("Is your child too anxious to fall asleep without an adult, either at bedtime or in the middle of the night?"--Often or Almost Always)
    6. Repeated nightmares involving the theme of separation. ("Does your child have nightmares?" --Often or Almost Always)
    7. Repeated complaints or expression of physical symptoms when separation from major attachment figures occurs or is anticipated. ("Does your child act or seem ill or in pain when he/she has to separate from you or other important adults?"--Often or Almost Always)
  2. The disturbance causes clinically significant distress for the child or leads to avoidance of activities or settings associated with the anxiety or fear ("You said that your child has trouble separating from you or other caregivers. Do you or your child miss out on things because of this?" --Often or Almost Always)
  3. The disturbance impairs the child's or family's functioning and/or the child's expected development.
  4. The disturbance does not occur exclusively during the course of pervasive developmental disorder.
  5. The disturbance lasts for at least 1 MONTH. ("You said that your child has trouble separating from you or other caregivers. How long has this been going on?" --At least a month)

300.01 Panic Disorder without Agoraphobia

  1. Both (1) and (2):
    1. recurrent unexpected Panic Attacks
    2. at least one of the attacks has been followed by 1 month ( or more) of one (or more) of the following:
      1. persistent concern about having additional attacks
      2. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
      3. a significant change in behavior related to the attacks
  2. Absence of Agoraphobia
  3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
  4. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations, Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

300.21 Panic Disorder with Agoraphobia

  1. Both (1) and (2):
    1. recurrent unexpected Panic Attacks
    2. at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
      1. persistent concern about having additional attacks
      2. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
      3. a significant change in behavior related to the attacks
  2. The presence of Agoraphobia
  3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
  4. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring an exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive- Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

300.22 Agoraphobia without History of Panic Disorder

  1. The presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea).
  2. Criteria have never been met for Panic Disorder.
  3. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
  4. If an associated general medical condition is present, that fear described in Criterion A is clearly in excess of that usually associated with the condition.

300.29 Specific Phobia

  1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
  2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
  3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
  4. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia without History of Panic Disorder.
Specify type:
Animal Type: if the fear is cued by animals or insects. This subtype generally has a childhood onset.
Natural Environment Type: if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset.
Blood-Injection-Injury Type: if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response.
Situational Type: if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. This subtype appears to be similar to Panic Disorder with Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset.
Other Type: if the fear is cued by other stimuli. These stimuli might include the fear of avoidance of situations that might lead to choking, vomiting, or contracting and illness; "space" phobia (i.e., the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters.

Specific Phobia (DC: 0-3R and Associated CHADIS Criteria)

Normal text is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005, p. 23). Italisized text conveys information about the CHADIS items assessing the DC: 0-3R criteria. Please note that per DC: 0-3R guidelines, anxiety disorders are only diagnosed in children 24 months and older. The only exception is Anxiety Disorder NOS, which can be diagnosed in CHADIS as young as age 4 months.

The diagnosis of Specific Phobia requires that ALL SIX of the following criteria be met:

  1. The presence or anticipation of a specific object or situation evokes excessive, unreasonable, marked, and persistent fear in the child. ("Does your child act more afraid than you would expect of any places or things?" --Often or Almost Always)
  2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response in the child, such as panic, crying, tantrums, freezing, or clinging. ("When your child gets close to the place or thing he/she fears, does he/she panic, cry, cling to you, have a temper tantrum, or seem to freeze?" --Often or Almost Always)
  3. The child avoids the phobic situation(s) or object or exhibits intense anxiety or distress when contact is unavoidable. Parents may facilitate the young child's avoidance of the phobic situation or object. ("You said that your child is too afraid of certain places or things. Do you or your child try to avoid things because of this fear?" --Often or Almost Always)
  4. The child's avoidance, anxious anticipation, or distress in the feared situation(s) causes clinically significant distress or leads to avoidance of activities or settings the child associates with the anxiety or fear. The disturbance impairs the child's or family's functioning and/or the child's expected development.
  5. The anxiety or phobic avoidance is not better accounted for by the DSM-IV TR diagnostic category of Obsessive-Compulsive Disorder (e.g., fear of dirt) or by Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with trauma), Separation Anxiety Disorder (e.g., avoidance of school/daycare), or Social Phobia (e.g., avoidance of social interactions).
  6. The disturbance lasts for AT LEAST 4 MONTHS. ("You said that your child is too afraid of certain places or things. How long has this been going on?"--At least 4 months)

300.23 Social Phobia (Social Anxiety Disorder)

  1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situation bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
  3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
  4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder with or without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
  8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specify if:
Generalized: if the fears include most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Note: Also consider the additional diagnosis of Avoidant Personality Disorder.

Social Anxiety Disorder (DC: 0-3R and Associated CHADIS Criteria)

Normal text is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005, pp. 23-24). Italicized text conveys information about the CHADIS items assessing the DC: 0-3R criteria. Please note that per DC: 0-3R guidelines, anxiety disorders are only diagnosed in children 24 months and older. The only exception is Anxiety Disorder NOS, which can be diagnosed in CHADIS as young as age 4 months.

The diagnosis of Social Anxiety Disorder requires that ALL SIX of the following criteria be met:

  1. The child exhibits marked and persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or possible scrutiny by others. The child must show this fear with both peers and adults. For the above, CHADIS requires all of the following:
    • "Compared to other children his/her age, is your child too afraid to join in around new people or in new situations?" --Often or Almost Always)
    • "You said that your child is too afraid to join in around new people or in new situations. Does he/she stay afraid longer than other children his/her age?" --Yes
    • "You said your child is too afraid to join in around new people or in new situations. Does this happen around both children AND adults?"--Yes
  2. Exposure to the feared social situation almost invariably provokes anxiety in the child, who may express anxiety by panic, crying, tantrums, freezing, clinging, or shrinking from social situations with unfamiliar people ("When he/she has to be around new people, does he/she panic, cry, have a temper tantrum, cling to you, or seem to freeze?"--Often or Almost Always)
  3. The child avoids the feared social or performance situation(s) or endures it with intense anxiety or distress. Parents often protect very young children from the feared situation ("You said that your child is very afraid of being around new people. Do you or your child miss out on things because of this fear?"--Often or Almost Always)
  4. The child's avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the child's functioning and/or the child's expected development.
  5. The fear or avoidance is not better accounted for by other disorders, including Pervasive Developmental Disorder, Separation Anxiety Disorder, Simple Phobia, or other anxiety disorders.
  6. The disturbance lasts for AT LEAST 4 MONTHS ("You said that your child is very afraid of being around new people. How long has this been going on?" -- At least 4 months)

309.81 Posttraumatic Stress Disorder

  1. The person has been exposed to a traumatic event in which both of the following were present:
    1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
    2. the person's response involved intense fear, helplessness, or horror. Note: In children, this maybe be expressed instead by disorganized or agitated behavior.
  2. The traumatic event is persistently re-experienced in one (or more) of the following ways:
    1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
    2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
    3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
    4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
    5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
  3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
    1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
    2. efforts to avoid activities, places, or people that arouse recollections of the trauma
    3. inability to recall an important aspect of the trauma
    4. markedly diminished interest or participation in significant activities
    5. feeling of detachment or estrangement from others
    6. restricted range of affect (e.g., unable to have loving feelings)
    7. sense of a foreshortened future (e.g., foes not expect to have a career, marriage, children, or a normal life span)
  4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
    1. difficulty falling or staying asleep
    2. irritability or outbursts of anger
    3. difficulty concentrating
    4. hypervigilance
    5. exaggerated startle response
  5. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
  6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more

Posttraumatic Stress Disorder (DC: 0-3R and Associated CHADIS Criteria)

Normal is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005, pp. 15-17). Italisized conveys information about the CHADIS items assessing the DC: 0-3R criteria.

The diagnosis of Posttraumatic Stress Disorder requires that ALL FIVE of the following criteria be met (Note that given the nature of the symptoms described below, PTSD is not diagnosed at the disorder level in children under 12 months):

  1. The child has been exposed to a traumatic event - that is, an event involving actual or threatened death or serious injury or threat to the physical or psychological integrity of the child or another person. For the above, CHADIS requires one or more of the following:
    • "In the past year, has your child been hospitalized?" (Yes, more than a week)
    • "Did your child have a medical procedure in the past year? (Yes, and it made him/her very upset)
    • "In the past year, has your child been seriously injured by any of the following?" (Bad fall; Animal bite; Accidental poisoning; Burning; Near-drowning; Serious vehicle accident; or Other)
    • "Over the past year, which of the following difficulties with your child have occurred?" (Shouting at your child more than once per month; Neglect or abuse of your child by anyone; Protective services involvement or child removed from the home; Spanking your child more than once per month; Shaking your child; Brothers or sisters having physical fights; or Child placement in foster care)
    • "Has your child been exposed to any of the following stressful situations?" (Child or immediate family member was abducted or held captive; Witnessing violence or being the victim of a crime; Witnessing or being involved in a natural disaster (fire, hurricane, terrible storm, tornado, earthquake, flood); Affected by war or terrorism; Child caused an event that resulted in someone being seriously injured or killed; Experiencing, witnessing, or being affected by a serious car accident; or Experiencing or witnessing some other traumatic event)
  2. The child shows evidence of reexperiencing the traumatic event(s) by AT LEAST ONE of the following symptoms (CHADIS question: "You said that your child has experienced something upsetting and scary. Since that event, have any of the following been true of your child?")
    1. Posttraumatic play... (Seems to act out or re-live the event)
    2. Recurrent and intrusive recollections of the traumatic event outside play - that is, repeated statements or questions about the event that suggest a fascination with the event or preoccupation with some aspect of the event. Distress is not necessarily apparent. (Talks about the event a lot)
    3. Repeated nightmares, the content of which may or may not be linked to the traumatic event. (Has nightmares)
    4. Physiological distress, expressed in language or behavior, at exposure to reminders of the trauma. (Seems upset when something reminds him/her of the event)
    5. Recurrent episodes of flashbacks of dissociation - that is, reenactment of the event without any sense on the child's part as to the source of the ideas. The behavior is dissociated from the child's intentionality or sense of purpose. This symptom may also present as staring or freezing ... (Suddenly freezes or stares for no good reason)
  3. The child experiences a numbing of responsiveness or interference with developmental momentum. The numbing or developmental problem appears or intensifies after the trauma and is revealed by AT LEAST ONE of the following symptoms:
    1. Increased social withdrawal (Seems less interested in playing with you or others)
    2. Restricted range of affect. (Shows feelings less strongly than he/she used to)
    3. Markedly diminished interest or participation in significant activities, including play, social interactions, and daily routines. (Seems to have lost interest in activities he/she used to enjoy)
    4. Efforts to avoid activities, places, or people that arouse recollection of the trauma, including efforts to avoid thoughts, feelings, and conversations associated with the trauma. (Tries to avoid things that remind him/her of the event)
  4. After a traumatic event, a child may exhibit symptoms of increased arousal, as revealed by AT LEAST TWO of the following:
    1. Difficulty going to sleep, evidenced by strong bedtime protest, difficulty falling asleep, or repeated night waking unrelated to nightmares. (Has trouble going to sleep)
    2. Difficulty concentrating (Has trouble sticking to one activity)
    3. Hypervigilance. (Seems to be always watching, in case something scary happens)
    4. Exaggerated startle response. (Startles easily or acts jumpy)
    5. Increased irritability, outbursts of anger or extreme fussiness, or temper tantrums. (Seems more irritable or fussy; or Has angry outbursts or temper tantrums)
  5. This pattern of symptoms persists for AT LEAST ONE MONTH. (You said that your child's behavior has been different since an upsetting and scary event. How long has his/her behavior been different? - A month or more)

308.3 Acute Stress Disorder

  1. The person has been exposed to a traumatic even in which both of the following were present:
    1. the person experience, witnessed, or was confronted with an even or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
    2. the person's response involved intense fear, helplessness, or horror
  2. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
    1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
    2. a reduction in awareness of his or her surroundings (e.g., "being in a daze")
    3. derealization
    4. depersonalization
    5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
  3. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
  4. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
  5. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
  6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas if functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
  7. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
  8. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

300.02 Generalized Anxiety Disorder (Includes Overanxious Disorder of Childhood)

  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
  2. The person finds it difficult to control the worry.
  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
    1. restlessness or feeling keyed up or on edge
    2. being easily fatigued
    3. difficulty concentrating
    4. irritability
    5. muscle tension
    6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
  4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g. the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
  5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  6. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Generalized Anxiety Disorder (DC: 0-3R and Associated CHADIS Criteria)

Normal text is quoted directly from the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Revised Edition (DC: 0-3R; Zero to Three, 2005, pp. 24-25). Italicized text conveys information about the CHADIS items assessing the DC: 0-3R criteria. Please note that per DC: 0-3R guidelines, anxiety disorders are only diagnosed in children 24 months and older. The only exception is Anxiety Disorder NOS, which can be diagnosed in CHADIS as young as age 4 months.

The diagnosis of Generalized Anxiety Disorder requires that ALL SEVEN of the following criteria be met:

  1. The child experiences excessive anxiety and worry more days than not for AT LEAST 6 MONTHS For the above, CHADIS requires all of the following:
    • "Does your child seem worried or nervous?" --Often or Almost Always
    • "You said that your child is worried or nervous. How long has this been going on?" --At least 6 months
  2. The child finds it very difficult to control the anxiety or worry (e.g., the child may repeatedly ask a parent for reassurance). ("You said that your child is worried or nervous. Does it seem very hard to put his/her mind at ease?" --Often or Almost Always)
  3. The anxiety and/or worry occurs during TWO OR MORE activities or settings and within TWO OR MORE relationships. For the above, CHADIS requires one or more of the following:
    • "You said that your child is worried or nervous. Does this happen during more than one everyday activity?"--Yes
    • "You said that your child is worried or nervous. Does this happen around more than one person?" --Yes
    • "You said that your child is worried or nervous. Does this happen in more than one place?" --Yes
  4. The anxiety and worry are associated with ONE (OR MORE) of the following six symptoms:
    1. Restlessness or feeling "keyed up" or "on edge". For the above, CHADIS requires one or more of the following
      • "Would you use the word "restless" to describe your child?" -- Yes
      • "Does your child seem "keyed up" or "on edge"?" --Often or Almost Always
    2. Fatigability. For the above, CHADIS requires one or more of the following:
      • "Does your child seem too tired?" --Often or Almost Always
      • "Does your child get tired too easily?" --Often or Almost Always
    3. Difficulty concentrating ("Does your child have a problem settling down and paying attention?" -- Almost Always)
    4. Irritability or tantrumming. For the above, CHADIS requires one or more of the following:
      • "Does your child act fussy or cranky?" --Often or Almost Always
      • "Does your child tantrum?" --Often or Almost Always
    5. Muscle tension ("Does your child's body seem tense?" --Often or Almost Always)
    6. Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep). For the above, CHADIS requires one or more of the following
      • "Once your child is in bed, does it take him/her too long to get to sleep?" --Often or Almost Always
      • "At night, what is the longest stretch your child usually sleeps without waking?" -- less than 4 hours for children under 12 months of age; less than eight hours for children 12 months and older.
  5. The focus of the anxiety or worry is not better accounted for by the DSM-IV-TR diagnostic category of Obsessive-Compulsive Disorder (e.g., fear of dirt or needing ritualized reassurance from a parent), Posttraumatic Stress Disorder, Separation Anxiety Disorder (e.g., anxiety about separation from a caregiver), or Social Phobia (e.g., worry about social interactions).
  6. The anxiety, worry, or physical symptoms interfere significantly with the child's functioning and/or the child's expected development.
  7. The disturbance is not due to the direct physiologic effect of a substance (e.g., asthma medication or steroids) and does not occur exclusively during a Pervasive Developmental Disorder.

Key Points

All Anxiety Disorders

Etiology of anxiety

See Clinical Guide Algorithm

Take me to: Separation Anxiety, General Anxiety, Specific Phobia, Social Phobia, PTSD keypoints, Panic,

Separation Anxiety Disorder

Generalized Anxiety Disorder

Social Phobia

Specific Phobia

Panic Disorder

Post Traumatic Stress Disorder

General

Assessment

(AACAP official action 1997) , (Bernstein, Gail A. 1996) (See: Clinical Guide Algorithm)

  1. Assess for symptoms of all the anxiety disorders
    1. Separation Anxiety[note]
    2. Generalized Anxiety Disorder[note]
    3. Social Phobia[note]
    4. Specific Phobia[note]
    5. Panic Attack[note]
  2. Assess for the mediators of anxiety
    1. Temperament[note](See Temperament).
    2. Environment[note]
    3. Recent Trauma
  3. Obtain family history
    1. Psychosocial[note]
    2. Medical conditions[note] causing anxiety
    3. Parental temperament current and as a child[note]
  4. Assess avoidance actions[note] being taken
  5. Assess level of family entanglement[note]

Differential Diagnosis and Comorbidity

  1. Physical conditions that may be experienced as anxiety
    1. Hypoglycemic episodes
    2. Hyperthyroidism
    3. Cardiac arrhythmia, MVP
    4. Acute bronchospasm
    5. Caffeinism
    6. Pheochromocytoma
    7. Seizures
    8. Migraines
    9. Brain tumor
    10. Infection of basal ganglia
  2. Medication reactions
    1. Antihistamines
    2. Anti-asthmatics
    3. Sympathomimetics
    4. Steroids
    5. Haldol
    6. SSRI
    7. Anti-psychotics
    8. Diet pills, ephedrine
    9. OTC cold remedies
    10. Beta agonists
    11. Withdrawal from CNS depressants
    12. Amphetamines: may cause ritualistic behaviors

COMORBIDITIES

Anxiety Disorders
1/3 of children with anxiety disorders meet criteria for two or more[note] anxiety disorders (Kashani, J. H. 1990) , (Strauss, C. C. 1993)
OCD
Attention Deficit Hyperactivity Disorder (ADHD)
15-24% of children with ADD/ADHD have separation anxiety disorder or generalized anxiety disorder.
Depressive Disorders
Rates of coexisting Major Depression in children with anxiety disorders may be as high as 47% (Bernstein, Gail A. 1991)
Medical Conditions
Any serious medical condition may be associated with anxiety.
Tourette's Disorder
There is a high incidence of OCD in individuals with Tourette's disorder[note]
Substance Abuse
Eating Disorders

Management

General Principles (See: General Principals For Helping Your Child Cope With Anxiety pt)

Specific Techniques, Behavior Therapy

Help the child understand anxiety (See: Helping Your Child Understand Anxiety pt)

Relaxation : (See: Relaxation training pt)

Relieving Physical Pain

Relaxation: Relaxing the Mind

Other Techniques

Pharmacotherapy (See Child Psychopharmacology DTW)

When to Consider Medication:

Take me to: Separation Anxiety, General Anxiety, Specific Phobia, Social Phobia, School Phobia, PTSD, Panic

Treatments for Specific Disorders:

Separation Anxiety

  1. Refer to Management of Anxiety and General Principles
  2. Reward for brave behavior (See: Incentives for brave behavior pt)
  3. Relaxation techniques (See: Relaxation training pt)
  4. Practice Separation (See: Separation Anxiety pt)
    1. Systematic desensitization (2)
    2. Role-play and Cross role-play[note]
    3. A Transitional Object[note] may make separation easier
  5. Determine if parental ambivalence will get in the way of techniques
  6. Pharmacology

Generalized Anxiety Disorder (See GAD pt)

  1. Refer to Management of Anxiety and General Principles
  2. Teach the child about anxiety (See: Helping Your Child Understand Anxiety pt)
  3. Relaxation Techniques (See: Relaxation Training pt)
  4. Pharmacotherapy

Specific Phobias (See: Specific Phobia pt)

  1. Refer to Management of Anxiety and General Principles
  2. Teach the parent and child:
    1. Fear = a strong physical, mental, and emotional reaction to a truly dangerous event
    2. Anxiety = fearful reaction to events that are not dangerous, or significantly less dangerous than the person imagines
    3. Phobia = extreme avoidance of anxiety-provoking fear interfering with daily activities
  3. Desensitization therapy:
    1. A series of small steps starting with the easiest and working up to the most difficult using encouragement, praise, and incentives
      1. Increases child's sense of control, reducing fear, and increasing chances of success
      2. The sooner the child faces the feared situation, the less opportunity exists for anticipatory anxiety to develop
      3. Use daily exposure- may have to be planned (bare minimum is once a week for desensitization to occur
      4. Don't allow early escape from a feared situation while anxiety is still high: on average it takes about 20 minutes for anxiety to subside in a feared situation
      5. Make sure exposures are the same the same every time, without variations
    2. Pharmacology

Social Phobia/School Phobia (See: Social Phobia pt)

  1. Refer to Management of Anxiety and General Principles
  2. Teach the parent about the cycle of avoidance
    1. Shy children tend to avoid social situations to the point where avoidance interferes with normal activities such as making friends or playing in the school yard
    2. The longer social situations are avoided, the less opportunity these children have to develop social skills
    3. Eventually, these children look different to their peers because of this lack of social skills
    4. Because they are perceived as being different, others interact differently with them
    5. Further avoidance occurs as a result, creating a vicious cycle
  3. Help them face the social situations they fear
    1. Start with what the child is already able to do
    2. Encourage them to invite another child over
    3. Gradually increase social exposure[note]
  4. Social Skills therapy if needed through a mental health agency or school
  5. Pharmacotherapy

School Phobia

  1. After Short Absences
    1. Return the child to school, expect them to stay there with lots of praise at the end of the day for being brave
  2. After long absence
    1. Create a plan for gradual reintroduction[note] to the class.
    2. Combine an incentive for facing the feared situation with a disincentive[note] for not facing it.
    3. May need a plan for drop off[note] or the bus
    4. Evaluate and discuss family dynamics contributing. Involve all family members in the plan.
  3. Avoid home tutoring[note]
  4. Expect setbacks after weekends and holidays
  5. Discuss condition and treatment plan with school authorities as well, developing a plan for a return to school as soon as possible
  6. Social Skills therapy if needed
  7. Family therapy if needed
  8. Make a contract[note] for illness symptoms
  9. Pharmacotherapy - SSRIs (See Child Psychopharmacology DTW)

Post-Traumatic Stress Disorder

  1. Refer to Management of Anxiety and General Principles
  2. Inform the parents that their reaction is the biggest determinant of how the child will cope
  3. For minor events:
    1. Early stages: let the child express his fears. If he is having difficulty doing this with a parent, a referral for individual therapy may be needed
    2. Watch for feelings of blame and desires for revenge to disembue
    3. For a minor event, do not let the child continue to talk about the event for a prolonged period of time.
    4. The goal is to not have the child see himself as a victim
    5. Pharmacotherapy may be indicated.[note]
    6. Role-play. Have the child practice a different ending to the witnessed trauma
    7. Relaxation exercises with breathing techniques or cassette tapes
    8. Parents may have been exposed to the same trauma and have symptoms needing treatment themselves
  4. For long term stress:
    1. Refer for Cognitive Behavioral Therapy to help the child deal with disturbing memories of abuse and feelings of associated anxiety
    2. Professional counseling for repeated traumas, serious trauma

Panic Disorder (See: Panic Disorder pt)

  1. Refer to Management of Anxiety and General Principles
  2. Relaxation Exercises (See: Relaxation pt)
  3. Teach the child about what is happening during a panic attack
  4. Pharmacotherapy (See Child Psychopharmacology DTW)

Appendices

Further Information for the Physician

Specific Phobias by developmental stage:

Temperament

Behavioral Inhibition (12):

Further Reading

The following links will connect you to recent research from the National Library of Medicine database.

Further Reading on Separation Anxiety

Further reading on Social Phobia

Further reading on Generalized Anxiety Disorder

Further reading on Specific Phobia

Further reading on PTSD

Further reading on Agoraphobia

Citations

  1. AACAP official action (1997). Practice Parameters for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. .
  2. Albano, Anne Marie, Kendall, Philip C. (2004). Cognitive Behavioural Therapy for Children and Adolescents With Anxiety Disorders: Clinical Research Advances. .
  3. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
  4. Anderson, J. C., Williams, S., McGee, R., Silva, P. A. (1987). DSM-III Disorders in Preadolescent Children: Prevalence in a Large Sample From the General Population. .
  5. Benjamin, R. S., Costello, E., Warren, M. (1990). Anxiety Disorders in a Pediatric Sample. .
  6. Bernstein, Gail A., Borchardt, Carrie M. (1991). Anxiety Disorders of Childhood and Adolescence: a Critical Review. .
  7. Bernstein, Gail A., Borchardt, Carrie M., Perwien, Amy R. (1996). Anxiety Disorders in Children and Adolescents: A Review of the Past 10 Years. .
  8. Biederman, J., Rosenbaum, J. F., Bolduc-Murphy, E. A., et. al. (1993). A 3-Year Follow-Up of Children With and Without Behavioral Inhibition. .
  9. Black, B., Uhde, T. W. (1995). Psychiatric Characteristics of Children With Selective Mutism: a Pilot Study. .
  10. Bowen, R. C., Offord, D. R., Boyle, M. H. (1990). The Prevalence of Overanxious Disorder and Separation Anxiety Disorder: Results From the Ontario Child Health Study. .
  11. Costello, E., Angold, A., March, J. S. (1995). Anxiety disorders in children and adolescents.
  12. Kagan, J., Reznick, J. S., Snidman, N. (1988). Biological Bases of Childhood Shyness. .
  13. Kashani, J. H., Orvaschel, H. (1990). A Community Study of Anxiety in Children and Adolescents. .
  14. Langley, Audra K., Bergman, R. Lindsey, Piacentini, John C. (2004). Assessment of Childhood Anxiety. .
  15. Last, C. G, Strauss, C. C., Francis, G. (1987). Comorbidity Among Childhood Anxiety Disorders. .
  16. Manassis, Katherina (1996). Keys to Parenting your Anxious Child.
  17. Ollendick, T., King, N. (1994). Diagnosis, Assessment, and Treatment of Internalizing Problems in Children. .
  18. Strauss, C. C., Last, C. G. (1993). Social and Simple Phobias in Children. .
  19. Walkup, John T., Ginsburg, Golda S. (2004). Anxiety Disorders in Children and Adolescents. .
  20. Walkup, John T., Labellarte, Michael J., Ginsburg, Golda S. (2004). The Pharmacological Treatment of Childhood Anxiety Disorders. .
  21. Whitaker, A., Johnson, J., Schaffer, D. (1990). Uncommon Troubles in Young People: Prevalence Estimates of Selected Psychiatric Disorders in a Nonreferred Adolescent Population. .
  22. M. Wolraich (Ed.) (1996). Diagnostic and Statistical Manual for Primary Care (DSM-PC): Child and Adolescent Version.

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