Anxiety Disorders

Description

Diagnosis Coding

ICD-10

F06.4, anxiety disorder due to another condition

F40.00, agoraphobia

F40.10, social phobia

F40.2, *specific phobia

F40.298, other specified anxiety disorder

F41.0, panic disorder

F41.1, generalized anxiety disorder

F41.9, unspecified anxiety disorder

F42, +obsessive-compulsive disorder

F43.10, post-traumatic stress disorder

F93.0, separation anxiety disorder of childhood

F94.0, selective mutism

Also, see Codes for Specific Substance/Medication-Induced Anxiety Disorders (PDF Document 39 KB) for a detailed list of codes by substance. 

*F40.2 is not a billable code; see ICD-10 Coding Details for Specific Phobic Stimulus (PDF Document 53 KB) for additional codes based on phobic stimulus.

+F42 is not a billable code; it has 5 additional codes:

  • F42.2, mixed obsessional thoughts and acts
  • F42.3, hoarding disorder
  • F42.4, excoriation (skin-picking) disorder
  • F42.8, other obsessive-compulsive disorder
  • F42.9, obsessive-compulsive disorder, unspecified 
Further coding details can be found by using the search feature at ICD10Data.com.

DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2015] generally designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits our including their codes or descriptions.

Description

Anxiety is defined as "anticipation of future threat." [American: 2015] Children with anxiety disorders tend to be worriers and can seem irritable or easily embarrassed. Specific anxiety disorders addressed in this module are:
Agoraphobia Selective mutism
Anxiety disorder due to another medical condition Separation anxiety disorder
Generalized anxiety disorder Social anxiety disorder (social phobia)
Obsessive-compulsive disorder (OCD) Specific phobia
Other specified anxiety disorder Substance/medication-induced anxiety disorder
Panic disorder Unspecified anxiety disorder
Post-traumatic Stress Disorder (PTSD)

To meet diagnostic criteria, the anxiety must cause significant daily distress or limit normal functioning; represent a distinct change from the patient’s baseline behavioral and emotional functioning; not be caused by a medication, substance abuse, or medical issue (unless defined as such); and be differentiated from anxiety that is normal for the child’s developmental level. Such anxiety is also generally persistent and not a temporary, short-term reaction to a stressor. Children and youth with special health care needs (CYSHCN) are at increased risk for mood disorders, including anxiety and depression. [Houtrow: 2011]

Obsessive-compulsive disorder and post-traumatic distress disorder are no longer classified as anxiety disorders, reflecting evolving understanding of their neurobiology. Because anxiety remains a prominent feature and their treatments are similar to other anxiety disorders, they will also be discussed in this module.

Prevalence

Anxiety disorders affect 6-20% of children and youth in the US and are the most common mental health disorders in kids. [Connolly: 2007] [Bagnell: 2011] [Wehry: 2015] Anxiety disorders tend to increase in prevalence once children reach school-age and with each passing year. [Wehry: 2015] Anxiety disorders are more common in females (2:1 compared to males). [American: 2015] Almost half of CYSHCN are estimated to be affected by anxiety or depression, with an estimated prevalence that is 25% greater than in typically developing children. [Houtrow: 2011]

Genetics

Although heredity seems to be a factor in many people with anxiety, to date the etiology of anxiety disorders is considered complex and polygenic and no specific causal or high-risk mutations have been identified. [Smoller: 2016] [Bagnell: 2011]

Prognosis

Anxiety in children - young girl hugging knees anxiously
Henrik Weis/Science Photo Library
Although anxiety disorders tend to persist into adulthood, they tend to have a waxing and waning course with varying degrees of symptom severity among episodes. [Beesdo: 2009] Younger children tend to have recurrent episodes of one anxiety disorder type, but the risk of developing multiple anxiety disorders increases with age. Anxiety disorders may contribute to development of depression and substance use disorders. [Beesdo: 2009] While many suicide prevention efforts focus on identifying youth with depression, youth affected by anxiety are also at increased risk of suicide attempts. [Wehry: 2015] Unrecognized and undertreated anxiety disorders can also lead to poorer health and educational outcomes, as well as financial and interpersonal difficulties. [Wehry: 2015]
Many people with anxiety disorders respond favorably to treatment with medication and/or therapy, and treatment effects can last beyond the acute treatment phase. [Piacentini: 2014] Only about a third of patents with anxiety disorders will improve without treatment; up to 1/3 of patients may have a chronic, treatment-resistant course despite intensive treatment, especially if anxiety symptoms are severe or are accompanied by a major depressive disorder. [Durham: 2012]

Roles Of The Medical Home

Anxiety disorders are encountered frequently in pediatrics and, due to the limited supply of mental health specialists and other barriers to seeking or accessing care (including social stigma and cost), must often be managed by the medical home. Unmet mental health care needs were reported in 5.62% of CYSHCN in 2009-10. [An: 2016] The primary care clinician performs screening and diagnosis and develops treatment plans in conjunction with the patient and the family. Additionally, the medical home helps coordinate ongoing care and accommodations within the school and community. Finally, the primary care clinician facilitates referral for patients who require specialist consultation and collaborates in ongoing care.

Practice Guidelines

Connolly SD, Bernstein GA.
Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 2007;46(2):267-83. PubMed abstract / Full Text

Geller D, March J.
Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.
J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113. PubMed abstract / Full Text

Cohen JA, Bukstein O, Walter H, Benson SR, Chrisman A, Farchione TR, Hamilton J, Keable H, Kinlan J, Schoettle U, Siegel M, Stock S, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.
J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-30. PubMed abstract / Full Text

Helpful Articles

PubMed search for anxiety disorders in children, last 2 years

Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR.
Assessment and treatment of anxiety disorders in children and adolescents.
Curr Psychiatry Rep. 2015;17(7):52. PubMed abstract / Full Text

Bagnell AL.
Anxiety and separation disorders.
Pediatr Rev. 2011;32(10):440-5; quiz 446. PubMed abstract

Kelly P.
Posttraumatic stress disorder.
Pediatr Rev. 2012;33(8):382-3. PubMed abstract

Krebs G, Heyman I.
Obsessive-compulsive disorder in children and adolescents.
Arch Dis Child. 2015;100(5):495-9. PubMed abstract / Full Text

Clinical Assessment

Overview

Several screening tools can help identify children and adolescents at increased risk of an anxiety disorder. Anxiety disorders are differentiated from normal, developmentally appropriate fears and worries by duration and impact on function. Children with history of neglect, abuse, or trauma may be at risk for post-traumatic stress disorder, which can have onset at any age. As with any mental health diagnosis, the patient’s cultural background should be considered as some fears or anxieties may be consistent with normative cultural beliefs. When assessing CYSHCN, clinicians should keep in mind that anxiety disorders are more common in these children. Females tend to be more frequently affected than males for most anxiety disorders.

Screening

For The Condition

While there is are no American Academy of Pediatrics screening recommendations for anxiety (only recommendations for depression and substance abuse), the American Academy of Child & Adolescent Psychiatry recommends that clinicians providing psychiatric assessment of children ask screening questions about anxiety disorders. [Connolly: 2007] There are no recommendations for routine anxiety screening in a general pediatrics population. If a child presents with emotional or behavioral issues, part of the evaluation should include asking about anxiety. If there is concern for anxiety disorder, screening tools may be helpful to supplement history, clinical observations, and pertinent medical evaluation. Commonly used tools include:
  • Generalized Anxiety Disorder 7-Question Screen (GAD-7): A 7-item report developed to screen for generalized anxiety disorder; it can be completed as a patient self-report or parent report. Scores >10 should prompt further inquiry. Instructions for use and links for the screening tool in multiple languages are included at Patient Health Questionnaire Screeners (agree to the terms of use and select free screener from drop-down menu).
  • Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) (PDF Document 218 KB): A child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders (including general anxiety disorder, separation anxiety disorder, panic disorder, and social and school phobia). Free to download or link to on-line Excel worksheet that calculates the score. Translations in Arabic, Chinese, French, German, Italian, Spanish, Tamil (Sri Lanka), and Thai. Based on published, peer-review studies.
  • Spence Children’s Anxiety Scale (SCAS): A child (45-question) and parent (39-question) form for school-aged children. The screen scores for overall anxiety disorder, as well as separation anxiety, social phobia, obsessive compulsive problems, panic/agoraphobia, generalized anxiety/overanxious, and symptoms and fears of physical injury. Based on DSM-IV, with free access to downloadable PDFs and online scoring versions. Available in many languages.
  • Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (PDF Document 442 KB): Assesses presence and severity of obsessions and compulsions for both diagnosis of OCD and monitoring treatment response in children ages 6-17. Completed by a clinician or trained interviewer, instructions and tips for how to ask questions and grade responses are included; free download.
Alternatively, the American Psychiatric Association offers free Online Assessment Measures (APA). These tools are not yet validated for use in children, but have acceptable test-retest reliability with parent informants in the DSM-5 field trial. [Freedman: 2013] Clinicians can use the Level 1 Cross-Cutting Symptom Measures assessment to determine areas of concern, then additional Level 2 assessments to assess scores for anxiety and other DSM-5 categories. There are also Disorder-Specific Severity Measures for use in youth ages 11-17 for social phobia, separation anxiety, specific phobia, and generalized anxiety disorders. The measures were developed to be administered at the initial patient interview and to monitor treatment progress. Instructions, scoring information, and interpretation guidelines are included.

Of Family Members

Routine screening of family members for anxiety disorders is not recommended.

Presentations

Many anxiety disorders start during childhood. Children with anxiety disorders often present first to primary care with vague, often recurrent somatic symptoms. Tantrums, irritability, and behavior problems including aggression are often present, especially in younger children, and may be confused with the mood lability of bipolar disorder. Spontaneous improvement of symptoms during weekends and school breaks may be indicative of separation anxiety disorder. Specific phobias and separation anxiety disorder tend to have onset in early childhood. School refusal can be a behavior associated with any anxiety disorder, although specific consideration should be made to social anxiety disorder which has onset in adolescence.

Concentration difficulties, academic difficulties, and restlessness that may be initially misdiagnosed as ADHD are also common symptoms of social anxiety disorder as well as generalized anxiety disorder, which tends to have onset in later adolescence. Obsessive-compulsive disorder also tends to have onset in late adolescence and early adulthood, and is associated with mental and behavioral rituals that might be confused with increased goal-directed activity seen in bipolar disorder or stereotyped behaviors in autism spectrum disorder.

Diagnostic Criteria

Anxiety disorders share some general principles. Anxiety disorders are present for several months, in contrast to normal or adaptive stress responses which generally last under 2 weeks. The anxiety is atypical for the child’s developmental age and is out of proportion to the stressor. Anxiety disorders also impair the child’s normal function. More than 1 anxiety disorder can manifest in the same person, either at the same time or at different times. Although all anxiety disorders are characterized by excessive and persistent fear or worry, careful clinical questioning can help the clinician further characterize the type of anxiety disorder that is present.

The following descriptions differentiate among specific anxiety disorders; see the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‑5) [American: 2015] for authoritative diagnostic criteria (copyright prevents detailing them here).

Agoraphobia - fear of situations, such as public spaces, related to a perceived lack of potential escape should panic or embarrassment occur. A person with panic disorder who avoids certain settings out of concern that he or she will have a panic attack and will not be able to escape, may have panic disorder with agoraphobia; however, agoraphobia may occur in a person without panic attacks.  

Generalized anxiety disorder - persistent, excessive worry and perception of lack of control of multiple domains of one’s life, such as home, school, extracurricular activities. Often associated with fatigue, sleep disturbance, irritability, restlessness, concentration difficulties, and muscle tension (e.g., a child who is tense and has trouble relaxing with nighttime worrying that can make it hard to fall asleep) 

Obsessive-compulsive disorder – persistent, unpleasant/unwanted thoughts or urges known as obsessions, and/or repetitive mental acts or behaviors known as compulsions that the patient carries out to obtain temporary relief from the obsessions or in accordance with irrational or overly rigid rules

Panic disorder - recurrent, unexpected panic attacks that typically last <1 hour and consist of severe anxiety and physical manifestations of autonomic activation including increased heart rate, palpitations, chest pain, difficulty breathing, sweating, tremulousness, dizziness, and other symptoms. Panic attacks can be seen in multiple psychiatric conditions including other anxiety disorders or reactions to stress. They can mimic medical disorders and are not considered to be mental disorders. Panic disorder always includes recurrent, unexpected panic attacks, but having panic attacks is not sufficient to diagnose panic disorder.

Post-traumatic stress disorder – persistent anxiety that arises from exposure to a potentially life-threatening event(s) or a close family member or caregiver being exposed to a potentially life-threatening event(s). Involves subsequent nightmares, flashbacks, hypervigilant behaviors, and/or avoidance of reminders of the traumatic event(s)

Selective mutism - persistent refusal or inability to speak in certain settings (e.g., school) despite demonstrating normal language use in another setting (e.g., home) that is not due to a problem with comprehension

Separation anxiety - developmentally inappropriate degree of fear or worry about circumstances that could lead to separation or loss of a caregiver. Associated behaviors include reluctance to leave the caregiver, nightmares, and somatic complaints (e.g., a child who has stomach aches before going to school, but not on weekends)  

Social anxiety disorder - avoiding the possibility of judgment or possible criticism and rejection from others. Associated behaviors include avoidance of social interactions, school refusal, and refusal to perform in front of others. Performance anxiety is a type of social anxiety. [Connolly: 2007]

Specific phobia - recurrent, disproportionate fear or avoidance of specific things or situations - for example animals, natural disasters, and medical environments or procedures. Kids may have more than 1 specific phobia at a time. [Connolly: 2007]  

Substance/medication-induced anxiety disorder – anxiety disorder due to intoxication or withdrawal from a substance (e.g., alcohol withdrawal or stimulant intoxication) or treatment side effects 

Unspecified anxiety disorder – may be used when it is clear that the child is significantly impacted by anxiety, but the clinician has not identified a more specific anxiety disorder diagnosis

Differential Diagnosis

The following conditions may have anxiety as a component or have signs and symptoms that mimic those of anxiety disorders. [Connolly: 2007] The DSM-5 Handbook of Differential Diagnosis (APA) offers differential diagnosis pathways and decision trees (available for purchase).
  • Attention deficit hyperactivity disorder - a pattern of persistent inattentiveness, distractibility, and/or hyperactivity starting in childhood and impairing function in more than one setting (see the Portal’s Attention Deficit Hyperactivity Disorder (ADHD))
  • Adjustment disorder - a transient change in mood associated with life stressors, usually lasting less than 6 months and resolving spontaneously
  • Asthma - may feel panicky in association with difficulty breathing or excessive coughing (see the Portal's Asthma)
  • Autism spectrum disorder - can involve social avoidance, irritability, or restlessness, associated with repetitive behaviors or restricted interests and ongoing social problems starting in early childhood (see the Portal’s Autism Spectrum Disorder)
  • Bipolar disorder - can involve restlessness, irritability, impaired sleep associated with depressive and manic cycles
  • Caffeine intake - can cause restless or anxious symptoms after consumption
  • Central nervous system disorders, such as brain tumors - can cause irritability or personality changes associated with other central nervous system abnormalities
  • Delirium - can include anxiety or irritability in association with other changes in awareness or behavior
  • Depression - can include somatic complaints, sleep difficulty, poor concentration associated with persistently depressed mood (see the Portal’s Depression)
  • Hyperthyroidism - can cause unexpected weight loss, rapid or irregular heartbeat, sweating, and irritability
  • Hypoglycemia – can cause anxiety, nervousness, shakiness, hunger, confusion, and other symptoms
  • Illness anxiety disorder - includes excessive, enduring worry about having a particular illness despite somatic symptoms that are minimal, absent, or disproportionate to actual circumstances (classified as a somatic disorder)
  • Lead intoxication - can cause irritability associated with abdominal pain, constipation, developmental delays or learning problems, fatigue, weight loss, or hearing loss, and lead exposure (Lead Poisoning (MayoClinic) provides a list of symptoms and tests)
  • Learning disabilities - can include worry about school performance in conjunction with difficulty in one or more skill area (e.g., reading, math)
  • Migraine - recurring headaches may be associated with light or sound sensitivity, nausea or vomiting, or aura (see the Portal’s Headache (Migraine & Chronic))
  • Pheochromocytoma - can involve anxiety or racing heart associated with high blood pressure, sweating, tremors, pallor, and other symptoms (see  Pheochromocytoma (MayoClinic) for symptoms and tests)
  • Psychotic disorders - can include social withdrawal, restlessness associated with abnormal thinking and perceptions
  • Seizure disorders - may feel panicky at onset of seizure. Seizures are often associated with repetitive movements, loss of consciousness; they are frequently shorter than most panic attacks (see the Portal’s Seizures/Epilepsy).
  • Somatic symptom disorders - anxiety may be a prominent feature, related to fear of having a particular illness; excessive preoccupation and worry about physical symptoms that may or may not be medically explained or other health-related concerns

Medical Conditions Causing Anxiety Disorders

The following medical conditions are known to precede anxiety symptoms and panic attacks and are a part of the diagnosis of anxiety disorder due to another medical condition.
  • Endocrine: hyperthyroidism, hypoglycemia, hyperadrenocortisolism, pheochromocytoma
  • Cardiovascular: congestive heart failure, pulmonary embolism, arrhythmias (e.g., atrial fibrillation)
  • Respiratory: asthma, pneumonia, chronic obstructive pulmonary disease (COPD)
  • Metabolic: Vitamin B12 deficiency, porphyria
  • Neurologic: seizure disorders, tumors, encephalitis, vestibular dysfunction

Comorbid Conditions

Anxiety disorders are often comorbid with Autism Spectrum Disorder; Attention Deficit Hyperactivity Disorder (ADHD); disruptive behavior disorders; learning disorder; mood disorders; somatic symptom disorders; Substance Abuse; and tic disorders (tics may increase in anxiety-provoking situations). Multiple anxiety disorders can present in the same person. [Bagnell: 2011]

Pearls & Alerts

Most common pediatric anxiety disorders

The “pediatric triad of anxiety disorders” includes generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder. These disorders affect similar areas of the brain, can frequently co-occur in children and youth, and tend to respond similarly to medication and behavioral interventions. [Wehry: 2015] The most common anxiety disorders in younger children are separation anxiety and specific phobias. The most common anxiety disorder in adolescents is social phobia. [Bagnell: 2011]

Seek information from other caregivers

Obtaining supplementary information from other caregivers, teachers, counselors, and others who regularly interact with the child can be extremely helpful in establishing the diagnosis and a treatment plan.

Identify specific stressors

Careful history-taking and delineation of the primary source of anxiety is necessary for appropriate diagnosis and treatment. If anxiety occurs predominantly in a particular situation or setting, such as school, more intensive interventions may be focused on those settings. If post-traumatic stress disorder is suspected and abuse, neglect, or safety concerns arise that have not been previously reported or investigated, adherence to mandated reporter laws in the clinician’s area of practice is imperative.

History & Examination

Periodic re-evaluation to assess for the presence of one or more anxiety disorders is a reasonable practice, since they can occur at any age and may change over time.

Family History

Taking a history of family members with anxiety disorders can help identify how familiar the family is with anxiety disorders, as well as how the family has responded to past behavioral and medical interventions. It also alerts the clinician to significant medical or psychosocial events that may trigger stress or maladaptive anxiety response in the child or family. [Wehry: 2015] Parental anxiety disorder has been associated with increased risk of anxiety disorder in offspring [Biederman: 2001] [Merikangas: 1999] and high levels of functional impairment in children with childhood anxiety disorders. [Manassis: 1998]

Current & Past Medical History

Ask about:
  • Prior mental health disorders and response to past treatments
  • Chronic or past acute medical conditions, noting those that can co-occur or result in anxiety
  • Prior hospitalizations, surgeries, and other medical tests and interventions that may have provoked anxiety
  • Medication history - Prescription drugs with side effects that may mimic anxiety include antiasthmatics, sympathomimetics, steroids, selective serotonin reuptake inhibitors (SSRIs), antipsychotics (akathisia), pimozide (neuroleptic-induced SAD), and atypical antipsychotics. Nonprescription drugs with side effects that may mimic anxiety include diet pills, antihistamines, and cold medicines. [Connolly: 2007]

Developmental & Educational Progress

Assess the child’s anxiety symptoms in the context of their developmental age. Determine if the child’s symptoms impact social relationships, school attendance and performance, or participation at school, home, or during extracurricular activities. Speaking with a teacher or counselor may be very helpful; consent may be required.

Maturational Progress

As children mature, different types of anxiety disorders, such as social phobia, become more common. Older children and adolescents with anxiety may try to self-medicate or abuse drugs or alcohol.

Social & Family Functioning

Awareness of family and peer support and relationships is useful. Bullying and cyberbullying is an increasing issue that may increase anxiety. Assess for traumatic exposures including abuse, neglect, and exposure to domestic violence. Family functioning and stressors strongly impact adherence to both behavioral and medical therapy plans. Parents who are anxious or avoidant may need extra support and training to not reinforce those traits in their children. Parents who are overprotective, over-controlling, and overly critical may increase anxiety in some children. Insecure parent-child attachment also may increase anxiety in some children. [Connolly: 2007]

Physical Exam

General

Children with anxiety disorders often present to primary care for evaluation of somatic complaints, including headaches, stomachaches, and insomnia. Anxiety may or may not be apparent during interaction with the patient in the clinical setting. Watch the patient’s interaction with the parent or caregiver for indications of nervousness or insecurity or unusual attachment for the child’s developmental stage. Children may appear sullen, withdrawn, tense, fidgety, or wary of interactions with others with or without caregivers present. Children with separation anxiety may become visibly upset when parents are asked to leave the room.

Vital Signs

Elevated blood pressure and mild tachycardia can occur with anxiety, but may be related to anxiety about being in a clinic; consider home monitoring if unclear.

Skin

Dry or moist skin may indicate thyroid concerns; however, sweating can occur during acute anxiety as well.

HEENT

Inspect and palpate the thyroid.

Heart

Evaluate for irregular heart rate or rhythm.

Abdomen

Inspect and palpate the abdomen. Anxious children may withhold stool, which can lead to co-occurring constipation or diarrhea.

Neurologic Exam

Children with anxiety disorders should have a normal neurologic examination. Anxiety can exacerbate tics.

Testing

No routine tests are advised in diagnosing anxiety. Neuropsychological testing may be helpful if there is concern about the differential diagnoses or medical conditions that can cause anxiety.

Subspecialist Collaborations & Other Resources

Psychologist, Child-18 (see Services below for relevant providers)

Most anxiety conditions can be diagnosed in the primary care setting. Behavioral health specialists should be consulted if there is difficulty sorting out a complicated diagnosis.

Psychiatrist, Child-18 (see Services below for relevant providers)

Refer if medical evaluation is needed.

Treatment & Management

Overview

Most pediatric anxiety disorders can be managed in the primary care setting, ideally in collaboration with behavioral health specialists for ongoing therapy and in consultation with child psychiatrists for diagnostic dilemmas or patients that are difficult to treat conventionally. Monitoring the impact of the anxiety disorder and response to treatment is vital.  The primary care clinician should offer information about cognitive behavioral therapy (CBT) and other behavioral health approaches, medications, and lifestyle changes. Pharmacologic treatment typically involves gradual titration to clinical response, continued treatment for several months or a year, and then attempt to wean gradually during a low-stress time. The short-term goal is to improve function and participation in regular activities. The long-term goal is that the child develops skills to sustain function and avoid relapses, which is a primary aim of behavioral therapy.

How should common problems be managed differently in children with Anxiety Disorders?

Growth Or Weight Gain

Anxiety disorders can be associated with appetite changes, but major fluctuations in weight are uncommon. Unexpected weight gain or loss should raise concern for medical issues, mood disorders, or eating disorders. Use of SSRIs can result in weight gain in some patients.

Over The Counter Medications

Many people use “natural” medicine to manage anxiety symptoms. Ask about all over-the-counter medications, herbs, supplements, and other treatments that have been, or are being, tried. Using large doses of anything can lead to side effects and toxicity. Product quality varies among manufacturers.  Herbs and Dietary Supplements Program (OSU) is an on-line training program for clinicians that categorizes various natural approaches to treating anxiety based on evidence and risks. Anxiety: Complementary & Alternative Medicine discusses often used alternative therapies.

Prescription Medications

Whether used alone or in conjunction with therapy, a step-wise approach to dosing is advised. Many anxiety medications have significant side effects and may interact with other medications; some may lower seizure threshold. (See  Drugs that May Lower Seizure Threshold (Epilepsy Foundation) for a list.) Black box warnings related to reports of increased suicidality are issued with many of these medications, particularly the SSRI and serotonin and norepinephrine reuptake inhibitors (SNRIs).

Common Complaints

Anxiety in children can be associated with somatic symptoms, and common complaints, such as headache, dizziness, racing heart, abdominal pain, fatigue, and difficulty sleeping can accompany an anxiety disorder. Clinical judgment is required to determine how far to evaluate symptoms that may be somatic manifestations of the child’s anxiety. Letting families know that these symptoms can be associated with anxiety can relieve some of their worry.

Other

Role of Healthy Lifestyle
Managing Anxiety in Children-Healthy Lifestyle Wheel
A healthy lifestyle is helpful in the treatment of anxiety. This includes regular exercise, healthy foods, adequate sleep, meaningful relationships, community engagement, stress management and relaxation practices, a sense of purpose, fun, and spirituality. [Kathi: 2010] When treating a child for anxiety, focusing on each of these components can augment or even take the place of treatment with prescription medications and therapy.

Image, left: Lifestyle changes in the areas on the wheel can be powerful in treating anxiety (adapted from Mental Health, Naturally by Kathi Kemper by Dr. Jennifer Goldman-Luthy).

Pearls & Alerts

Therapy alone vs. combination therapy

Cognitive behavioral therapy (CBT) and other therapy modalities are effective in treating anxiety disorders and can have long-lasting effects. Therapy alone is low risk and often effective for mild to moderate anxiety. For patients with moderate to severe anxiety, there is evidence that combination treatment is superior to therapy or medication alone both in acute phase treatment and for longer-term benefit. [Piacentini: 2014] [Walkup: 2008]

SSRI dosing may be higher for anxiety than for depression

Treatment of anxiety with SSRIs may require higher doses than treatment for depression does. Starting doses are the same, although, for individuals with significant worry about side effects, a lower dose may be chosen. For CYSHCN, lower doses and slow titration of medications is recommended due to higher risk of side effects.

A medication trial must be of adequate dose and duration

Treatment duration is as important as optimal dosing. A medication should be tried for at least 4-6 weeks at an adequate dosage before considering it a failure. Therapy is a useful adjunct to medication during this time and can help the individual learn other coping mechanisms for managing anxiety.

Short-acting benzodiazepines are not recommended

Short-acting benzodiazepines should only be considered for severe anxiety (i.e., complete refusal of life activities and inability to function as a result of anxiety) and with supervision by a psychiatrist. Longer-acting formulations are preferred, and a plan to taper should be developed at initiation.

Behavioral interventions for sleep anxiety

For anxiety about going to sleep, behavioral interventions can be very helpful. For example, gradually moving a child’s sleep location from the parents’ bed to the floor and eventually to the child’s bed, or systematically checking/reassuring the child with timed intervals (5, 10, 15 minutes), and coupling these with positive rewards can help many children.

Systems

Mental Health/Behavior

Cognitive behavioral therapy (CBT) is the best-known behavioral treatment for anxiety disorders in children. It is helpful to explain to families that CBT helps children learn to recognize and gain better control over their anxiety. CBT can be similarly effective in children with high-functioning autism spectrum disorder who experience anxiety. [Earle: 2016] The CBT process uses several components, such as psychoeducation, training to better manage one’s somatic complaints, cognitive restructuring (such as rethinking negative self-talk), exposure methods (i.e., gradually getting used to an anxiety-provoking situation), and plans to prevent and manage relapses. [Connolly: 2007] CBT therapists may use workbooks for kids and parents; some families defer therapy and simply use CBT-based workbooks, such as What to Do When You Worry Too Much at home. Mindfulness-based CBT is an emerging approach that may be beneficial. [Connolly: 2007] For more in-depth information and reviews of the evidence behind CBT used for different types of pediatric anxiety, see [Connolly: 2007].

Psychodynamic psychotherapy has been used extensively, though there is less high-quality evidence supporting its effectiveness. [Connolly: 2007] This approach aims to help the patient uncover and explore unconscious thoughts that contribute to their anxiety. 

Parents are routinely involved in both forms of therapy to help improve parent-child relationships and teach parents more effective skills to manage their child’s anxiety and support their therapeutic process.

Consider assessing children with anxiety for substance use with appropriate toxicology tests, particularly if their symptoms have sudden/episodic onset or if there are accompanying concerns on physical examination, such as mental status or autonomic changes.

Subspecialist Collaborations & Other Resources

Psychologist, Child-18 (see Services below for relevant providers)

Refer for additional testing to elucidate a diagnosis or tease out comorbid learning or cognitive disorders. Some psychologists work as therapists. School psychologists may assist in school support plans and accommodations for children whose anxiety negatively impacts their ability to effectively participate in the educational process.

Clinical Social Worker (LCSW, MSW) (see Services below for relevant providers)

Refer if therapy is needed or if help navigating social systems and coordinating services would benefit the family.

Pharmacy & Medications

Prescription medications are often used alone or in conjunction with therapy. Ongoing monitoring of tolerance and for side effects and drug interactions is important, as well as for comorbid conditions such as depression or other anxiety disorders. Medication can also be beneficial for kids who are unable to access therapy or who are highly anxious about starting therapy. Be aware that many of these medications have significant side effects and may interact with other medications; some may lower seizure threshold. (See Drugs that May Lower Seizure Threshold (Epilepsy Foundation) for a list.) Black box warnings are issued with many of these medications, particularly the SSRIs and SNRIs, due to increased risk of suicidality. 

The goal in treatment of anxiety disorders is symptom improvement and return to an adequate baseline level of functioning with tolerable side effects. A step-wise approach is advised, in which subsequent steps are taken only when a step is not effective or tolerated. Each step may require 4-6 weeks of a medication trial in order to fully assess efficacy. The following is adapted from the Pediatric Anxiety Flowchart (UACAP) (PDF Document 402 KB) with permission from the author, Travis Mickelson:

Step 1: In children with anxiety disorder, SSRIs have the best evidence for use, particularly fluoxetine (Prozac) and sertraline (Zoloft). Fluvoxamine (Luvox) is an SSRI that is also FDA-approved for use in children with OCD, but it is generally not used first-line due to higher risk of drug-drug interactions. Citalopram (Celexa) and escitalopram (Lexapro) are also likely effective. Paroxetine (Paxil) has some evidence for use in social anxiety disorder in youth. [Strawn: 2012]
  • Fluoxetine: Start 5-10 mg daily and increase every 2-4 weeks as tolerated, up to 60 mg daily.
  • Sertraline: Start 12.5-25 mg daily and increase every 2-4 weeks as tolerated, up to 200 mg daily.
See Selective Serotonin Reuptake Inhibitors (SSRI) Use in Children with Autism and Other Neurodevelopmental Disabilities for helpful advice about the increased risk of side effects, decreased success with use, and different approaches to dosing and titration. [Earle: 2016]

Step 2: Try an alternate SSRI - switch to different SSRI if no benefit from first. Fluvoxamine (Luvox) may be helpful in severe OCD if fluoxetine and/or sertraline are ineffective or not tolerated. 

Step 3: Switch to an SNRI - Venlafaxine (Effexor) has some evidence for use in children with generalized anxiety [Strawn: 2012] or social phobia. Duloxetine (Cymbalta) has been approved for use in kids 7-17 with generalized anxiety disorder. There are some moderate quality studies showing good response to treatment of comorbid anxiety with venlafaxine or duloxetine in children with ASD when SSRIs are not successful. [Earle: 2016] However, for children on the autism spectrum or with other neurodevelopmental disabilities, second-line therapy is typically an alpha-2 agonist (clonidine, guanfacine), used to address hyperactivity or anxiety/hyperarousal states. See Alpha-2 Agonist Use in Children with Autism. Consultation with a child and adolescent psychiatrist may be appropriate after 2 failed medication trials for anxiety.

Step 4: Consider augmentation or alternative medications that can be used alone if serotonergic medications are not tolerated, or as add-on therapy for partial response to one of the above meds. Consultation with a child psychiatrist is recommended at this point if not sought previously. Note that “as needed” medications for anxiety are generally discouraged; however, they might be considered for panic disorder or procedural anxiety. The following are from [American: 2012]:
  • Antihistamines – They can be useful for as-needed treatment of anxiety, but the effectiveness tends to wear off with long-term use. They can cause significant sedation and other side effects, as well as decrease anxiety. They also can lower seizure threshold and interact with other medications. Examples of antihistamines include hydroxyzine (Vistaril) and diphenhydramine (Benadryl).
  • Anticonvulsants – Gabapentin (Neurontin) is used to treat certain seizure disorders and neuropathic pain, but is sometimes used for anxiety. Pregabalin (Lyrica), an anticonvulsant GABA-derivative, is better studied, but it is expensive. It is approved for use in adults with generalized anxiety disorder, but not for children.
  • Antihypertensives - Clonidine (e.g., Kapvay, Catapres) and guanfacine (e.g., Intuniv, Tenex) are alpha-agonists used for second-line treatment of ADHD and have some anxiolytic properties.
  • Atypical anti-anxiety medications - Buspirone (Buspar) is an anxiolytic 5-HT1A agonist that takes 1-4 weeks for onset of action and is approved for generalized anxiety disorder in adults. It is not currently FDA-approved for use in children. It does not cause dependency. There is a study with positive evidence for buspirone to treat comorbid anxiety in children with autism spectrum disorder.  [Earle: 2016]
  • Atypical antipsychotics - There is significant risk of side effects. They are used occasionally for severe anxiety and aggressive behaviors.
  • Benzodiazepines - Little evidence exists for use in pediatric anxiety disorders. [Connolly: 2007] Clonazepam (Klonopin) is preferred in certain cases due to longer half-life and it is less addictive due to no euphoric effect. Procedural anxiety may be treated with lorazepam (Ativan) or diazepam (Valium), although there is some reported risk of behavioral disinhibition in young children. [Nutter: 2016] They are best used short term, but can be used to bridge the starting of SSRI therapy in youth with panic disorder. Benzodiazepines are frequently avoided due to risk of abuse and diversion, and they cause significant sedation. [Nutter: 2016] Of note, children with seizures often have a benzodiazepine reserved for management of status epilepticus; regular use for treatment of anxiety may result in increased tolerance to the medication.
  • Beta blockers - Propranolol has been used in adults for as-needed management of performance anxiety. [Fourneret: 2001] It also has been used to decrease aggressive behaviors and nervousness in children with neurodevelopmental disabilities. [Dulcan: 2015] Little research has been done on beta blockers for pediatric anxiety; however, there is a positive case review of propranolol use for school avoidance. [Kung: 2012]
  • Prazosin - This is an alpha-1 antagonist that may be useful for treatment of nightmares associate with posttraumatic stress disorder. [Kung: 2012]
  • Tetracyclic antidepressants - Tetracyclic antidepressants, such as mirtazapine (Remeron), can be very sedating, so should be dosed at night. Sedative effects tend to decrease with increased doses. They can be useful in treating comorbid depression and insomnia. There is some evidence for use in treating comorbid anxiety in children with autism spectrum disorder. [Earle: 2016]
  • Tricyclic antidepressants - These have a significant side effects, can lower seizure threshold, and increase risk of morbidity or mortality with overdose. Examples include clomipramine, imipramine, amitriptyline. Clomipramine can be useful in treatment of OCD; imipramine can be useful for treatment of enuresis. There is inconclusive evidence for use in separation anxiety disorders.
Many of these medications can take 4-6 weeks to determine response. Note that some medications used to treat anxiety, such as guanfacine, clonidine, and propranolol, can affect heart rate and/or blood pressure and abrupt discontinuation should be avoided.
If a patient is taking serotonergic medications for depression or anxiety, such as selective serotonin reuptake inhibitors (SSRIs), serotonin syndrome is a potential rare but serious risk characterized by autonomic instability, mental status changes, and hyperthermia. Serotonin syndrome usually results from serotonin agonist polypharmacy. Treatment ranges from supportive in mild cases to ventilation and dialysis in severe cases. [Perry: 2012]

Subspecialist Collaborations & Other Resources

Psychiatrist, Child-18 (see Services below for relevant providers)

Refer for assistance in diagnosis and treatment of complicated, refractory (generally defined as more than 2 ineffective adequate antidepressant medication trials or worsening of symptoms despite treatment), or severe cases. May provide brief consultation or routine follow-up, depending on the needs and preferences of the primary care clinician and family. The patient may see a nurse practitioner or physician assistant who is supervised by a physician. Frequency of visits is usually a few times per year.

Learning/Education/Schools

If anxiety affects school participation and performance, school accommodations should be considered. Accommodations might include decreased homework, an adult outside the classroom to talk to when needed, or reduced distractions during work/test completion. [Connolly: 2007] While the primary care clinician cannot prescribe specific accommodations in the educational setting, a letter of support for the child’s 504 plan with suggested interventions may be helpful for the school.

Subspecialist Collaborations & Other Resources

Mental Health Counselor (LPC, CMHC) (see Services below for relevant providers)

Involving mental health counselors at school can be helpful for children experiencing anxiety in the school setting.

Frequently Asked Questions

What are the recommendations for treating anxiety in children with autism spectrum disorder?

According to a 2016 review of psychoactive medications used to treat anxiety and depression in children with autism, response to medications may differ from responses in neurotypical youth. There is reasonable evidence suggesting better control of anxiety symptoms with use of extended release guanfacine (Intuniv), atomoxetine (Strattera), and buspirone (BuSpar). SSRI use (citalopram, sertraline, fluoxetine) remains the first-line medical treatment, but there is limited evidence for SSRI use in treating anxiety in children with ASD and increased risk of activation. Children with “high-functioning” ASD often can benefit from CBT. See Selective Serotonin Reuptake Inhibitors (SSRI) Use in Children with Autism and Other Neurodevelopmental Disabilities for more details.

What are the recommendations for treating anxiety in children with ADHD?

It is often recommended to treat anxiety first, but because uncontrolled ADHD symptoms can exacerbate anxiety (such as worrying about inadequate performance in the classroom setting), and because stimulant trials are faster than SSRI trials, some practitioners may choose to treat the ADHD symptoms first. Careful clinical questioning regarding the primary source of distress and use of screening questionnaires can be helpful in determining which to treat first. If a patient appears more anxious or agitated on stimulant medication, consideration should be made to treat anxiety first. Clonidine and guanfacine may be helpful in treating some symptoms of both anxiety and ADHD. See Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD) for more information.

How long should a child with anxiety disorder be treated with medications?

Many children and families are eager to stop medications as soon as they feel better and symptoms are under control. However, currently it is recommended to continue medication treatment for 6-12 months once symptoms are under control before attempting to wean medication. Some disorders, including OCD, may require lifelong pharmacologic management.

When does worry become an anxiety disorder after a stressful life event?

Many children experience temporary and transient worry after life changes such as moves or transitions. Adjustment disorder can be considered for children who experience mood or anxiety symptoms after a stressor, and these generally resolve within 6 months. The DSM-5 clearly outlines the times for which symptoms must persist in order to meet criteria for anxiety disorder (for most anxiety disorders, symptoms must be present for at least 6 months, although there are some exceptions). If a child is not experiencing significant disruptions in functioning (academic, social, or otherwise), then they may not meet severity criteria for a disorder. Medications may not be warranted in this case, but brief therapy may be helpful to aid in the transition.

Issues Related to Anxiety Disorders

Resources

Information for Clinicians

Depression and Anxiety (Medical Home Newsletter) (PDF Document 318 KB)
Contains referral, screening, treatment, and family support information for medical home providers treating children who may be experiencing depression or anxiety.

Drugs, Herbs, & Supplements (MedlinePlus)
A searchable database with information about side effects, dosages, and precautions for prescription and over-the-counter medications. The information may be helpful for clinicians evaluating CAM use by families; from the U.S. National Library of Medicine.

Helpful Articles

PubMed search for anxiety disorders in children, last 2 years

Bagnell AL.
Anxiety and separation disorders.
Pediatr Rev. 2011;32(10):440-5; quiz 446. PubMed abstract

Kelly P.
Posttraumatic stress disorder.
Pediatr Rev. 2012;33(8):382-3. PubMed abstract

Krebs G, Heyman I.
Obsessive-compulsive disorder in children and adolescents.
Arch Dis Child. 2015;100(5):495-9. PubMed abstract / Full Text

Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR.
Assessment and treatment of anxiety disorders in children and adolescents.
Curr Psychiatry Rep. 2015;17(7):52. PubMed abstract / Full Text

Clinical Tools

Algorithms/Care Processes

Pediatric Anxiety Flowchart (UACAP) (PDF Document 402 KB)
One-page algorithm for assessment and treatment of pediatric anxiety; created by Dr. Travis Mickelson/Utah Academy of Child & Adolescent Psychiatry (based on DSM-IV).

Assessment Tools/Scales

Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) (PDF Document 218 KB)
A child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders, including general anxiety disorder, separation anxiety disorder, panic disorder, and social and school phobia. Free to download, or link to on-line Excel worksheet that calculates the score. Translations in Arabic, Chinese, French, German, Italian, Spanish, Tamil (Sri Lanka), and Thai.

Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (PDF Document 442 KB)
Assesses presence and severity of obsessions and compulsions for both diagnosis of OCD and monitoring treatment response in children ages 6-17. Completed by a clinician or trained interviewer. Instructions and tips for how to ask questions and grade responses are included in the screening materials link.

Spence Children’s Anxiety Scale (SCAS)
Child (45-question) and parent (39-question) forms for school-aged children. Scores for overall anxiety disorder plus scores for separation anxiety, social phobia, obsessive compulsive problems, panic/agoraphobia, generalized anxiety/overanxious symptoms and fears of physical injury. Based on DSM-IV, with free access to downloadable PDFs and online scoring versions. Available in many languages.

Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) (PDF Document 47 KB)
Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.

Online Assessment Measures (APA)
Assessments are administered at the initial patient interview and to monitor treatment progress. Instructions, scoring information, and interpretation guidelines are included - no fee required; American Psychiatric Association.

Youth Outcome Questionnaire (Measures)
A 64-item report completed by the parent/guardian. It is a measure of treatment progress for children and adolescents (ages 4-17) receiving mental health intervention. It is designed to track the patient’s sense of well-being over time in order to gauge response to mental health interventions; available for a fee.

DSM-5 Handbook of Differential Diagnosis (APA)
A workbook with differential diagnosis pathways and decision trees that are practical for clinical use; for purchase from the American Psychiatric Association.

Toolkits

Bright Futures in Practice: Mental Health—Volume II, Tool Kit (Bright Futures)
A comprehensive selection of downloadable mental health tools for health professionals and families; American Academy of Pediatrics.

Patient Health Questionnaire Screeners
Free screening tools to be used by clinicans to help detect mental health disorders: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4. All PHQ, GAD-7 screeners and translations are downloadable from this website and no permission is required to reproduce, translate, display, or distribute them.

Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit (AAP)
CD-ROM of clinical tools provide step-by-step decision support for assessment and care of children with the most common mental health symptoms, available for a fee; American Academy of Pediatrics.

Screens for Anxiety and Mental Illness (UACAP)
Screens for anxiety, ADHD, sleep, depression, and suicide that are free and easily downloaded; Utah Academy of Child & Adolescent Psychiatry.

Other

First-Line Management of Pediatric Mental Health Problems (AAP)
On-line, free, webinar on primary care management of mental health problems in the pediatric population (49:13 minutes- July 2011) ; by Jane Meschan Foy, MD, FAAP / American Academy of Pediatrics.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Anxiety Disorders Resource Center (AACAP)
Information and short videos about features, diagnosis, and treatment of anxiety disorders. Includes links to Facts for Families, brief handouts that explain diagnosis, treatment options, and when and how to find treatment; American Academy of Child Adolescent Psychiatry.

Depression and Anxiety Fact Sheet (Utah Family Voices) (PDF Document 49 KB)
Information, tips, and resources for families.

What to Do When You Worry Too Much
An interactive self-help book designed to guide 6–12 year olds and their parents through the cognitive-behavioral techniques most often used in the treatment of generalized anxiety. Metaphors and humorous illustrations make difficult concepts easy to understand, while prompts to draw and write help children to master new skills related to reducing anxiety; written by Dawn Huebner, PhD.

Family Toolkit for Anxiety (Utah Academy of Child & Adolescent Psychiatry)
Information about diagnosis and help at home and school, includes complimentary treatments; info is presented alphabetically by condition, so may need to scroll to find anxiety toolkit.

Anxiety Disorders (healthychildren.org)
Defines anxiety disorders for families; sponsored by the American Academy of Pediatrics.

Emotional Problems (healthychildren.org)
Helpful information about emotional difficulties, including anxiety and associated problems; American Academy of Pediatrics.

Drugs & Supplements Related to Anxiety: Patient Information (MayoClinic)
Describes for families precautions, proper use (includes pediatric use), and side effects of drugs and supplements used for anxiety. Can also search by first letter of drug/supplement name.

Acupressure for Stress and Anxiety (Memorial Sloan Kettering Cancer Center)
Patient information about acupressure and integrative medicine.

Mental Health, Naturally by Kathi Kemper
Holistic health expert and pediatrician Dr. Kathi J. Kemper presents natural treatments used for mental health issues such as ADHD, depression, anxiety, stress, and substance abuse; available for purchase on American Academy of Pediatrics website.

Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety
Book that helps parents identify and understand anxiety in their children, outlines effective and convenient parenting techniques for reducing anxiety, and shows parents how to promote bravery for long-term confidence; by Dr. Donna Pincus - creator of The Child Anxiety Network, Associate Professor at Boston University, and the Director of the Child and Adolescent Fear and Anxiety treatment Program at Boston University.

Support National & Local

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

The Child Anxiety Network
Parent-focused information about phobias, specific anxiety disorders in children, and treatment.

National Alliance of Mental Illness (NAMI)
A national organization that provides information and resources for families and professionals, including helpline, local chapter resources, and advocacy.

Services for Patients & Families

Clinical Social Worker (LCSW, MSW)

See all Clinical Social Worker (LCSW, MSW) services providers (226) in our database.

Mental Health Counselor (LPC, CMHC)

See all Mental Health Counselor (LPC, CMHC) services providers (305) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (29) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (150) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Reviewing Author: Mary Steinmann, MD - 11/2016
Content Last Updated: 11/2016

Bibliography

American Academy of Child & Adolescent Psychiatry.
Psychiatric Medication For Children And Adolescents: Part II - Types Of Medications.
(2012) http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-G.... Accessed on 11/27/2016.

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2015. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...

An R.
Unmet mental health care needs in U.S. children with medical complexity, 2005-2010.
J Psychosom Res. 2016;82:1-3. PubMed abstract

Bagnell AL.
Anxiety and separation disorders.
Pediatr Rev. 2011;32(10):440-5; quiz 446. PubMed abstract

Beesdo K, Knappe S, Pine DS.
Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V.
Psychiatr Clin North Am. 2009;32(3):483-524. PubMed abstract / Full Text

Biederman J, Hirshfeld-Becker DR, Rosenbaum JF, Hérot C, Friedman D, Snidman N, Kagan J, Faraone SV.
Further evidence of association between behavioral inhibition and social anxiety in children.
Am J Psychiatry. 2001;158(10):1673-9. PubMed abstract

Cohen JA, Bukstein O, Walter H, Benson SR, Chrisman A, Farchione TR, Hamilton J, Keable H, Kinlan J, Schoettle U, Siegel M, Stock S, Medicus J.
Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder.
J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-30. PubMed abstract / Full Text

Connolly SD, Bernstein GA.
Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 2007;46(2):267-83. PubMed abstract / Full Text

Dulcan MK, Ballard R.
Medication Information for Parents and Teachers: Propranolol—Inderal.
American Psychiatric Publishing, Inc.; (2015) http://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615370283.m.... Accessed on 11/27/2016.
From Helping Parents and Teachers Understand Medications for Behavioral and Emotional Problems: A Resource Book of Medication Information Handouts, Fourth Edition. Washington, DC, American Psychiatric Publishing, 2015

Durham RC, Higgins C, Chambers JA, Swan JS, Dow MG.
Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups.
J Affect Disord. 2012;136(3):875-81. PubMed abstract

Earle JF.
An Introduction to the Psychopharmacology of Children and Adolescents With Autism Spectrum Disorder.
J Child Adolesc Psychiatr Nurs. 2016;29(2):62-71. PubMed abstract

Fourneret P, Desombre H, de Villard R, Revol O.
[Interest of propranolol in the treatment of school refusal anxiety: about three clinical observations].
Encephale. 2001;27(6):578-84. PubMed abstract

Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, Yager J.
The initial field trials of DSM-5: new blooms and old thorns.
Am J Psychiatry. 2013;170(1):1-5. PubMed abstract / Full Text

Geller D, March J.
Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder.
J Am Acad Child Adolesc Psychiatry. 2012;51(1):98-113. PubMed abstract / Full Text

Houtrow AJ, Okumura MJ, Hilton JF, Rehm RS.
Profiling health and health-related services for children with special health care needs with and without disabilities.
Acad Pediatr. 2011;11(6):508-16. PubMed abstract / Full Text

Kathi J. Kemper.
Mental Health, Naturally: The Family Guide to Holistic Care for a Healthy Mind and Body.
1st ed. American Academy of Pediatrics; 2010. 1581103107 http://shop.aap.org/Mental-Health-Naturally-The-Family-Guide-to-Holist...

Kelly P.
Posttraumatic stress disorder.
Pediatr Rev. 2012;33(8):382-3. PubMed abstract

Krebs G, Heyman I.
Obsessive-compulsive disorder in children and adolescents.
Arch Dis Child. 2015;100(5):495-9. PubMed abstract / Full Text

Kung S, Espinel Z, Lapid MI.
Treatment of nightmares with prazosin: a systematic review.
Mayo Clin Proc. 2012;87(9):890-900. PubMed abstract / Full Text

Manassis K, Hood J.
Individual and familial predictors of impairment in childhood anxiety disorders.
J Am Acad Child Adolesc Psychiatry. 1998;37(4):428-34. PubMed abstract

Merikangas KR, Avenevoli S, Dierker L, Grillon C.
Vulnerability factors among children at risk for anxiety disorders.
Biol Psychiatry. 1999;46(11):1523-35. PubMed abstract

Nutter D.
Pediatric Generalized Anxiety Disorder Medication.
Medscape; (2016) http://emedicine.medscape.com/article/916933-medication#1. Accessed on 11/27/2016.

Perry PJ, Wilborn CA.
Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and management.
Ann Clin Psychiatry. 2012;24(2):155-62. PubMed abstract

Piacentini J, Bennett S, Compton SN, Kendall PC, Birmaher B, Albano AM, March J, Sherrill J, Sakolsky D, Ginsburg G, Rynn M, Bergman RL, Gosch E, Waslick B, Iyengar S, McCracken J, Walkup J.
24- and 36-week outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS).
J Am Acad Child Adolesc Psychiatry. 2014;53(3):297-310. PubMed abstract / Full Text

Smoller JW.
The Genetics of Stress-Related Disorders: PTSD, Depression, and Anxiety Disorders.
Neuropsychopharmacology. 2016;41(1):297-319. PubMed abstract / Full Text

Strawn JR, Sakolsky DJ, Rynn MA.
Psychopharmacologic treatment of children and adolescents with anxiety disorders.
Child Adolesc Psychiatr Clin N Am. 2012;21(3):527-39. PubMed abstract

Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, Ginsburg GS, Rynn MA, McCracken J, Waslick B, Iyengar S, March JS, Kendall PC.
Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety.
N Engl J Med. 2008;359(26):2753-66. PubMed abstract / Full Text

Wehry AM, Beesdo-Baum K, Hennelly MM, Connolly SD, Strawn JR.
Assessment and treatment of anxiety disorders in children and adolescents.
Curr Psychiatry Rep. 2015;17(7):52. PubMed abstract / Full Text