Behavioral Issues

Anxiety Disorders


Anxiety disorders in children include phobias, generalized anxiety, separation anxiety, panic disorders, obsessive-compulsive disorders,   and post-traumatic stress disorder/acute stress disrder.


Anxiety disorders are the most common psychiatric illnesses in children and adolescents, affecting 8% to 10%. Girls are more affected (2:1) 

Normal fears vs. phobias

a. Normal fears

i. Unpleasant feelings in response to realistic dangers
ii. Do not effect daily activities, play, or development
iii. Respond to reassurance, extinguished by distraction
iv. Plausible event as cause
v. Age specific

1. Stranger anxiety (7-8 mo)
2. Separation anxiety (12-18 mo)
3. Fear of dark, monsters (preschool)
4. Fear of bodily harm (school age)

b. Phobias

i. Fears that are excessive, not based in reality, last for 6 months and effect daily functions.
ii. May affect daily activities, play, and development
iii. Do not respond to reassurance or distraction
v. Common types of phobias:

1. Animal type is fear elicited by animals or insects
2. Natural environment type (e.g., heights, storms, water)
3. Blood/injection/injury type is fear related to seeing blood, injuries, or injections, or having an invasive medical procedure
4. Situational type is fear caused by specific situations (e.g., airplanes, elevators, enclosed places)
5. Other type (e.g., fear of choking, vomiting, or contracting an illness; in children, fear of loud sounds or costumed characters)

vi. Treatment of phobias: cognitive behavioral therapy, minimal role for SSRI's

Separation anxiety disorder:

a. Unrealistic fear of harm to the child or his/her primary caregivers, difficulty going to sleep without being near the parents, and reluctance to go to school.
b. Separation anxiety common in kids 10 mo-2 years.
c. Separation anxiety disorder may not manifest until 8-10 years of age after a holiday or period of being home with an illness.
d. Tx: cognitive behavioral therapy, family therapy, SSRIs.

Social phobia:

a. Excessive anxiety in social situations, especially school, that lead to social isolation, though there is a desire for social interation with peers.
b. There is often (but not aoways) a history of shyness.
c. Tx: CBT, SSRIs


a. Fear of places/situations from which escape could be diffficult;agoraphobia situations are avoided or endured with distress
b. Treat with SSRI, exposure therapy.

Panic disorder:

a. Recurrent, discrete episodes where there is abrupt onset of marked fear accompanied by physical symptoms of palpitations, sweating, shaking, shortness of breath, dizziness, chest pain, and nausea.
b.Uncommon before adolescence.
c. Can occur with/without agoraphobia
d. Tx: CBT, SSRIs

Generalized anxiety disorder:

a. Unrealistic worries about "everything"- their own competence, appearaance, health, potential disasters(tornados, war) leading to impairment in social and school functioning, sleep disturbances, and diffficulty concentrating.
b. Frequently present with somatic symtpoms and may have other co-morbid anxiety disorders.
c. Often present in adolescence.
d. Tx:  Cognitive behavioral therapy, SSRIs may be used in severe cases.

Obsessive-Compulsive Disorder

a. Specific repetitive thoughts that invade consciousness (obsessions) or repetitive rituals or movements that are driven by anxiety (compulsions).
b. The most common obsessions are concerned with bodily wastes and secretions, the fear that something calamitous will happen, or the need for sameness.
c. The most common compulsions are handwashing, continual checking of locks, and touching. At times of stress (bedtime, preparing for school), some children touch certain objects, say certain words, or wash their hands repeatedly.
d. Do not need both obsessions and compulsions for diagnosis of OCD
e. Controversial issue-In 10% of children with OCD, the symptoms are triggered or exacerbated by group A beta-hemolytic streptococcal infection.  This subtype is known as pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS).
f. Tx: CBT, exposure therapy, SSRIs.

Post-traumatic stress disorder:

a. Cluster of symptoms following life-threatening events that pose harm to the child or caregiver, including re-experiencing the trauma, avoidance of situations that remind the child of the trauma, and hyperarousal.
b. Re-experiencing may occur through intrusive memories, nightmares, and reenactment in play.
c. Avoidance of situations that remind the child of the trauma e.g. isolation, amnesia
d. Symptoms of hyperarousal include hypervigilance, poor concentration, extreme startle response, and sleep problems.
e. Acute stress disorder has symptoms days after event
f. Post-traumatic stress disorder has symptoms greated than 1 month after traumatic event.
g. Tx: individual, group, and/or family therapy, cognitive behavioral therapy, and possible use of pharmacotherapy such as clonidine for sleep disturbance or SSRIs for affective numbing and comorbid depression.


ADAA Podcasts about treating children and teens with anxiety and related disorders- Click Here


  1. Dieleman GC, Ferdinand RF.  Pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children and adolescents: an overview. Dutch Journal of Psychiatry. 2008; 50(1): 43-53.
  2. Overview of fears and specific phobias in children.
  3. Kliegman (2007) Nelson Textbook of Pediatrics, 18th edition. Saunders, An Imprint of Elsevier.
  4. Thienemann M, Hamilton JD. Learning evidence-based practices for anxious children. Journal of the Americal Academy of Child and Adolescent Psychiatry. Oct 2007; 46(10):1367-74.

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