By Debra E. Koss, M.D.

Worries are common throughout childhood. For example, toddlers worry about the dark, grade school children worry about starting school, and teens worry about being accepted by their friends. These types of worries are temporary and resolve with support from caring adults. Other types of worries or fears can occur in response to danger as part of an adaptive and protective reaction. Consider, for example, a student’s swift reaction to escaping a bully on the playground. These types of worry are in sharp contrast to the symptoms of anxiety disorders which result in significant impairment in children’s ability to function and require comprehensive evaluation and treatment. 

Clinical example:

Gianna is an 8-year-old girl who presents for evaluation of intermittent stomachaches and nausea. She is accompanied to the office by her mother who reports her symptoms started one month ago and were associated with vomiting, diarrhea, and low-grade fever (100 F).  Gianna’s two siblings also experienced nausea, vomiting, and diarrhea but their symptoms resolved completely within 48 hours. Mother reports that Gianna’s stomachaches are worse on school days. Gianna frequently asks to stay home from school, but her parents can usually get her to school by offering to drive her. Gianna’s teacher reports that she generally seems distracted and her schoolwork has declined. Gianna shares that she’s afraid she’s going to vomit in the classroom, just like her brother did. She’s afraid to eat because she believes this will make her stomachache worse. Gianna also reports she’s afraid to be in her room alone, especially at night. She worries that she’s going to get sick and no one in her family will hear her call for help. Mother notes that Gianna has always been a worrier. She’s slow to warm up to a new teacher, doesn’t like to speak in front of the class, and worries about her grades. She is shy around groups of children, has never wanted to attend a playdate, and will only participate in dance class if her mother observes. Gianna is also afraid of the dark and usually sleeps in a sleeping bag in her parents’ room.

Anxiety disorders are among the most common reasons why children and adolescents are referred for a mental health evaluation. Presenting symptoms may include physical complaints such as stomachaches and headaches, sleep disturbance, and difficulty concentrating. Children with anxiety may be described as slow to warm up to new situations or avoidant of situations that trigger anxiety. Alternatively, they may become irritable and oppositional when confronted with a situation that triggers anxiety and their symptoms may be misunderstood as oppositional behavior. Adolescents experience anxiety in response to developmental milestones such as consolidation of body image, sexual identity, and social acceptance. Adolescents with anxiety may experience panic and social phobia.

Clinicians need to distinguish normal, developmentally appropriate worries from symptoms of anxiety that are exaggerated or unreasonable and associated with impairment of functioning. A comprehensive evaluation will include:

• An interview with the child or adolescent 
• A physical exam
• A review of symptoms and history with parents/guardians
• Administration of standardized screening instruments
• Outreach to other caring adults (teachers, therapists)

Risk factors, such as school failure, peer rejection, exposure to traumatic events, and family history of anxiety disorders, must be addressed during treatment planning. Just as important are protective factors, such as good coping skills, supportive parents, and a positive school climate, which can assist with treatment and improve treatment outcomes. 

Are you a pediatrician interested in learning more about the evaluation and treatment of anxiety disorders in children and adolescents? Register now for a webinar hosted by the New Jersey Pediatric Psychiatry Collaborative, “Evaluating Anxiety Symptoms in Pediatric Primary Care.” This webinar is the first in a three-part series, starting on Wednesday, October 30, 2024, at 12:15 PM.

Author Profile:

Debra E. Koss, MD
Clinical Assistant Professor, Department of Psychiatry Rutgers-RWJMS
NJPPC Project Manager for the New Jersey Psychiatric Association