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Anxiety in Children and Youth: Information for Primary Care

Summary: Anxiety Disorders are the most common illness in children and youth. Treatments include psychotherapy/counseling (such as interpersonal/attachment approaches as well as CBT) as well as SSRI medication.
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Epidemiology

  • Anxiety disorders are the most common mental health conditions affecting children and youth
  • Point prevalence 6%

Presentation

  • Signs/Symptoms
    • Thoughts: Worry thoughts
    • Feelings: Anxiety and worry 
    • Behaviours: Avoidance of anxiety-provoking situations
    • Physical: Troubles with sleep, appetite, energy due to prolonged autonomic arousal 

Hx/Interviewing Questions

  • Who to ask?
    • With younger children, most questions will be directed primarily towards the parents
    • With youth and older children, most questions can be directed at parents and the youth
  • General screen
    • Physician (to parent): “Does your child tend to be a worrier, or an anxious or nervous person?”
    • Physician (to child/youth): “Do you tend to be an anxious or nervous person?”
    • If patient answers positive, then screen for other anxiety conditions such as obsessive-compulsive disorder, phobias  and panic disorder.
  • Obsessive-Compulsive Disorder
    • Physician (to parent) for obsessions: “Does your child have any habits or rituals, such as excessive handwashing, or checking things repeatedly?”
    • Physician (to child/youth): “Do you have any habits or rituals, such as checking things repeatedly or washing your hands over and over?”
    • For impairment: “Do these habits get in the way of your child’s life?” or “Do these habits get in the way of your life?”
  • Simple phobia
    • Physician (to parent): “Does your child have any phobias (e.g. fear of the dark, insects, storms) that are so severe that it causes problems?”
  • Social phobia  (Social Anxiety Disorder)
    • Physician (to parent): “Is your child excessively shy? Does it lead your child to avoid social situations? Does this cause problems?”
  • Panic Attacks
    • Developmentally less common in children  
    • Physician: “Do you have sudden times, out of the blue, when you get scared or panicky?”
  • Panic Disorder with Agoraphobia
    • Developmentally less common in children
    • Physician: “Have you had to avoid where you can go because of your anxiety?

DDx of Anxiety Disorders

 

Is there, or are there...

Consider…

Any medical condition contributing to the anxiety?

Anxiety due to General Medical Condition

  • Anxiety symptoms are caused by a medical conditions, e.g. hyperthyroidism

Any significant psychosocial stressors contributing to anxiety?

Adjustment Disorder with Anxiety

  • Life stress that has been difficult to cope with
  • Within 3-months of the stress, onset of anxiety symptoms resulting from the life stress

Fear of specific objects or situations?

Simple Phobia

  • Extreme, unreasonable fear of specific objection or situation that causes dysfunction
  • Top fears are heights; enclosed spaces; the dark; snakes; spiders; injections with needles; thunder and lightning; having a disease

Fear of separation from caregivers?

Separation Anxiety Disorder

  • Three or more of following must be present during the past four weeks
    • Distress when separated from home or major attachment figures (e.g. parents)
    • Complaints of physical symptoms when separating from major attachment figures
    • Concern about harm to major attachment figures
    • Fear of being alone at home and in other settings
    • Reluctance to go to sleep without a major meltdown

Fear of social situations?

Social Anxiety Disorder

  • Is there fear of social situations?
  • Present for at least six months:
  • Fear of social situations where the child is exposed to unfamiliar people or to scrutiny by others
  • Exposure to the feared situation provokes anxiety
  • Anxiety must occur in peer settings (not just in interactions with adults)
  • The feared situation(s) are avoided or are endured with intense distress

Many worries, with physical symptoms related to worries

Generalized Anxiety Disorder (GAD)

  • Excessive anxiety and worry with at least one of the following symptoms during the past six months:
    • Restlessness
    • Fatigue
    • Difficulty concentrating
    • Irritability
    • Muscle tension
    • Sleep disturbance

Obsessions or compulsions?

Obsessive Compulsive Disorder (OCD)

  • Presence of obsessions (worries causing distress, e.g. worries about contamination) and compulsions (repetitive behavior that relieves distress, e.g. handwashing) 

Episodic bursts of severe anxiety?

Panic Attack

  • Period of intense fear peaking within 10-minutes with at least 4 or more of following symptoms, which include: palpitations; sweating, trembling, shaking, shortness of breath; dizziness or lightheadedness; sense of impending death; paresthesias

Episodic bursts of severe anxiety plus avoidance of situations?

Panic Disorder

  • Recurrent unexpected panic attacks with a month of at least one of the following symptoms:
    • Concerns about having additional attacks
    • Worry about the consequences of the attack
    • Significant behaviour changes related to attacks

Anxiety symptoms don't fit in other categories?

Anxiety Disorder Not Otherwise Specified (Anxiety Disorder NOS)

  • Symptoms of anxiety, however symptoms do not clearly fit in any single diagnostic category

 

Screening / Diagnostic Tools

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    Kutcher Generalized Social Anxiety Scale For Adolescents (K-GSADS-A)
    Permission To Use   Public Domain
    Produced By Dalhousie University
    Conditions Addressed Social Anxiety Disorder
    Ages Served 12 - 20 years
    Website teenmentalhealth.org/for-health-professi...
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    SCARED
    Permission To Use   Copyright, but free to use
    Produced By Dr. Boris Birmaher
    Conditions Addressed Anxiety
    Ages Served 8 - 17 years
    Complete this survey on eMentalHealth.ca
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    Self-Report for Childhood Anxiety Related Disorders (SCARED)
    Permission To Use   Public Domain
    Ages Served All ages
    Website www.wpic.pitt.edu/research
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    Spence Children's Anxiety Scale (SCAS)
    Permission To Use   Copyright, but free to use
    Ages Served 2 - 12 years
    Website www2.psy.uq.edu.au/~sues/scas/

Physical Exam (Px)

  • There is no diagnostic physical exam for anxiety conditions per se, however physical exam is important to rule out contributory medical conditions
  • CNS
    • In general, anxiety is characterized by heightened sympathetic nervous system (SNS)
    • Generalized anxiety disorder (GAD): Tremor, elevated heart rate, rapid breathing, sweaty palms, restlessness
    • Panic disorder: During acute panic, classic signs of sympathetic activation
    • Somatic complaints
    • OCD
      • Eczema, excessive washing leading to reddish skin, dry, or excoriated skin
      • Hair loss with hair pulling (trichotillomania)
      • Excoriations from compulsive skin picking

Investigations

Rule out conditions such as:

  • Anemia (CBC and differential)
  • Infection (CBC and differential, monospot, STIs)
  • Thyroid problems (TSH)
  • Chronic illness (liver tests, electrolytes, kidney tests)
  • Pregnancy (pregnancy test)
  • Malnutrition (Vitamin B12, Folate, Vitamin D)
  • Less frequent conditions like cancer
  • Medication induced anxiety, e.g. non-prescribed (e.g. caffeine, energy drinks) or prescribed (e.g. ADHD stimulant medication), or OTC (e.g. caffeine supplements)

Management in Primary Care

  • Education about anxiety for parents
    • Counsel parents about how to communicate, listen, and validate that the child is feeling worried
  • Lifestyle interventions
    • Sleep
    • Diet
    • Exercise
    • Relaxation
  • Counseling/therapy or referral to counseling/therapy
    • For more severe anxiety, or anxiety that does not respond to non-medication strategies, consider medications

School Letter

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I am writing to give you an update regarding your student, who is coping with an Anxiety Condition.   Accommodations are essential for this student to function in the academic program. Specific accommodations will need to be devised for this student in collaboration with the youth and family.   Assume that deep down, the child wants to be successful. If this child is n...
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There are many ways that schools can help a child with panic disorder succeed in the classroom. Meetings between parents and school staff, such as teachers, guidance counselors, or nurses, will allow for collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifi...
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Medication Management in Primary Care

  • Consider medications when 1) anxiety does not respond to non-medication strategies, or when 2) anxiety is moderate to severe along with impaired function
  • First-line medications for anxiety are Specific Serotonin Reuptake Inhibitors (SSRIs) such as:
    • Fluoxetine (Prozac)
    • Sertraline (Zoloft)
    • Fluvoxamine (Luvox)

When to Refer to Mental Health Professionals

  • When the anxiety is not improving despite initial course of medication / non-medication treatment

Who to Refer to

  • Mental health clinics in hospitals or community mental health agencies
  • Private practice professionals
    • Psychiatrists
    • Psychologists
    • Certified clinical counselors (CCC)

References

About this Document

Written by members of the eMentalHealth.ca/PrimaryCare team which includes members of the Department of Psychiatry and Family Medicine at the University of Ottawa. Reviewed by members of the Family Medicine Program at the University of Ottawa, including Dr's Farad Motamedi; Mireille St-Jean; Eric Wooltorton.

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified expert or health professional. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

Creative Commons License

You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

Date Posted: Jun 13, 2013
Date of Last Revision: Dec 8, 2015

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