Pediatric Generalized Anxiety Disorder

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Generalized anxiety disorder (GAD) is associated with persistent, excessive, and unrealistic worry that is not focused on a specific object or situation.

Children with GAD worry more often and more intensely than other children in the same circumstances. They may worry excessively about their performance and competence at school or in sporting events, about personal safety and the safety of family members, or about natural disasters and future events.

The focus of worry may shift, but the inability to control the worry persists. Because children with GAD have a hard time “turning off” the worrying, their ability to concentrate, process information, and engage successfully in various activities may be impaired. In addition, problems with insecurity that often result in frequent seeking of reassurance may interfere with their personal growth and social relationships. Further, children with GAD often seem overly conforming, perfectionistic, and self-critical. They may insist on redoing even fairly insignificant tasks several times to get them “just right.” This excessive structuring of one’s life is used as a defense against the generalized anxiety related to the concern about the individual’s overall and specific performance. (See Treatment.)

Little empiric data are available regarding the physiologic indicators of anxiety in children. [1] The high cost, lack of normative data, idiosyncratic patterns, and high sensitivity of cardiovascular and electrodermal measures in children contribute to the difficulties in physiologic assessment of anxiety in children. [2] (See Differentials.)

The specific DSM-5 criteria for generalized anxiety disorder are as follows [3] :

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).

The individual finds it difficult to control the worry.

For children, the anxiety and worry are associated with one (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Restlessness or feeling keyed up or on edge

Being easily fatigued

Difficulty concentrating or mind going blank


Muscle tension

Sleep disturbance (difficulty falling or staying asleep, or restlessness, unsatisfying sleep)

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

The disturbance is not better explained by another mental disorder.

Potential complications of GAD include the following (see Prognosis):

Comorbid depression and other comorbid conditions

School truancy and withdrawal from other age-appropriate activities

Strained family relationships when the child’s anxiety contributes to irritability, noncompliance, demanding behavior, and/or chronic reassurance seeking

“Self-medication” leading to substance abuse by adolescents

Parents’ inability to help in the child’s treatment or to model adaptive coping/anxiety management because of their own untreated anxiety (or other psychiatric condition)

Multiple factors are thought to contribute to the development of generalized anxiety disorder (GAD) and to the broad category of anxiety disorders. Biologic, familial, and environmental factors are considered important. Behavioral inhibition, an early temperament associated with aversion to novel situations, has been found to be associated with later development of anxiety disorders.

Research has demonstrated an association between parents with anxiety disorders and children with behavioral inhibition. The tendency of anxiety to occur in families also has been established. Anxious parents may genetically predispose their children to anxiety, model anxious behavior, and behave and/or parent in ways that encourage and maintain anxious behavior in the child. 

Genetic studies of pediatric anxiety disorders (including generalized anxiety disorder) reveal heritability estimates from 20% to 65%, consistent with a significant genetic contribution. Earlier onset is thought to represent a more genetically vulnerable population. Nonetheless, studies have had difficulties identifying risk genes due to a complex, multifactorial pattern of inheritance. [4]

Environmental factors, such as other parental emotional problems, disrupted attachment, stressful life events, and traumatic experiences, also may place the child at risk for developing GAD.

The role of the family in understanding child anxiety is important, particularly in situations in which the needs of younger children who are developmentally limited in their ability to benefit from direct individual intervention are considered.

The prevalence of generalized anxiety disorder (GAD) in children and adolescents ranges from 2.9-4.6%. According to the DSM-5, the 12-month prevalence for generalized anxiety disorder is 0.9% among adolescents and 2.9% among adults in the general community of the United states. The 12-month prevalence of the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk is 9.0%. [3]

In childhood, the sex distribution tends to be equal for females and males. In adolescence, a female-to-male ratio of 6:1 has been suggested; however, epidemiologic study results vary.

The age of onset varies, but GAD is more common in adolescents and older children than in young children. In addition, affected adolescents and older children tend to have more symptoms than do affected younger children.

The prognosis is thought to be relatively good when treatment is implemented early and effectively. However, the child remains at risk for developing generalized anxiety disorder (GAD) or other anxiety disorders.

For example, Last and colleagues reported an 80% recovery rate from overanxious disorder during a 3- to 4-year follow-up period. However, 35% of the children developed a new psychiatric disorder in the same interval. [5]

Anxiety disorders have a high rate of comorbidity. Children and teens with GAD are also likely to meet criteria for other anxiety disorders and, to a lesser degree, for a depressive or disruptive behavior disorder.

Deaths related to GAD in childhood and adolescence are related more to comorbid conditions, such as depression, than to GAD. Children and adolescents with both depression and an anxiety disorder tend to have more severe forms of depression; therefore, GAD should be viewed as a risk factor for morbidity and mortality. Anxiety disorders tend to be unstable over time. That is, a child may struggle with anxiety for a long period, but it may not necessarily be a result of the same specific anxiety disorder.

Anxiety is a serious problem in children and adolescents. We now understand that, in addition to deleteriously affecting the child’s social and academic functioning, anxiety can cause serious long-term consequences. Many children and teens with one of the anxiety disorders suffer intermittently for the rest of their lives. Other serious psychiatric conditions, such as major depressive disorder and substance misuse, are closely associated with pediatric anxiety if not treated in a timely and effective manner.

GAD also may co-occur with conditions associated with stress, such as irritable bowel syndrome and headaches. The long-term physiologic effects of stress are more likely to cause nonpsychiatric gastrointestinal, cardiovascular, or other sequelae later in life.

Psychoeducation should be part of the treatment process. Patients and parents should have a good understanding of the contributing and maintaining factors of anxiety. Also, they should be clear regarding treatment goals, processes, and expectations.

For patient education information, see the Anxiety Center, as well as Anxiety, Panic Attacks, and Hyperventilation.

Barrios BA, Hartmann DB. Fears and anxieties. Marsh EJ, Terdal LG, eds. Behavioral Assessment of Childhood Disorders. 2nd ed. New York, NY: Guilford; 1988. 196-264.

Kendall PC. Childhood Disorders. London, England: Psychology Press; 2000.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

Sakolsky DJ., McCracken JT, Nurmi EL. Genetics of Pediatric Anxiety Disorders. Child Adolesc Psychiatric Clin N Am. 2012. 21:479-500. [Full Text].

Last CG, Perrin S, Hersen M, Kazdin AE. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 1996 Nov. 35(11):1502-10. [Medline].

Cornacchio D, Crum KI, Coxe S, Pincus DB, Comer JS. Irritability and Severity of Anxious Symptomatology Among Youth With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry. 2016 Jan. 55 (1):54-61. [Medline].

March JS, Parker JD, Sullivan K, Stallings P, Conners CK. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997 Apr. 36(4):554-65. [Medline].

Kendall PC, Chu BC, Pimental SS. Treating anxiety disorders in youth. Kendall PC, ed. Child & Adolescent Therapy: Cognitive-Behavioral Procedures. 2nd ed. New York, NY: Guilford; 2000. 235-87.

Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008 Dec 25. 359(26):2753-66. [Medline]. [Full Text].

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996 Apr. 64(2):333-42. [Medline].

Last CG, Hansen C, Franco N. Cognitive-behavioral treatment of school phobia. J Am Acad Child Adolesc Psychiatry. 1998 Apr. 37(4):404-11. [Medline].

Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Lumpkin PW, Carmichael DH. Treating anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial. J Consult Clin Psychol. 1999 Dec. 67(6):995-1003. [Medline].

Ginsburg GS. The Child Anxiety Prevention Study: intervention model and primary outcomes. J Consult Clin Psychol. 2009 Jun. 77(3):580-7. [Medline].

McGrath PJ, Lingley-Pottie P, Thurston C, et al. Telephone-based mental health interventions for child disruptive behavior or anxiety disorders: randomized trials and overall analysis. J Am Acad Child Adolesc Psychiatry. 2011 Nov. 50(11):1162-72. [Medline].

Manassis K. Generalized anxiety disorder in the classroom. Child Adolesc Psychiatr Clin N Am. 2012 Jan. 21 (1):93-103, ix. [Medline].

Rynn MA, Walkup JT, Compton SN, Sakolsky DJ, Sherrill JT, Shen S, et al. Child/Adolescent anxiety multimodal study: evaluating safety. J Am Acad Child Adolesc Psychiatry. 2015 Mar. 54 (3):180-90. [Medline].

Cymbalta (duloxetine) [package insert]. Indianapolis, IN 46285: Lilly USA, LLC. October 29, 2014. Available at [Full Text].

Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. 2006 Jan. 163(1):41-7. [Medline].

Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007 Apr 18. 297(15):1683-96. [Medline].

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Elk Grove, Ill: APA; 1987.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision. 4th ed. Washington, DC: APA Press; 2000.

Keeton CP, Kolos AC, Walkup JT. Pediatric generalized anxiety disorder: epidemiology, diagnosis, and management. Paediatr Drugs. 2009. 11(3):171-83. [Medline].

Manassis K. Keys to Parenting Your Anxious Child. Hauppage, NY: Barron’s Educational Series; 1996.

Spence S. Helping Your Anxious Child: A Step-By-Step Guide for Parents. Oakland, Calif: New Harbinger Publications; 2000.

Strawn JR, Prakash A, Zhang Q, Pangallo BA, Stroud CE, Cai N, et al. A randomized, placebo-controlled study of duloxetine for the treatment of children and adolescents with generalized anxiety disorder. J Am Acad Child Adolesc Psychiatry. 2015 Apr. 54 (4):283-93. [Medline].

Dennis Anthony Nutter, Jr, MD President, Owner, and Director, North Georgia Neuropsychiatry, PC

Dennis Anthony Nutter, Jr, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Medical Association, American Psychiatric Association, Georgia Psychiatric Physicians Association, Physicians for a National Health Program

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chet Johnson, MD Professor and Chair of Pediatrics, Associate Director, Developmental Pediatrician, Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies, University of Kansas School of Medicine; LEND Director, University of Kansas Medical Center

Chet Johnson is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Lene Holm Larsen, PhD Instructor, Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital of Chicago

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Pediatric Generalized Anxiety Disorder

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