Paeds · mental-behavioural-and-psychosomatic
Anxiety disorders in children and adolescents
Also known as Childhood anxiety · Paediatric anxiety disorder · Separation anxiety disorder · Social anxiety disorder in youth · Generalised anxiety disorder in children · Selective mutism · Paediatric panic disorder
Fellowship guide to anxiety disorders in children and adolescents: distinguish the seven DSM-5-TR disorders from normal developmental fear, assess multi-informant with SCARED/SCAS/RCADS, exclude medical mimics and comorbid depression, deliver stepped care from psychoeducation through exposure-based CBT (Coping Cat, FRIENDS) to SSRI (sertraline, fluoxetine), anchored by CAMS, Cochrane 2020 and AACAP Walter 2020 evidence, with activation and suicidality monitoring and adapted care for neurodiverse, Indigenous, refugee and rural youth.
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Target exams
Red flags
- Active suicidal ideation, intent, plan, or escalating self-harm in an anxious child or adolescent — same-day structured risk assessment and safety planning, not 'just anxiety'
- Comorbid moderate-severe depression with hopelessness — higher suicide-risk priority than the anxiety alone
- Sudden-onset panic with cardiovascular features (palpitations, syncope, exertional chest pain, family history of sudden death) — exclude arrhythmia (e.g. SVT, long QT) before attributing to panic
- Anxiety symptoms with weight loss, heat intolerance, tachycardia at rest, goitre, or exophthalmos — screen thyroid before psychiatric framing
- Marked behavioural activation or new suicidal thinking after starting an SSRI — urgent review
- Acute behavioural change with cognitive disorganisation, hallucinations, or neurological signs — consider seizure, delirium, or psychosis prodrome, not primary anxiety
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Behavioural and developmental paediatrics
- Adolescent medicine
- Renewed curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum — Learning goal 16: Mental health
- Developmental and behavioural paediatrics
- Adolescent and youth medicine
- Clinical Applications — mental and behavioural health presentations
- Long Cases
- Short Cases
- Communication stations
- 2. Professional skills and knowledge: Communication
- 4. Professional skills and knowledge: Patient management
- 9. Mental health and behavioural presentations
- 10. Long-term conditions
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History
- Communication
- Development
- General Pediatrics Content Outline — Domain 5: Mental and Behavioral Health
- General Pediatrics Content Outline — Domain 6: Psychosocial Aspects
- Patient Care: Behavioral and mental health
- Medical Knowledge: Development and behavior
- Interpersonal and Communication Skills: Patient- and Family-Centered Communication
- Medical Expert
- Health Advocate
- Collaborator
Overview & Definition
A worried child is not, by itself, a diagnosis. Fear is a normal, healthy alarm: it keeps a toddler close to a caregiver, makes a teenager rehearse before an exam, and warns of real danger. Anxiety crosses into a disorder when that alarm fires too often, too loudly, for too long, and starts to shrink the child's world. The threshold examiners want is impairment plus persistence plus developmental excess. [2] [5]
Across the DSM-5-TR anxiety disorders, the shared mechanism is a fear or anxiety response that is out of proportion to the actual danger, lasts beyond a normal developmental window, and causes clinically significant distress or functional impairment. The disorders differ mainly in what the threat is — separation from an attachment figure, a specific object, social scrutiny, the unpredictability of everyday life, or the body's own sensations. [2]
Your role as a general paediatrician is not to deliver a definitive psychiatric label on the first visit. It is to recognise the anxiety, quantify the impairment, exclude medical and safeguarding danger, stratify suicide risk, and start evidence-based stepped care — psychoeducation and CBT first, escalating to an SSRI when severity demands. [2] [10]
References14ShowHide
- [1]Walkup JT, Albano AM, Piacentini J, Birmaher B, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med, 2008.PMID 18974308
- [2]Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, et al. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry, 2020.PMID 32439401
- [3]James AC, Reardon T, Soler A, James G, Creswell C. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev, 2020.PMID 33196111
- [4]Bridge JA, Iyengar S, Salary CB, Barbe RP, 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.PMID 17440145
- [5]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.PMID 17242630
- [6]Wang Z, Whiteside SPH, Sim L, Farah W, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis. JAMA Pediatr, 2017.PMID 28859190
- [7]Birmaher B, Axelson DA, Monk K, Kalas C, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry, 2003.PMID 12649628
- [8]The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med, 2001.PMID 11323729
- [9]Strawn JR, Mills JA, Schroeder H, et al. Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study. J Clin Psychiatry, 2020.PMID 32857933
- [10]Merikangas KR, He JP, Burstein M, Swanson SA, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry, 2010.PMID 20855043
- [11]Birmaher B, Khetarpal S, Brent D, Cully M, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry, 1997.PMID 9100430
- [12]Spence SH. A measure of anxiety symptoms among children. Behav Res Ther, 1998.PMID 9648330
- [13]Chorpita BF, Yim L, Moffitt C, Umemoto LA, Francis SE. Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale. Behav Res Ther, 2000.PMID 10937431
- [14]Østergaard KR Treatment of selective mutism based on cognitive behavioural therapy, psychopharmacology and combination therapy - a systematic review. Nord J Psychiatry, 2018.PMID 29447060