presentation of anxiety in childhood

A .gov website belongs to an official government organization in the United States.

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Data and Statistics on Children's Mental Health

Anxiety and Depression in Children

• Although fears and worries are typical in children, persistent or extreme forms of fear and sadness could be due to anxiety or depression.
• If you’re concerned about anxiety or depression in your child, the first step is to talk with a health care provider such as your child’s primary care provider, or a mental health specialist, about getting an evaluation.

Get help now‎

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat 988lifeline.org .

See available help and support resources here.

Many children have fears and worries, and may feel sad and hopeless from time to time. Strong fears may appear at different times during development. For example, toddlers can often become very distressed about being away from their parents, even if they are safe and cared for. Although fears and worries are typical in children, persistent or extreme forms of fear and sadness could be due to anxiety or depression. Because the symptoms primarily involve thoughts and feelings, they are sometimes called internalizing disorders .

Signs and symptoms

When a child does not outgrow the fears and worries that are typical in young children, or when there are so many fears and worries that they interfere with school, home, or play activities, the child may be diagnosed with an anxiety disorder. Anxiety is not one disorder but rather a category of conditions.

• Separation anxiety disorder: Being very afraid when away from parents, sometimes with extreme fear of the potential for being separated.
• Phobia: Having extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor.
• Social anxiety disorder: Being very afraid of going to places where there are people, such as school.
• Generalized anxiety disorder: Experiencing excessive, ongoing anxiety and worry that are difficult to control and interferes with day-to-day activities, but not necessarily specific to a particular situation or context.
• Panic disorder: Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty.

Anxiety may present as fear or worry but can also make children irritable and angry. Anxiety symptoms can also include trouble sleeping, as well as physical symptoms like fatigue, headaches, or stomachaches. Some anxious children keep their worries to themselves and, thus, the symptoms can be missed.

Occasionally being sad or feeling hopeless is a part of every child's life. However, some children feel sad or are uninterested in things that they used to enjoy, or feel helpless or hopeless in situations they are able to change. When children feel persistent sadness and hopelessness, they may be diagnosed with depression. Like anxiety, depression is not one disorder but a category of conditions. Major depressive disorder is the most common.

Examples of behaviors often seen in children with depression include:

• Feeling sad, hopeless, or irritable a lot of the time.
• Not wanting to do or enjoy doing fun things.
• Changes in eating patterns—eating a lot more or a lot less than usual.
• Changes in sleep patterns—sleeping a lot more or a lot less than normal.
• Changes in energy – being tired and sluggish or tense and restless a lot of the time.
• Having a hard time paying attention.
• Feeling worthless, useless, or guilty.
• Showing self-injury and self-destructive behavior.

Extreme depression can lead a child to think about suicide or plan for suicide. For youth ages 10-14 years, suicide is the second leading cause of death. 1

Some children may not talk about their helpless and hopeless thoughts and may not appear sad. Depression might also cause a child to make trouble or act unmotivated, causing others not to notice that the child is depressed or to incorrectly label the child as a troublemaker or lazy. Depression can also cause children to act irritable or angry. Depression and anxiety often co-occur among children, adolescents, and adults.

Managing symptoms: staying healthy

Good physical and mental health is important for all children and is especially important for children with depression or anxiety. In addition to getting the right treatment, practicing healthy lifestyle behaviors can play a role in managing symptoms of depression or anxiety. Here are some healthy behaviors that may help:

• Having a healthy eating plan centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds.
• Participating in physical activity for at least 60 minutes each day.
• Getting the recommended amount of sleep each night based on age.
• Practicing mindfulness or relaxation techniques.

Treatment for anxiety and depression

The first step to treatment is to talk with a health care provider such as your child's primary care provider, or a mental health specialist, about getting an evaluation.

• The United States Preventive Services Taskforce recommends screening for anxiety in children ages 8 to 18 years and for depression in adolescents ages 12 to 18 years.
• Some of the signs and symptoms of anxiety or depression in children could be caused by other conditions, such as trauma .
• It is important to get a careful evaluation to get the best diagnosis and treatment.
• Consultation with a health provider can help determine if medication should be part of the treatment.

A mental health professional can develop a therapy plan that works best for the child and family.

• Behavior therapy includes child therapy, family therapy, or a combination of both. The school can also be included in the treatment plan. For very young children, involving parents in treatment is key.
• Cognitive-behavioral therapy is one form of therapy that is used to treat anxiety or depression, particularly in older children. It helps the child change negative thoughts into more positive, effective ways of thinking and coping, leading to more effective behavior.
• Behavior therapy for anxiety may involve helping children cope with and manage anxiety symptoms while gradually exposing them to their fears to help them learn that bad things do not occur.

Treatments can also include a variety of ways to help the child feel less stressed and be healthier like nutritious food, physical activity , sufficient sleep , predictable routines, and social support.

Get help finding treatment

Pediatricians and other health care professionals that interact regularly with children can help support children's mental health and work with families to identify when specialist care is needed for diagnosis and treatment. To find a pediatrician near you, visit HealthyChildren.org , a service of the American Academy of Pediatrics (AAP) practice organization.

Families can also seek out referrals for a mental health provider through multiple avenues, including the child’s school, a primary care provider, or through health insurance. They can also ask for advice from trusted family or friends who may have some experience with providers in the local area.

If you need insurance coverage, learn more about enrolling in Medicaid, Children's Health Insurance Program (CHIP), or a Marketplace plan at HealthCare.gov . If your child does not qualify for insurance coverage, you can get low-cost health care at a nearby community health center .

Mental health specialists

Here are additional tools to find a healthcare provider familiar with treatment options:

• Psychologist Locator , a service of the American Psychological Association (APA) Practice Organization.
• Child and Adolescent Psychiatrist Finder , a research tool by the American Academy of Child and Adolescent Psychiatry (AACAP).
• Find a Cognitive Behavioral Therapist , a search tool by the Association for Behavioral and Cognitive Therapies.
• If you need help finding treatment facilities, visit FindTreatment.gov .

What CDC is doing

It is not known exactly why some children develop anxiety or depression. Many factors may play a role, including biology and temperament. But it is also known that some children are more likely to develop anxiety or depression when they experience the following: trauma or stress; violence, abuse, or neglect; being bullied or rejected by other children; or when their own parents have anxiety or depression.

Although these factors appear to increase the risk for anxiety or depression, there are ways to decrease the chance that children experience them. Learn about public health approaches to prevent these risks:

• Anxiety and Children - American Academy of Child & Adolescent Psychiatry (AACAP) fact sheet
• Depression in Children and Teens (AACAP fact sheet)
• Screening for anxiety in children and adolescents - The United States Preventive Services Taskforce (USPST)
• Screening for depression screening in children and adolescents (USPSTF)
• Recommendations for school-based cognitive behavioral therapy to reduce depression and anxiety symptoms (Community Preventive Services Task Force)
• Practice Parameters – AACAP healthcare provider guidelines for diagnosing and treating mental health conditions in children and adolescents
• CDC's Mental Health Homepage
• CDC. (2024). Facts About Suicide. Retrieved August 8, 2024 from https://www.cdc.gov/suicide/facts/index.html

Children’s Mental Health

About Children's Mental Health

ALICIA KOWALCHUK, DO, SANDRA J. GONZALEZ, PhD, AND ROGER J. ZOOROB, MD, MPH

Am Fam Physician. 2022;106(6):657-664

Author disclosure: No relevant financial relationships.

Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children eight years and older; there is insufficient evidence to support screening in children younger than eight years. Symptoms of anxiety disorders in children and adolescents are similar to those in adults and can include physical and behavioral symptoms such as diaphoresis, palpitations, and tantrums. Care should be taken to distinguish symptoms of a disorder from normal developmental fears and behaviors, such as separation anxiety in infants and toddlers. Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration.

Childhood anxiety is a common psychiatric disorder. It is estimated that more than 7% of adolescents 13 to 17 years of age have been diagnosed with anxiety, and more than 36% of children with behavioral problems have been diagnosed with anxiety disorders. 1 A systematic review of studies conducted in 27 countries estimates that the worldwide prevalence of anxiety disorders in children is 6.5%. 2 In the United States, nearly 1 in 12 children three to 17 years of age have anxiety. 1 The National Institute of Mental Health estimates that the prevalence of anxiety disorders in adolescents 13 to 18 years of age is 1 in 4, and the prevalence of severe anxiety is about 1 in 17. 3 Prevalence rates are approximately 20% for specific phobias, 9% for social anxiety disorder, 8% for separation anxiety disorder, and 2% each for agoraphobia, panic disorder, and generalized anxiety disorder. 3

Etiology and Risk Factors

Risk factors for anxiety disorders in children and adolescents include low socioeconomic status, exposure to violence, trauma, and biologic factors such as heritability and temperament. Parental anxiety predisposes children to a higher risk of functional impairment and anxiety disorders. 4 In the past decade, there has been increasing concern over the impact of social media use and engagement with online content on anxiety symptoms and the development of anxiety disorders in children and adolescents. The impact can have positive and negative associations and varies by gender, age, social media platform, and time spent using. Fear of missing out and validation seeking drive engagement with and time spent on social media and can lead to increases in general anxiety symptoms (more common in boys) and anxiety around body image (more common in girls). 5 Cyberbullying can lead to increased anxiety and risk of anxiety disorders, especially in marginalized youths, although positive effects of increased connection to online communities have been noted. 5 The impact of the COVID-19 pandemic on child and adolescent mental health has become a growing concern. A 2021 meta-analysis that included more than 80,000 youths in 29 studies showed a pooled prevalence of clinically elevated anxiety symptoms of 21%, with higher prevalence rates in data collected later in the pandemic and in girls. 6

The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children and adolescents eight to 18 years of age (grade B recommendation). There is insufficient evidence to support screening in children younger than eight years. 7

Clinical Presentation

Symptoms include excessive anxiety, fear, or worry that is out of proportion to the situation, event, person, object, or threat. Symptom context and triggers can help distinguish between specific anxiety disorders. Physical symptoms of anxiety disorders in children and adolescents manifest as autonomic nervous system activation, including diaphoresis, palpitations, chest tightness, nausea, faintness, chills, and muscle tightness. Peak autonomic nervous system activation is seen in panic attacks, which can occur with any anxiety disorder. Additional behavioral responses indicative of an anxiety disorder include avoidance of or reluctance to engage in certain activities or with certain objects or individuals. Children can display behaviors such as crying, tantrums, or clinging when confronting or anticipating engagement with a situation, event, person, object, or threat. Anxiety disorder symptoms persist over time and negatively impact functioning in one or more domains, such as education and social and interpersonal performance. 8 , 9

Diagnostic Criteria and Differential Diagnosis

Table 1 summarizes the Diagnostic and Statistical Manual of Mental Disorders , 5th ed., diagnostic criteria for anxiety disorders commonly diagnosed in children and adolescents and highlights exclusionary symptoms of the differential diagnosis specific to each disorder. 9 , 10 Table 2 lists the differential diagnosis for anxiety disorders in children and adolescents, distinguishing symptoms, physical examination findings, and recommended diagnostic studies. 3 , 9

Diagnosis is based on a clinical interview with the child or adolescent and their primary caretakers. It is important to gather medical and psychiatric histories; family history of anxiety and other mental disorders; current and past treatments, including prescribed, over-the-counter, and herbal or alternative products; and current substance use by adolescents, primary caretakers, or others within the household. Clinicians should also inquire about trauma history, current psychosocial stressors, current and past social functioning with adults (e.g., parents or guardians, teachers) and peers, and educational performance. Assessing for suicide risk, including self-harming behaviors and suicidal ideation, is critical. 3 , 8

Table 3 summarizes some of the validated self-reported and caretaker-reported screening measures that are useful for baseline symptom and severity assessment and ongoing monitoring. 8 , 9 , 11 The Screen for Child Anxiety Related Emotional Disorders (SCARED; for use in patients eight years and older) and the Spence Children’s Anxiety Scale (SCAS; for use in patients six to seven years of age) are available for free online. For younger patients (i.e., 30 months to 6.5 years of age), clinicians can use the parent-reported Preschool Anxiety Scale (PAS), which was adapted from the SCAS. 8 , 9 The 5-item version of the SCARED tool has a sensitivity of 74% and specificity of 73% using a cutoff score of 3. 12 The 8-item parent version of the SCAS has a sensitivity of 85% and specificity of 75% using a cutoff score of 7.5. 11

A detailed psychosocial history and comprehensive picture of current stressors allow for the differentiation of developmentally appropriate worries, fears, and stress responses from an anxiety disorder. 8 , 9 Identifying individual and family strengths, resources, and support is important for developing a therapeutic alliance. 3

Physical examination should focus on ruling out medical conditions presenting with anxiety-like symptoms. This includes the cardiopulmonary, abdominal, and nervous systems, and may include targeted examination of the head and neck and musculoskeletal and integumentary systems. Laboratory tests, such as thyroid function testing for hyperthyroidism, imaging, and other diagnostic testing are rarely needed, but they may be indicated to rule out a specific differential diagnosis suggested by the history and physical examination. 3 , 9

Behavioral and Pharmacologic Treatments

The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that primary care clinicians work with caregivers to understand the child’s symptoms of anxiety and degree of functional impairment. Following assessment and diagnosis, psychological and pharmacologic treatments may be considered based on symptom severity, patient and parent preferences, and availability and quality of psychosocial treatment.

PSYCHOLOGICAL THERAPIES

For mild to moderate symptoms, strong evidence from randomized trials supports the use of cognitive behavior therapy (CBT), delivered individually or in group settings, as a first-line treatment, 13 with a number needed to treat (NNT) of 6 for the primary outcome of remission of any anxiety disorder diagnosis vs. wait-list controls. 14 CBT focuses on how thoughts affect mood and behavior. It is a directive and time-limited approach addressing factors that maintain anxiety symptoms. Sessions may be conducted with the child or the child and their parents and include homework assignments that provide an opportunity for the child to practice skills outside of therapy. For most childhood anxiety disorders, treatment with CBT lasts between 12 and 20 weeks with booster sessions occasionally occurring over several months to reinforce skills.

CBT has two components: modifying thinking patterns (i.e., cognitive) and changing behavioral patterns (i.e., behavior). Cognitive restructuring is an essential aspect of CBT that assists children or adolescents in becoming more aware of their self-talk, providing an opportunity to examine the accuracy of thoughts and replace them with more adaptive ones. The behavioral component uses strategies such as social skills training, relaxation strategies, and exposure techniques to change behavior. Exposure techniques are used to address avoidance behavior, which is known to maintain or worsen anxiety over time. One exposure technique that is commonly used is systematic desensitization, which is a gradual, progressive exposure to feared stimuli. 15

PHARMACOLOGIC THERAPY

Although CBT is the preferred treatment for mild to moderate symptoms of anxiety disorders, pharmacologic treatment may be considered when the child or adolescent presents with moderate to severe symptoms (e.g., presence of panic attacks, inability or refusal to go to school), is unwilling or unable to participate in psychotherapy, or has shown a poor response to CBT. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medications for anxiety disorders and are generally well tolerated. 8 Fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro) are antidepressant medications that effectively treat childhood anxiety disorders. 13 Serotonin-norepinephrine reuptake inhibitors (SNRIs) have also shown effectiveness.

Duloxetine (Cymbalta) is the only medication approved by the U.S. Food and Drug Administration (FDA) for generalized anxiety disorder in children seven years and older. In a 10-week randomized, placebo-controlled study of youths seven to 17 years of age, patients treated with duloxetine showed a significantly greater likelihood of symptom improvement on the Pediatric Anxiety Rating Scale, remission (NNT = 6), and functional improvement compared with placebo. 16 In a large, multisite, double-blind, randomized controlled trial, patients six to 17 years of age who received extended-release venlafaxine for generalized anxiety disorder and social phobia showed significant improvement in symptoms over the eight-week trial period compared with placebo. 8 A Cochrane systematic review of 22 randomized trials concluded that the likelihood of treatment response was significantly greater with pharmacotherapy compared with placebo (58.1% vs. 31.5%; NNT = 4). 17 Medication was not as well tolerated compared with placebo, although only 5% of participants withdrew from studies because of adverse effects.

Antidepressants such as SSRIs and SNRIs have an FDA boxed warning regarding the increased risk of suicidal thoughts and behaviors in children and adolescents. Family physicians should discuss this risk with patients and their caregivers when obtaining informed consent and use medications selectively. Initiation of pharmacologic therapy should be at the lowest dose available for the medication selected, with upward titration after the first week, if tolerated. Symptoms should be regularly monitored after initiating pharmacologic therapy. Typical therapeutic dose ranges are similar to those in adults because children tend to metabolize medications quickly. 18 – 20 The long-term effects of antidepressant use in children and adolescents are unknown; therefore, the FDA recommends limiting duration of use. The AACAP recommends that children and adolescents remain on medication for six to 12 months after anxiety symptoms have resolved and, if possible, taper and discontinue during a stress-free time (e.g., end of school, beginning of summer).

COMBINED TREATMENT

CBT and CBT combined with medication have been shown to be most effective in treating childhood anxiety disorders. A randomized controlled trial of 488 children with social anxiety disorder, generalized anxiety disorder, or separation anxiety disorder found that the combination of CBT and sertraline was more effective than either CBT or sertraline alone (81% vs. 60% and 55%, respectively; NNT = 2, 3, and 3, respectively). 21

In October 2020, the AACAP published clinical practice guidelines using the systematic review conducted by the Mayo Clinic Evidence-Based Practice Center and the Agency for Healthcare Research and Quality. 21 The AACAP recommends that children and adolescents six to 18 years of age diagnosed with social anxiety disorder, generalized anxiety disorder, separation anxiety disorder, specific phobia, or panic disorder receive treatment with CBT or an SSRI . 8 , 10 , 11 , 13 The findings of the review were not sufficient to recommend a particular order of treatments; however, depending on symptom severity and patient response, a judicious approach starting with CBT may be chosen ahead of an SSRI. 22 Combination treatment could be offered preferentially over CBT or an SSRI alone. 8 , 11 , 13

There is a sufficient body of empirical evidence that shows significant improvement in childhood anxiety disorders with psychotherapy or pharmacotherapy, with a combination of therapies providing the most benefits. Despite effective treatments, some childhood anxiety disorders persist into adulthood. In a longitudinal study examining the remission rates of anxiety among 319 youths, researchers found that after four years only 22% of study participants were in stable symptom remission, 48% had relapsed, and 30% were chronically ill. 23 Evidence-based treatments, early intervention, caregiver support and modeling, professional collaboration, and care coordination are all important elements leading to a better prognosis. 24

Data Sources: We searched PubMed using the key terms anxiety and children and adolescents, and included meta-analyses, randomized controlled trials, clinical trials, and reviews. Essential Evidence Plus, the Agency for Healthcare Research and Quality effective health care reviews, the Cochrane Database of Systematic Reviews, and the U.S. Preventive Services Task Force were also searched. Search dates: November 19, 2021; April 15, 2022; and September 2, 2022.

Ghandour RM, Sherman LJ, Vladutiu CJ, et al. Prevalence and treatment of depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206:256-267.e3.

Polanczyk GV, Salum GA, Sugaya LS, et al. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345-365.

Walter HJ, Bukstein OG, Abright AR, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124.

Zhu Y, Chen X, Zhao H, et al. Socioeconomic status disparities affect children’s anxiety and stress-sensitive cortisol awakening response through parental anxiety. Psychoneuroendocrinology. 2019;103:96-103.

Cataldo I, Lepri B, Neoh MJY, et al. Social media usage and development of psychiatric disorders in childhood and adolescence: a review. Front Psychiatry. 2021;11:508595.

Racine N, McArthur BA, Cooke JE, et al. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA Pediatr. 2021;175(11):1142-1150.

U.S. Preventive Services Task Force. Anxiety in children and adolescents: screening. Accessed October 12, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents

Wehry AM, Beesdo-Baum K, Hennelly MM, et al. Assessment and treatment of anxiety disorders in children and adolescents. Curr Psychiatry Rep. 2015;17(7):52.

Freidl EK, Stroeh OM, Elkins RM, et al. Assessment and treatment of anxiety among children and adolescents. Focus (Am Psychiatr Publ). 2017;15(2):144-156.

Ringeisen H, Casanueva C, Stambaugh L, et al.; Center for Behavioral Health Statistics and Quality; Research Triangle Institute. DSM-5 Changes: Implications for Child Serious Emotional Disturbance . Substance Abuse and Mental Health Services Administration (US); 2016. Accessed April 20, 2022. https://www.ncbi.nlm.nih.gov/books/NBK519712/

Reardon T, Spence SH, Hesse J, et al. Identifying children with anxiety disorders using brief versions of the Spence Children’s Anxiety Scale for children, parents, and teachers. Psychol Assess. 2018;30(10):1342-1355.

Birmaher B, Brent DA, Chiappetta L, et al. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38(10):1230-1236.

Wang Z, Whiteside SPH, Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis [published correction appears in JAMA Pediatr . 2018; 172(10): 992]. JAMA Pediatr. 2017;171(11):1049-1056.

James AC, Reardon T, Soler A, et al. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2020(11):CD013162.

Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci. 2015;17(3):337-346.

Strawn JR, Prakash A, Zhang Q, 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;54(4):283-293.

Ipser JC, Stein DJ, Hawkridge S, et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2009(3):CD005170.

Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63(3):332-339.

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;297(15):1683-1696.

Rynn M, Puliafico A, Heleniak C, et al. Advances in pharmacotherapy for pediatric anxiety disorders. Depress Anxiety. 2011;28(1):76-87.

Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety [published correction appears in N Engl J Med . 2013; 368(5): 490]. N Engl J Med. 2008;359(26):2753-2766.

Wang Z, Whiteside S, Sim L, et al. Anxiety in children. Comparative effectiveness review no. 192. AHRQ publication no. 17-EHC023-EF. Agency for Healthcare Research and Quality; August 2017. Accessed, January 18, 2022. https://www.ncbi.nlm.nih.gov/books/NBK476277/pdf/Bookshelf_NBK476277.pdf

Ginsburg GS, Becker-Haimes EM, Keeton C, et al. Results from the child/adolescent anxiety multimodal extended long-term study (CAMELS): primary anxiety outcomes. J Am Acad Child Adolesc Psychiatry. 2018;57(7):471-480.

Martini R, Hilt R, Marx L, et al. Best principles for integration of child psychiatry into the pediatric health home. American Academy of Child and Adolescent Psychiatry; 2012. Accessed January 9, 2022. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/systems_of_care/best_principles_for_integration_of_child_psychiatry_into_the_pediatric_health_home_2012.pdf

Continue Reading

More in AFP

More in pubmed.

Copyright © 2022 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Internet Explorer is no longer supported

Please upgrade to Microsoft Edge , Google Chrome , or Firefox .

Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares.

Get this as a PDF

Enter email to download and get news and resources in your inbox.

Share this on social

Quick guide to anxiety in children, what is anxiety.

Anxiety is a very general term used to describe a feeling of extreme worry or unease. Feeling anxious is natural after something upsetting happens. But when a child feels anxiety that lasts a long time and prevents them from doing things like going to school or seeing friends, then it becomes an anxiety disorder. Children can be diagnosed with several different anxiety disorders. The specific disorder depends on what the child is struggling with most, but many of the symptoms overlap. 

What are the symptoms of anxiety in children?

Anxiety has many symptoms and can look very different from child to child. Here are some common signs that a child might have an anxiety disorder: 

• Trouble sleeping 
• Complaining about stomachaches or other physical problems 
• Avoiding certain situations 
• Being clingy around parents or caregivers 
• Trouble concentrating in class or being very fidgety 
• Tantrums 
• Being very self-conscious 

Children can be diagnosed with different kinds of anxiety depending on what they are most worried about. 

What kinds of anxiety disorders can children experience?

Separation anxiety disorder:  Children feel extremely upset when they have to be away from parents or caregivers. This anxiety goes beyond what other kids their age normally feel. 

Symptoms of separation anxiety include: 

• Worry about parents or caregivers getting sick or dying 
• Refusing to leave home or go to school 
• Fear of sleeping or being alone 
• Nightmares about separation 
• Physical symptoms (such as headaches or stomachaches) before an upcoming separation 

Children with separation anxiety disorder show symptoms for at least four weeks.   

Social anxiety disorder:  Children with social anxiety disorder feel extremely self-conscious around other people. They are so afraid of being embarrassed that they avoid social situations and even speaking in class. 

Symptoms of social anxiety disorder in children include: 

• Avoiding most social situations or feeling terrible when they have to participate in them 
• Physical symptoms like shaking, sweating or trouble breathing in social situations 
• In young children, tantrums and crying in social situations 
• Fear of others seeing their anxiety and judging them for it  

For a child to be diagnosed with social anxiety disorder, their worry must be so extreme that it interferes with daily life. 

Selective mutism:  Children with selective mutism have a hard time speaking in some situations, like at school. These kids aren’t just shy. Their anxiety is so bad that they feel frozen and are not able to speak.  

To get a diagnosis of selective mutism, the child must: 

• Be able to speak in some situations but not others 
• Have had the problem for at least a month  
• Have problems with school and social activities as a result 

Children are not diagnosed with selective mutism if their trouble speaking is caused by a communication disorder or language barrier. 

Generalized anxiety disorder:  Children with generalized anxiety disorder worry about a lot of everyday things. Their worry is not caused by anything specific and it is bad enough to get in the way of daily life.     Symptoms of generalized anxiety disorder in children include: 

• Restlessness 
• Feeling on edge 
• Feeling tired much of the time 
• Problems concentrating 
• Feeling angry 

To be diagnosed with generalized anxiety disorder, children must experience symptoms most days for at least six months. 

Panic disorder:  Children with panic disorder have frequent, unexpected panic attacks. Panic attacks cause physical feelings that can make kids think they are dying or having a heart attack.   Children are diagnosed with panic disorder when they experience at least one panic attack and show other signs including: 

• Constant fear of more panic attacks 
• A big change from normal behavior after the panic attacks, like avoiding places that remind them of an attack 

When diagnosing a child with panic disorder, a professional also rules out medical causes and other disorders like PTSD.  

Obsessive-compulsive disorder (OCD) : Children with OCD have thoughts and worries that make them very anxious. They develop rules for themselves that they feel they must follow to control the anxiety.  

• Obsessions are the unwanted thoughts that make kids feel upset and anxious. 
• Compulsions are the rules kids feel they have to follow to get rid of their anxiety. 

Children can be diagnosed with OCD when they have obsessions, compulsions or both. 

Specific phobia:  Kids with specific phobias are very afraid of one or more specific things. This fear is of something that isn’t normally considered dangerous. Phobias disrupt kids’ lives when they go out of their way to avoid the things they’re afraid of. 

Common phobias in children include: 

• Animals or insects 
• Parts of the natural world, like water or heights 
• Blood or shots 
• Specific situations, like crowds or tight spaces 
• Others including vomiting, choking or loud sounds 

How is anxiety treated?

Almost all types of anxiety are best treated with cognitive behavioral therapy (CBT). CBT is based on the idea that how we think and act both affect how we feel. By learning to change negative thoughts and unhealthy actions, kids can change their bad feelings.  

An important part of CBT in treatment for anxiety is called exposure and response prevention. In exposure and response prevention, the therapist helps the child face the thing they’re afraid of a little at a time. By dealing with their fear in small amounts in a safe space, kids learn to deal with the big feelings that come up. 

For some children, taking medication for anxiety in addition to going through therapy makes treatment more effective. 

Was this guide helpful?

Explore popular topics, subscribe to our newsletters.

" * " indicates required fields

This site is protected by  reCAPTCHA  and the Google  Privacy Policy  and  Terms of Service  apply.

Stay Updated

Sign up for free weekly expert tips, guides, and resources to support your mental health journey—straight to your inbox.

Different Presentations of Anxiety in Children

By Emily Habelrih (@theplayfulpsychologist)

Anxiety is the most common mental health condition that affects an individual’s ability to concentrate, sleep, and carry out basic daily tasks. Anxiety affects 1 in 10 children and is the most common type of mental health condition in both children and adults. Often, children who seem angry, defiant, or oppositional are severely anxious, and can be misdiagnosed as their presentation differs greatly from how anxiety presents itself in adults. In children, age appropriate ‘fears’ are often mislabelled as anxiety. Fear itself is a natural emotion that helps us survive, cope with difficulties, and manage challenging situations. The key difference between fear and anxiety is that we often feel fear in regards to a real threat or danger. Anxiety however is commonly a response to an imagined threat or danger. Anxiety becomes a concern for children when it begins to impact their everyday life: from difficulty maintaining friendships, to lack of engagement in social activities, and behavioural problems such as avoidance/difficulty separating. Anxiety in youth has a variety of causes, including:

- Parental mental health concerns

- Emotional regulation difficulties

- Friendship and peer difficulties

- Low self-esteem

- Social modelling from caregivers

- Being the victim of bullying

- Traumatic experiences

- The need for social acceptance

- Academic difficulties

- Academic pressure

Anxiety is not often caused by one of these factors, and is usually a combination of several different factors. Furthermore, there is a common misconception that ‘anxiety’ is an umbrella term that covers all different types of worries, which is in fact false. There is also another common misconception that children can’t experience certain types of anxiety because they are ‘too young.’ Again, false ! Anxiety is completely dependent on experience, and unfortunately, children are often exposed to situations/events that are age inappropriate, leading to a variety of anxiety-related disorders. Let’s go through the most common anxiety presentations:

Generalised Anxiety Disorder (GAD)

GAD is when children experience multiple non-specific fears. Their fear is not focused on one specific object, situation or event. Children with GAD appear to worry about almost everything and anything. This may even include a fear of worrying about worrying.

Separation Anxiety Disorder

Separation anxiety disorder is classified as a fear of being separated from a parent or attachment figure. Children who experience separation anxiety often display clingy behaviour and/or refusal to go to school/pre-school. Although somewhat age appropriate in early periods of separation, children with separation anxiety are not able to regulate their emotions long after their caregiver has left. An example of this is, one child might cry and have a small meltdown when his mother drops him at school. He may even cry for 10-15 minutes after she has left, however he is eventually able to regulate his emotions and be redirected by his teacher. A child with separation anxiety disorder however, might cry for hours on end, and may be completely unable to concentrate on any task or engage in any activity until they see their parent/caregiver again at home time.

Social Anxiety Disorder

Social anxiety relates to a fear of being negatively evaluated by others, or of embarrassing oneself in front of other people. Social anxiety has an impact on social functioning and social skills may potentially have further impacts in later life (e.g., obtaining employment).

Post-Traumatic Stress Disorder (PTSD)

PTSD occurs after the experience of a traumatic event. Trauma is usually perceived as life threatening to the child or others. It includes recurring fearful thoughts and memories after the traumatic event has occurred. Children who experience PTSD often try to avoid situations or events that remind them of the traumatic event. Often, PTSD can lead to GAD or separation anxiety disorder.

Specific Phobia

Specific Phobia’s are a fear about a particular object, event or situation (e.g., fear of spiders, injections, heights, rollercoasters, small spaces). It often includes the overestimation of the likelihood that the particular object will cause harm. Specific phobia’s differ to GAD in that the anxiety is confined to one or two specific things.

Obsessive Compulsive Disorder (OCD)

OCD is commonly known for repetitive or compulsive behaviours (e.g., turning a light switch on and off multiple times before leaving a room). These behaviours are often triggered by intrusive, repetitive and obsessive thoughts that harm will occur if a particular behaviour is not performed correctly.

Panic Disorder

Panic disorder relates to a fear of unexpected panic attacks. Panic attacks include intense and extreme bouts of anxiety which occur in short isolated periods. Attacks mainly consist of uncontrollable physical symptoms such as heart palpitations and rapid breathing. The difference between a panic attack and panic disorder is that, a panic attack is a single episode of anxiety. Contrastingly, panic disorder is the fear of future panic attacks.

Anxiety disorders can be treated in a variety of ways. If you believe your child might be experiencing anxiety, it is best to consult a child psychologist, who can assist with both assessment of the child’s anxiety and therapy to assist with management of the anxiety.

Recent Posts

Free Telehealth Feelings Check-in

Different Ways to Use Thumb Ball in Therapy

Free Emotional Regulation Workbook