Anxiety is a normal human emotion, triggered by expected challenges (taking a test) and the reaction is proportional. Normal anxiety can be severe and chronic if the life challenge is severe and chronic.

Scope in Pediatrics

  • Pathological anxiety is triggered by normal developmental experiences (ie, going to school, ordering food in a restaurant); the reactions are disproportionate, unexpected and highly stereotypical across children.
  • Family history is a key predictor of anxiety disorder in a child.
  • Anxiety disorders first present prior to puberty and are arguably the most common psychiatric disorder in children.
  • For the pediatrician, physical complaints will often be the first presenting symptom of an anxiety disorder.
  • The 3 anxiety disorders with broad functional impact are separation, generalized, and social anxiety disorders
  • Children with anxiety cope by avoiding their anxiety triggers (normal developmental experiences) and loving parents/caregivers often facilitate avoidance to relieve their child’s distress. However, it is important for families to know that engaging, and not avoiding, is key to the behavioral management of anxiety disorder symptoms.
  • Treatment with cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitor (SNRIs) are effective and most effective when CBT and medication are combined.

Teaching Points

  • Collecting a family history and knowing the early symptoms of anxiety is essential for early identification.
  • Anticipatory guidance instructs parents and caregivers to help their child engage rather than avoid anxiety triggers, which slowly increases the child’s ability to tolerate distress.
  • Combined medication treatment and CBT offer substantially better short term and long-term outcomes.
  • A stepped care approach starting with CBT can be useful as long as the family understands that: 1) remission is the goal of treatment; and 2) if not remitted after 12-16 weeks of CBT, medication treatment is the next step.
  • SSRIs are the medication treatment of choice for anxiety disorders. They are safe and effective. Benefit outweighs the risk. NNT = 2-3; Suicidal thoughts NNH = 140

Recommended Reading

  • Parenting Through Puberty by Suanne Kowal-Connelly, MD, FAAP
  • Building Resilience in Children and Teens, 4th Edition by Kenneth R. Ginsburg, MD, MS Ed, FAAP
  • Reaching Teens: Strength-Based, Trauma-Sensitive, Resilience-Building Communication Strategies Rooted in Positive Youth Development, 2nd Edition. Editor Kenneth R. Ginsburg, MD, MS Ed, FAAP, FSAHM; Associate editor: Zachary Brett Ramirez McClain, MD
  • Promoting Mental Health in Children and Adolescents. Editor: Jane Meschan Foy, MD, FAAP
  • Raising Kids to Thrive: Balancing Love With Expectations and Trust by Kenneth R. Ginsburg, MD, Med, FAAP
  • Raising an Organized Child: 5 Steps to Boost Independence, Ease Frustration, and Promote Confidence by Damon Korb, MD, FAAP
  • Understanding Anxiety Disorders in Children {available in packs of 10}
  • Mental Health Care of Children and Adolescents: A Guide for Primary Care Physicians. Editor: Jane Meschan Foy, MD, FAAP
  • Keys to Parenting Your Anxious Child by Katharina Manassis, MD, FRCPC
  • Helping Your Anxious Child: A Step-by-Step Guide for Parents by Ronald Rapee, PhD et al. 

Additional Information


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Special Acknowledgment

The AAP gratefully acknowledges support for the Pediatric Mental Health Minute in the form of an educational grant from SOBI.