Anxiety disorders are common in children and teens, affecting around 8% of adolescents. Left untreated, anxiety can interfere with daily functioning and academic or social performance. Cognitive behavioral therapy and selective serotonin reuptake inhibitors are both effective treatments, with the best results seen from a combination of the two. Common anxiety disorders in youth include separation anxiety disorder, specific phobias, generalized anxiety disorder, and social anxiety disorder.

1. Anxiety Disorders in Kids
An Overview for Parents and Teachers
Sherri McClurg, Psy.D.
Managing Director, Family Center by the Falls
Stephen Grcevich, MD
President and Founder, Family Center by the Falls
Presented at Lake Ridge Academy
October 6, 2011

2. Some fears are normal and age-appropriate
in children:
 Infants: Fear of loud noises, fear of being
startled
 Toddlers/Young Children: Fear of imaginary
creatures, fear of the dark, animals, strangers
 School-age children: Worry about injury, natural
events (storms), death
 Older children, teens: Fears related to school
performance, social competence, health issues
J Am Acad Child Adolesc Psychiatry 2007;46(2) 267-83.

3. How are kids with anxiety disorders
different from their peers?
 They misperceive the level of threat, danger in
their environment
 They think too much…eventually to the point
that academic performance, family functioning,
friendships, extracurricular activities are
compromised…rumination, perseveration,
indecisiveness, perfectionism
 Decision to treat is grounded in the degree to
which anxiety interferes with daily functioning

4. Epidemiology of Anxiety Disorders:
 8% of teens ages 13-18 have anxiety disorders, most
with onset around age 6 (only 18% have received
treatment)
 Girls>Boys (especially phobias, panic disorder,
agoraphobia, separation anxiety)
 Severity=persistence
 Kids often develop new anxiety disorders over time
 Greater risk of depression, substance abuse
 Genetics, parent-child interactions, parental modeling,
temperament are risk factors
 Coping skills may be considered as protective factors
http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-adolescents/index.shtml
J Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

5. Warning signs of significant anxiety in
children and teens:
 “What if” questions
 Avoidance
 Excessive need for reassurance
 Excessive physical complaints
 Sleep disturbances (especially increased sleep latency)
 Difficulties with concentration, attention
 Perfectionism
 Excessive absence from school
 Easily distressed
 Lying

6. Specific Anxiety Disorders in Children,
Adolescents:
Note: Kids may experience different manifestations of anxiety as they
progress through developmental stages
 Separation Anxiety Disorder
 Specific Phobia
 Generalized Anxiety Disorder
 Social Anxiety Disorder
 Panic Disorder
 Obsessive-Compulsive Disorder
 Selective Mutism
J Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

7. Conditions associated with or mistaken
for anxiety disorders in children, teens:
 ADHD (treatment may exacerbate anxiety)
 Asperger’s Disorder
 Learning Disabilities
 Depression
 Psychotic Disorders
 Medication-induced anxiety

8. Treatment of anxiety disorders in
children, adolescents:
 Cognitive-behavioral therapy (with
modifications for specific anxiety
disorders)
 SSRIs, other medications
 Parent-child, family interventions
 Classroom-based accommodations,
interventions
Evidence-based interventions in red
J Am Acad Child Adolesc Psychiatry, 2007; 46(2):267-283

9. Medications Used in Kids With
Anxiety Disorders
 SSRIs (Sertraline, Fluvoxamine, Fluoxetine)
 Clomipramine
 Venlafaxine
 Tricyclic antidepressants (imipramine)
 Buspirone
 Benzodiazepines
J Am Acad Child Adolesc Psychiatry 2007; 46(2) 267-283

10. CAMS (Child-Adolescent Anxiety
Multimodal Study):
 NIMH-funded, RCT comparing placebo, sertraline,
CBT and combination treatment (CBT+sertraline)
for treatment of separation anxiety disorder, social
anxiety disorder, generalized anxiety disorder
 Children, ages 7-17, N=488
 CBT: 14 sessions, using “Coping Cat” curriculum
 Sertraline: started at 25 mg/day, increased by fixed-
flexible titration (mean dose:133 mg/day)
Walkup JT et al, N Engl J Med, 2008;359:2753-2766

11. CAMS (Child-Adolescent Anxiety
Multimodal Study):
 Response rates: COMB: 80.7%, CBT: 59.7%, SER:
54.9%, PBO: 23.7%
 COMB>CBT=SER>PBO
 Effect Sizes: COMB: 0.86, SER: 0.45, CBT: 0.31
 No adverse effects>PBO in medication groups
 Beneficial effects of COMB vs. SER evident after
week 8
Walkup JT et al, N Engl J Med, 2008;359:2753-2766

12. CAMS (Child-Adolescent Anxiety
Multimodal Study):
 Response rates: COMB: %Responders
80.7%, CBT: 59.7%, SER: 100
54.9%, PBO: 23.7% 80
 COMB>CBT=SER>PBO 60
 Effect Sizes: COMB: 0.86, 40
SER: 0.45, CBT: 0.31 20
%Responders
0
 No adverse effects>PBO in
medication groups
 Beneficial effects of COMB
vs. SER evident after week 8
Walkup JT et al, N Engl J Med, 2008;359:2753-2766

13. Cognitive Behavioral Therapy (CBT)
What is CBT?
The goal is to alter cognitive processes by
increasing self awareness, facilitate better self-
understanding, and improving self control by
developing more appropriate cognitive and
behavioral skills.

14. Cognitive Behavioral Therapy (CBT)
Thoughts
Three Components:
 Cognitive
 Emotional/Physiological
 Behavioral Behavior Feelings

15. Cognitive Behavioral Therapy (CBT)
Unhealthy Process Healthy Process
Thoughts Distorted thinking: Overly More positive, acknowledge
negative, self-critical, success, balanced, and
selective and biased recognized strengths
Feelings Unpleasant, anxious, Pleasant, relaxed, happy,
depressed, angry calm
Behavior Avoid, give-up, Confront, try, appropriate
inappropriate

16. Cognitive Behavioral Therapy (CBT)
Common Pattern of Anxiety
Child enters difficult situation
Child becomes anxious and fearful
Anxious behavior escalates and child gets stuck
Child avoids the situation or asks others to help
Child continues to think the situation is
dangerous and feels helpless

17. Cognitive Behavioral Therapy (CBT)
Build Confidence Reduce Anxiety
Build stronger relationships Learn to communicate
Take on more responsible roles Develop new skills
Increase independence and self- Gradually face fears
help skills

18. Cognitive Behavioral Therapy (CBT)
What not to do
Do not try to convince them it will be okay.
Do not minimize their experience.
Do not tell them to fight the anxiety.
Do not physically force them into the situation.
Do not verbally bully them into the situation.

19. Cognitive Behavioral Therapy (CBT)
What to do
Accept their feelings
Demonstrate understanding
Build competence
Have expectations but alter the process
Parent cooperatively vs. balancing
Respond vs. react

20. Cognitive Behavioral Therapy (CBT)
Calming Strategy
 Catch your breath
 Accept negative feelings
 Label emotions
 Model coping skills

21. Conclusions:
 Anxiety is one of the two most common mental health
disorders among children and teens in the U.S.
 The vast majority of kids with significant anxiety
develop symptoms during their grade school years (or
earlier) and receive no treatment for their condition.
 Kids with anxiety may be overrepresented among the
student body at independent schools
 Cognitive-Behavioral therapy (CBT) and medication
are effective treatments for kids with anxiety…best
response when CBT, medication used together

22. Questions?

23. Stay in Touch!
Family Center by the Falls: http://www.fcbtf.com
Phone: (440) 543-3400
E-mail: drgrcevich@fcbtf.com, drsherri@fcbtf.com
https://www.facebook.com/StephenGrcevichMD
@drgrcevich

24. Additional Resources:
American Academy of Child and Adolescent Psychiatry:
http://www.aacap.org/cs/AnxietyDisorders.ResourceCenter
National Institute of Mental Health
http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-
adolescents/index.shtml
Anxiety Disorders Association of America
http://www.adaa.org/living-with-anxiety/children