Mental Health: Anxiety Management in Pediatric Practice: Evidence-Based Approaches
Column Author: Sara Anderson, MD, MPH | Clinical Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Column Editor: Trent Myers, MD | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Imagine a child’s mind consumed by persistent worries: Will there be a storm today? Are my parents safe? Will my friends still like me? For many children, these aren’t fleeting concerns but daily struggles that disrupt focus, relationships and wellbeing. Up to 20% of youth experience clinically significant anxiety disorders, which often intertwine with academic challenges, social difficulties and somatic complaints like headaches or stomachaches. While transient fears are developmentally normal, impairing symptoms — such as refusal to attend school, relentless reassurance-seeking or physical distress during routine activities — signal the need for intervention. Pediatricians and mental health professionals must distinguish adaptive anxiety from pathological patterns, recognizing red flags like tantrums in younger children or avoidance behaviors in teens.
Social Anxiety Disorder
Clinical Features: Children with social anxiety disorder endure intense fear of social scrutiny, avoiding speaking in class, peer interactions or public events. Social anxiety disorder is more common in middle and high schoolers. Physical symptoms — trembling, shortness of breath, blushing or gastrointestinal distress — often accompany catastrophic thoughts (e.g., “What if I embarrass myself?”). Younger children may cry, cling to caregivers or throw tantrums, while adolescents report ruminations on what may happen, which can lead to school refusal. Left untreated, this disorder risks academic underachievement, loneliness and adult depression.
Management Strategies
(Pharmacotherapy details to follow in medication management section.)
First-line: Cognitive behavioral therapy (CBT), including online formats (e.g., guided internet-delivered CBT), demonstrates efficacy comparable to in-person therapy.
Combination therapy: CBT + selective serotonin reuptake inhibitors (SSRIs) yields superior outcomes (78% response rate), particularly for adolescents with comorbid depression.
Separation Anxiety Disorder
Clinical Features: Children with separation anxiety disorder (SAD) experience excessive distress when separated from caregivers, manifesting as school refusal, clinginess or somatic complaints such as stomachaches or headaches. They may exhibit intense fears about harm befalling caregivers (e.g., accidents, illness) or themselves (e.g., getting lost), often accompanied by physical symptoms like nausea, muscle tension or dizziness during separations. Younger children (ages 3-5) typically display tantrums, bedtime resistance or refusal to sleep alone, while older children and adolescents report persistent “what if” catastrophic thoughts (e.g., “What if Mom never comes back?”). Developmental variations are notable: preschoolers may cling to caregivers in public settings, whereas adolescents might avoid sleepovers or extracurricular activities. Left untreated, SAD can lead to academic decline, social isolation and an increased risk for adult anxiety disorders.
Age-Tailored Management Strategies
(Pharmacotherapy details to follow in medication management section.)
- Preschoolers: Parent-child interaction therapy (PCIT) shows 82% remission rates via play-based exposure and parental coaching.
- Older children: CBT with exposure therapy (e.g., school re-entry plans) and SPACE (Supportive Parenting for Anxious Childhood Emotions) to reduce family accommodation of avoidance behaviors.
Generalized Anxiety Disorder
Clinical Features:
Children and adolescents with generalized anxiety disorder (GAD) experience persistent, excessive worries about several different topics, such as academics, safety, family health or future events, often disproportionate to actual risks. Key symptoms include restlessness, fatigue, irritability and somatic complaints such as headaches, gastrointestinal distress (e.g., stomachaches), muscle tension or dizziness. Younger children may exhibit clinginess, frequent reassurance-seeking or sleep disturbances, while teens often report catastrophic “what if” thinking (e.g., “What if I fail this test and ruin my future?”). Perfectionism is common, with children obsessing over academic performance or avoiding tasks unless they can achieve unrealistic standards. Symptoms typically persist for six months or more and impair daily functioning.
Management Strategies
(Pharmacotherapy details to follow in medication management section.)
CBT is the primary first-line therapy for pediatric anxiety, but for moderate-to-severe cases, combined treatment with CBT and SSRIs is recommended, showing a 78% response rate compared to monotherapy. This approach optimizes recovery and functional improvement.
Pharmacotherapy Considerations
Medication Details: SSRIs like sertraline (12.5-25 mg/day), fluoxetine (5-10 mg/day) or escitalopram (2.5-10 mg/day) are first-line. Doses should be started low to minimize side effects (e.g., gastrointestinal upset, insomnia). For children under 6, fluoxetine may begin at 1-2 mg/day due to heightened sensitivity. Serotonin-norepinephrine reuptake inhibitors (SNRIs; e.g., duloxetine) are alternatives for partial SSRI responses or comorbidities. Combining SSRIs with CBT enhances outcomes (e.g., 78% response rates).
Parental Counseling: Address fears of dependency or personality changes by emphasizing that SSRIs restore function without altering identity. Position medication as a bridge to bolster CBT participation (e.g., reducing somatic symptoms for exposure therapy). Schedule regular follow-ups (two to four weeks initially) to guide dosing adjustments and monitor tolerability.
Key takeaways
Early identification via validated tools such as SCARED (Screen for Child Anxiety Related Emotional Disorders) and tailored interventions — prioritizing CBT with SSRIs for severe cases — optimizes outcomes. Developmental considerations, parental education and cross-disciplinary collaboration are pivotal in mitigating long-term risks. By addressing anxiety’s cognitive, behavioral and biological dimensions, clinicians empower children to reclaim their lives from fear’s grip.
References:
- Centers for Disease Control and Prevention. Anxiety and depression in children. Children’s Mental Health. January 31, 2025. https://www.cdc.gov/children-mental-health/about/about-anxiety-and-depression-in-children.html
- Chiu A, Falk A, Walkup JT. Anxiety disorders among children and adolescents. Focus (Am Psychiatr Publ). 2016;14(1):26-33. doi:10.1176/appi.focus.20150029
- Patel DR, Feucht C, Brown K, Ramsay J. Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr. 2018;7(1):23-35. doi:10.21037/tp.2017.08.05
- 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. doi:10.1016/j.jaac.2020.05.005