See also

Acute behavioural disturbance: Acute management  
Acute behavioural disturbance: Code response 
Mental state examination 

Key Points

1. Consider whether anxiety is contributing to the presentation for all children
2. Psychological therapy should be first line and ongoing treatment for anxiety
3. If medication is being considered, this should be in conjunction with ongoing psychological therapy

Background

• Anxiety disorders are among the most common mental health conditions in children
• While some degree of anxiety is recognised as a normal response to stress, anxiety disorders can be distinguished by their intensity, duration and impact on daily function
• Anxiety disorders are characterised by excessive fear, apprehension and other behavioural disturbances in response to an anticipated potential threat
• Care should be patient-centred, with respect given to children and their parents/carers, and with their involvement in decisions about their health

Assessment

History

• Assess for symptoms and signs of anxiety disorder, and determine whether the symptoms meet the diagnostic criteria in DSM-5 or ICD-11 (see below)
• Consider the presence, severity and impact of anxiety in the context of all areas of the child’s life
• Presentations of anxiety will differ across ages and developmental stages and may include:
• Regularly avoiding everyday experiences and situations, eg school, social events, playing, sport, eating or sleeping
• Frequent physical complaints, such as tummy aches and headaches
• Sudden emotional or angry outbursts, tantrums or ‘meltdowns’
• Difficulty sleeping
• Changes in appetite
• Seeking reassurance often
• Being preoccupied or unable to concentrate
• Overplanning situations and overthinking things
• Assess for other medical, neurodevelopmental comorbidities or life experiences (see below) that may increase risk of anxiety, contribute to presentation, or impact on medication options
• Medications eg prescription, over the counter, complementary

Risk factors for anxiety in children

• Mental health conditions eg eating disorders
• Neurodevelopmental disorders eg autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), intellectual disability, communication disorders, developmental delay
• Disturbances in sleep, behaviour, appetite/weight or somatic symptoms
• Chronic illness that impacts daily functioning, quality of life, autonomy eg cystic fibrosis
• Sensory impairment
• Gender-related concerns
• Experience of trauma eg family experience/history of violence, trauma, conflict, out of home care or traumatic event resulting in a disability
• Family history of anxiety, depression, obsessive compulsive disorder (OCD) or substance use disorders
• Substance misuse

Note: this list is not exhaustive, and clinicians should also rely on professional judgement and clinical assessment

Examination

• Baseline physical exam including cardiac exam, blood pressure, heart rate and growth parameters
• Further targeted exam as indicated, to rule out organic causes that may mimic anxiety symptoms eg hyperthyroidism 
• Assess for symptoms of anxiety disorder and determine whether symptoms meet diagnostic criteria in DSM-5 or ICD-11
• Rating scales and screening tools may be useful in assessing anxiety but must be supplemented by clinical interview and observations when making a diagnosis. A variety of screening instruments are available including
• Spence children's anxiety scale
• SCARED
• Social phobia inventory

Management

• Management of anxiety includes psychoeducation, psychological therapy, and medication with the aim of reducing anxiety symptoms, remission of anxiety diagnosis and improved functioning
• Anxiety commonly co-occurs with other mental health, neurodevelopmental and physical conditions and it is important to consider these as part of assessment and management

Investigations

No investigations are required unless considering an alternative diagnosis

Treatment

A discussion of treatment and support options should always begin with psychoeducation, followed by consideration of the psychological and medication treatment options acceptable to the child and family

Psychoeducation

Psychoeducation for children and carers is a core component of management and should include education and information on the following 

• Symptoms of anxiety and perpetuating factors
• Secondary impacts of anxiety on the family, individual’s quality of life and behavioural functioning
• Possible negative impacts of receiving a diagnosis, including stigma and labelling

To ensure shared and informed decision making when planning care, explore

• Family and individual beliefs and understanding about methods to manage mental health conditions
• The likelihood of the child adhering to the treatment plan for psychological and medication treatments, and anything that can be implemented to support this

Psychological therapy

First line treatment for anxiety in most situations should be psychological therapy for the following reasons 

• Demonstrated efficacy and effectiveness in alleviating anxiety symptoms
• Minimises potential side effects and risks of medication
• Addresses underlying causes
• Builds skills to manage anxiety-related challenges and prevents relapse in the future including coping skills, emotional regulation techniques and problem-solving abilities
• Empowers young individuals to take an active role in their wellbeing

When recommending psychological therapy consider

• The developmental age and stage of the child
• Feasibility of child and family’s capacity to participate in full course of sessions
• Alternatives if barriers to access eg cost of therapy or lengthy waitlists 

Cognitive behavioural therapy (CBT) should be used for remission of anxiety diagnosis, reduction of anxiety symptoms and improvement in daily functioning of children aged 8-18, who have mild-moderate symptoms, as a first line treatment before considering medication

Evidence informed Internet CBT (CBT using online/app-based programs) can be used for children ≥8 yo with anxiety, individually or with assistance, depending on age/developmental stage

• BRAVE Program
• Cool Kids Anxiety Program

Play therapy could be considered for children <8 yo, those with procedural anxiety or medical trauma, or those <12 yo who have may have difficulty engaging in CBT Acceptance and commitment therapy (ACT) could be used for children and young people 12-18 yo, particularly for those with concurrent chronic health conditions

Further information on other therapies can be found in resources below

Medication

• Should not be considered a first-line treatment except in exceptional circumstances
• Best initiated by a clinician with knowledge, training, and experience in prescribing psychotropic medications in children
• Could be used in conjunction with psychological therapies if the child’s anxiety is:
  • Too severe to allow meaningful engagement in psychological therapy and medication may assist
  • associated with significantly reduced access to education due to limited school attendance
  • associated with a moderate or greater risk of deliberate self-harm*
  • associated with a significant risk to the wellbeing of the family member
• Psychological therapy should be continued in conjunction with medication

*NB commencing medications may not reduce this risk and may increase agitation initially. See side effects/activation syndrome below

Initiating medication
Selective serotonin reuptake inhibitors (SSRIs) are first-line medication for anxiety

• As no SSRIs are currently licensed by TGA for use in anxiety or depression in children and adolescents in Australia, medications will be prescribed off label
• Clinicians should familiarise themselves with 2 or 3 SSRIs with respect to initial and target doses and adverse effect profiles
• As fluoxetine and escitalopram are approved by FDA for depressive episodes, it is sensible to consider using these
• When commencing medication, start with a low dose, noting that doses vary depending on age, developmental stage and symptoms
• An example of common prescribing patterns below

Those unfamiliar with prescribing SSRIs should discuss with senior clinician

• titrate up slowly whilst monitoring for adverse effects to reach a minimum effective dose
• SSRIs take several weeks to become effective for anxiety and the benefits, when seen, often continue to increase over time (months)
• SSRIs remain the first-line medication if the anxiety disorder is comorbid with depression, ADHD or OCD

Ensure the child and family have clear understanding of indications to cease medications (adverse side effects), formulation options and methods for safe medication storage and disposal

Adverse effects

• Most common - nausea, vomiting, loss of appetite, dry mouth, agitation, insomnia (or sometimes sedation), headaches, dizziness, sweating and sexual dysfunction
• SSRIs should be gradually reduced to minimise discontinuation symptoms
• Consider SSRIs with longer half-lives eg fluoxetine, or those deemed to be at lower risk of discontinuation syndrome if concern about medication adherence
• Activation syndrome is a well-known adverse effect of SSRIs and presents with increased activity, impulsivity, disinhibition, restlessness, irritability, and insomnia
• Caution when prescribing SSRIs is recommended for the following children:
• highly aroused/ADHD with comorbid anxiety
• family history of bipolar disorder
• younger age
• Dosing needs to be low, and up-titration should be done slowly

Dose adjustment
Monitor treatment response using validated rating scales eg Revised child anxiety and depression scale (RCADS). Monitor adverse effects and adherence, and adjustment of dose accordingly

• When considering medication changes for a child who has been taking SSRIs, the first change to consider is to another SSRI
• When an SSRI is not tolerated, other medications can be considered
• Clinicians could cautiously consider the use of short acting benzodiazepines to assist in the management of an acute crisis in high-risk settings (eg emergency department) Acute behavioural disturbance - Acute management
• Anti-psychotic medications, alpha-2 agonists (clonidine and guanfacine), atomoxetine, reboxetine and tricyclic antidepressants are not recommended for the treatment of anxiety disorders in isolation

Follow up

• Symptom and adverse effect rating scales (eg RCADS) should be used throughout the course of both psychological and medication treatment
• Encourage child to undertake this with parent support
• On medication initiation, and while establishing stability, clinical response and adverse effects should be reviewed every 2 weeks
• Trial period of ceasing treatment (psychological or medical) can be considered when the overall balance of benefits and harms indicates this may be appropriate
• Medications such as SSRIs with discontinuation symptoms should be gradually reduced then discontinued (see switching and stopping antidepressants)

Consider consultation with local paediatric team when

Developmental or physical health concerns

Consider consultation with local Child and Adolescent Mental Health specialist when

Anxiety presentation with any of the following

• complicated by coexisting mental health problems
• significant risk identified for patient or others
• beyond the comfort of the clinician

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

• Risk assessment regarding risk of harm to self or others completed and deemed safe for discharge
• Appropriate follow up arranged. Children with anxiety will likely require ongoing follow up with a paediatrician or other appropriate clinician

Parent information

Factsheets

• RCH Kids Health Info: Anxiety (primary school aged children)
• Healthdirect: Anxiety in children
• Childhood anxiety: A guide for parents, carers and supporters
• Beyond Blue
  

       Raising Children’s Network:

• Anxiety and fears in children (0-8 years)
• Generalised anxiety in children (3-8 years)
• Anxiety: the stepladder approach (3-18 years)
• Raising Healthy Minds App

Helplines

• Kids Help Line: A free, confidential 24/7 online and phone counselling service for young people
• Parentline: A free phone counselling service to discuss parenting challenges 

Online/App based programs and toolkits

• The Brave Program: An interactive online program aimed at 8-12 yo to help them overcome worries and learn coping strategies
• Triple P Online Course: A toolkit to help children manage anxiety and become more emotionally resilient
• Cool Kids Program: An interactive online program aimed at 7-12 yo to help them overcome anxiety and build confidence
  
• Mental health and wellbeing toolkit: Advice to support student mental health and wellbeing, aimed at students, parents and caregivers, and school
• Smiling Mind Kids Care Packages: A series of calming activities and audio recordings for children based on mindfulness meditation

Additional notes

Evidence-based Clinical Practice Guideline for anxiety in children that integrates the available evidence, as well as clinical expertise and lived experience perspectives

Types of Anxiety Disorder

Last updated April 2024