Anxiety Disorders in Children
Judith A. Axelrod, M.D.
Developmental-Behavioral Pediatrician
Square One: Specialists in Child and
Adolescent Development
Childhood Anxiety Disorders
• Most common emotional/behavioral
disorder in childhood
• Incidence 10-15%
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Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Separation Anxiety
Adjustment Disorders
Panic Attacks
ADHD
Tourette syndrome
Autism spectrum disorders
Anxiety
• Apprehension of danger and dread
• Accompanied by
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Restlessness
Tension
Rapid heart rate
Shortness of breath
• Unattached to a clearly identifiable
stimulus
As for you, my fine friend, you’re a
victim of disorganized thinking. You are
under the unfortunate delusion that
simply because you run away from
danger, you have no courage. You’re
confusing courage with wisdom.
--The Wizard of Oz, addressing the Cowardly Lion (1939)
Case study
B.F. is a sweet, loving, intelligent, honest youngster
of 10 years who has an over developed sense of
consciousness. He is sensitive and compassionate.
He is distractible, intrusive, impulsive and very
disorganized. Precision and accuracy are important to
him. He is a worrier. He worries about floating off
his bed into space. He understands that this is not a
rational fear but he cannot stop this worry. He is
afraid of becoming something other than himself (like
in movies when characters change into something
else). He is worried about getting “ cooties”. If he
touches a girl, mother sometimes included, he must
wipe off the “cooties.” At night he prays that people
who have irrational fears will stop having these fears.
Case study
C.S. a 4 year old is a very sensitive, well behaved,
anxious youngster who follows rules. He is a shy,
needy child who asks a lot of questions. He is a
worrier. He frequently asks if the power will go out.
He talks about about death. He is fearful of being
alone; he doesn’t like to go to his room alone. He
brings everyone to his room to play.
He has always been a shy youngster who would not
respond to people who speak to him other than close
family members. He talks while in stores however if
someone directly speaks to him he stops talking.
Social Phobia
• Excessive fear in social situations
where child is exposed to unfamiliar
people/evaluation by others
• Excessively self conscious/ shy
• Tremendous concern about social
failure/embarrassment/humiliation
Selective Mutism
• Children either talk minimally or not at all in
certain settings or situations that are part of
their daily lives (e.g., school).
• Reflects underlying problems with anxiety
• Often inadvertently reinforced by other
individuals (i.e., parents, friends) in the
child’s daily life (e.g., speaking for the child,
permitting the use of nonverbal
communication, etc.).
• Considered an extreme form of social phobia
Case study
S.M. is an 11 year old who worries about the
weather: tornados, storms, fire. She is
frightened of dark clouds. She worries if the
electricity is turned off and if chores were
completed. She is fearful of scary movies,
the News and she is easily scared. Mother
must be careful of what is said around Sarah
because of her worry. Sarah is anxious and
clingy to her mother. She has a prayer ritual;
it takes her 15 minutes to complete her
evening prayers.
Case study
• C.G. is a 12 year old who has specific routines for
getting dressed and going to bed. She repeatedly
hand washing, such that her hands bleed. She
brushes her teeth with repetitive motion of putting
the brush under water. She steps forward and back.
She turns light switches on and off. She opens and
closes drawers. She picks things off tables or floors
with a specific repetitive pattern. Her clothing must
be put out in a certain order or this must be
repeated. It takes her a long time to get dressed.
She erases a lot. She is not turning in her
assignments and is having hesitation abut going to
school. She is afraid to start the school day.
Obsessive-Compulsive Disorder
• Characterized by patterns of repetitive
behaviors, rituals, and obsessive thinking that
interfere with daily activities.
• Typically diagnosed between the ages of
seven and twelve years.
• Occurs approximately in 1 in 200 children in
the United States.
• Caused by an aberrant function of brain
circuitry, possibly in the part of the brain
called the striatum.
Obsessive-Compulsive Disorder
• Obsessions are intrusive and persistent
thoughts or ideas that cause distress.
• Compulsions are repetitive behaviors
that are done to alleviate the
obsessions.
• Not performing the rituals causes
anxiety.
Generalized Anxiety Disorder
• Children with Generalized Anxiety disorder are chronic worriers.
They seem to be on edge about something. These children
have a difficult time relaxing and often have trouble falling to
sleep. Physical symptoms often accompany the worry, such as
headaches, feeling shaky or sweating. Young children with
Generalized Anxiety Disorder can also suffer from separation
anxiety. As children get older, depression can accompany the
feeling of generalized anxiety. Similar to other anxiety
disorders, Generalized Anxiety Disorder typically responds well
to cognitive-behavioral strategies that are developed while
working with a psychotherapist. Sometimes medical treatment
of anxiety is warranted.
Tourette Syndrome
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one year history of multiple motor and phonic/vocal tics. Tics are sudden,
intermittent, involuntary contractions of muscles that produce movements or
sounds. Phonic or motor tics may appear simultaneously or at separate times.
Tics may occur many times during the day, nearly every day or intermittently.
Tourette Syndrome is usually life-long, although there are periods of remission
that last from weeks to years. The frequency and severity of the symptoms are
variable and may diminish during adolescence and adulthood. Sometimes
symptoms disappear entirely, usually after early adulthood. Tourette Syndrome
is associated with a variety of behaviors and learning difficulties. The most
common associated finding is Attention Deficit Hyperactivity Disorder.
Symptoms of Attention Deficit Hyperactivity Disorder typically precede the onset
of phonic and motor tics by two years. In addition, approximately 30-40% of
individuals with Tourette disorder have obsessive-compulsive behaviors. Thirty
percent of individuals with Tourette syndrome have mood lability, described as
high levels of anxiety, emotional lability, fearfulness, low frustration tolerance,
aggressiveness and impulsivity.
NONVERBAL LEARNING
DISORDER
• Difficulties with nonverbal problem solving.
• Visual, spatial organization and tactile perceptual skill
defects.
• Math is a specific and significant academic challenge
• Significant problems adapting to new or complex
situations.
• Weakness in social perception and social judgment
• At risk for internalizing psychological disorders such
as depression and anxiety.
• Often individuals with this profile exhibit social
withdrawal and can become more socially isolated as
they get older.