Managing anxiety in primary care pediatrics

managing anxiety in children

Anxiety is common in children and adolescents, but at what point does it cross the line and become a mental health concern? Notes posed this question to clinical psychologist Keneisha Sinclair-McBride, PhD, and child psychiatrist Olivia Carrick, MD, both in the Department of Psychiatry at Boston Children’s, and asked their management advice.

Assessing anxiety in children and adolescents

anxiety in children
Source: Merikangas KR; et al. J Am Acad Child Adolesc Psychiatry 2010 Oct; 49:980-9.

A careful history is important in diagnosing and gauging the severity of anxiety. Interview both the child and the parent/caregiver. Occasional worries (the start of the school year, fitting in with peers) are normal and part of social development.

“Temperament and personality differences will make some children bigger worriers than others,” notes Sinclair-McBride.

Ask parents if the child can face and overcome worries through positive strategies, like talking to supportive friends and family and engaging in enjoyable activities.

Worries become concerning when they significantly affect a child’s functioning, like refusing to participate in activities because of their fears. Significant crying, trouble sleeping or behavior problems related to worries can be warning signs of an anxiety problem. Others include:

  • avoiding activities or situations that cause anxiety
  • frequently seeking reassurance or praise
  • trouble concentrating, inattention
  • a decline in grades
  • moodiness, irritability or explosive outbursts
  • somatic symptoms (headaches, stomach aches, increased or decreased appetite, pain)

A free tool, SCARED (Screen for Child Anxiety Related Disorders) can help with your evaluation.

When should I refer a child for therapy?


Raise the possibility of therapy if worrying is causing a child to struggle at home, at school or socially, or if the child has panic attacks (extreme physical reactions to anxiety), phobias or compulsive behaviors.

“Discuss treatment options with the family,” says Sinclair-McBride. “A range of behavioral health providers can help a child manage anxiety, including psychologists, social workers, licensed professional counselors and marriage and family therapists.”

In making a referral, your priority should be a practitioner with experience with children or adolescents and the use of cognitive behavioral therapy (CBT), a proven technique that helps children adjust their thoughts and behaviors. If medication is necessary, you may choose to refer to a psychiatrist or psychiatric nurse practitioner.

What about medication?


A trial of CBT with a skilled therapist should almost always be completed before trying medication. Most children respond well to CBT.

“Adding medication may be indicated when anxiety symptoms are causing moderate to severe impairment, or if symptoms do not improve or get worse despite psychotherapy,” says Carrick. “Tools like the SCARED rating scale can help classify severity and gauge improvement during a course of treatment.”

If you want to initiate medication yourself, the first-line medications are the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline. These must be prescribed off-label, since the FDA has not approved SSRIs for non-OCD anxiety disorders in children or adolescents, but there is much evidence for their efficacy, especially when combined with CBT.

While these medications are generally well tolerated, close monitoring is important because of the possibility of side effects — in particular, with SSRIs, changes in mood and the potential for suicidality, says Carrick.

“Such symptoms, while rare, would likely manifest within the first month of medication initiation or dose change,” she says. “We recommend follow-up by phone at one week or in the office within two weeks when initiating and adjusting the dose of an SSRI, with monthly visits thereafter to assess symptom improvement.”

If symptoms do not improve with first-line medication, consider a referral to a child psychiatry practice. In Massachusetts, the Massachusetts Child Psychiatry Access Project (MCPAP) can provide phone consults and, in some cases, can do a one-time evaluation in person. If your practice is part of the Pediatric Physicians’ Organization at Children’s (PPOC), our Outpatient Psychiatry Service can also provide consults.

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