Anxiety Disorders in Youth
Mary L. Keeley, MS
Eric A. Storch, PhD
Anxiety disorders are one of the most prevalent categories of childhood and adolescent psychopathology. Due to their
distressing, time-consuming, and/or debilitating nature, impairments in academic, social, and family functioning are often
substantial. This article reviews the nature, etiology, assessment, and treatment of anxiety disorders in youth. We conclude by
reviewing implications for nurses involved in the care of youth with anxiety disorders.
© 2008 Published by Elsevier Inc.
Key words: Anxiety disorders; Children; Treatment; Obsessive-compulsive disorder; Social phobia; Cognitive-behavioral therapy
fear is the shared primary symptom. Normal
anxiety may be defined as “a diffuse, unpleasant,
vague sense of apprehension, often accompanied by
autonomic symptoms—such as headaches, palpita-
tions, tightness in the chest, restlessness, mild
stomach discomfort that can be an appropriate
response to a threatening situation or stimulus”
(Kaplan & Sadock, 1998, p. 591). Whereas fear is
considered specific and targeted, anxiety is con-
sidered more diffuse and unfocused. Pathological
anxiety and fear, as compared to normal symptoms,
are diagnosable conditions when the anxiety, fear,
or both cause significant distress, interfere with
functioning, or are marked by time consumption
(American Psychiatric Association [APA], 2000).
When distinguishing normal, transient anxiety
symptoms from pathological conditions, clinicians
should be sensitive to age- and gender-appropriate
norms in relation to developmental tasks and
progressions. The nature of a child's fears and
anxieties changes throughout childhood as devel-
oping cognitive abilities enable youth to recognize
and understand dangers in different situations as
well as to evaluate their sense of control over
a particular situation (Ollendick, Yule, & Ollier,
1991). In the field of child and adolescent devel-
opment, evidence-based studies systematically
measure child populations at different ages to assess
similarities and differences across different devel-
opmental periods, spanning prenatal to older
adolescent development (Bongers, Koot, van der
NXIETY DISORDERS ARE conditions in
which extreme, often disabling, anxiety or
Ende, & Verhulst, 2003; Muris, Merckelbach,
Mayer, & Prins, 2000). These studies provide
developmental norms and characterize normal
versus pathological development. Common fears
in infancy include fears of loud noises, being
startled, and strangers. Toddlers are commonly
fearful of the dark as well as separating from
attachment figures. Among school-aged children,
common worries include concerns regarding injury
experience competency-based concerns and also
have worries associated with the health status of
and Adolescent Psychiatry [AACAP], 2007).
Although all children report fears and worries
(Lapouse & Monk, 1964), it is when the frequency
and intensity of such symptoms are excessive
or exaggerated in relation to the developmental
norm that concern about psychopathology should
be noted. A clinical diagnosis is warranted when
the child's symptom presentation meets specific
diagnostic criteria (outlined below) and causes
From the Department of Clinical and Health Psychology and
Department of Psychiatry (MK), University of Florida, Gaines-
ville, FL; Department of Psychiatry and Department of
Pediatrics (EAS), University of Florida, Gainesville, FL.
Corresponding author: Eric A. Storch, PhD, Department of
Psychiatry, University of Florida, Gainesville, FL 32610.
0882-5963/$-see front matter
© 2008 Published by Elsevier Inc.
Journal of Pediatric Nursing, Vol 00, No 00 (April), 20081
ARTICLE IN PRESS
significant distress or impairment in functioning.
Research has demonstrated that children with
anxiety disorders have significant impairments in
academic, familial, or social functioning (Langley,
Bergman, McCracken, & Piacentini, 2004), with
those experiencing chronic symptoms often
reporting persistent interference in everyday func-
tioning into adulthood (Pine, Cohen, Gurley,
Brook, & Ma, 1998).
SYMPTOMS OF ANXIETY
According to Lang's (1968) multiple-systems
theory of emotion, symptoms are of a cognitive
(e.g., worry thoughts), physiological (e.g., racing
heart rate), or behavioral (e.g., avoidance) nature.
The cognitive component of anxiety is related to
the anxious thoughts that develop in response to
cognitive distortions in the attention, interpretation,
and memory components of information processing
(Beck, 1976). Although the specific content of
thoughts varies across anxiety orders, these
thoughts are generally focused on the risk of
being harmed (Rinck & Becker, 2005). Table 1
provides examples of worries or cognitive distor-
tions associated with specific anxiety disorders.
The physiological component of anxiety dis-
orders consists of the associated autonomic or
somatic sensations. Although individuals experi-
ence physiological arousal symptoms in response to
feared situations, individuals with anxiety disorders
experience physiological symptoms that are exces-
sive in duration or intensity for the particular
situation or stimulus (Hoehn-Saric & McLeod,
2000). Sleep-related problems are more prevalent
among clinically anxious youth and are associated
with increased anxiety severity and interference in
family functioning (Alfano, Ginsburg, & Kingery,
2007). In a recent study of sleep-related problems in
children with generalized anxiety disorder (GAD),
separation anxiety disorder (SAD), and/or social
phobia, Alfano et al. (2007) reported that the most
common sleep-related problems were insomnia,
nightmares, and refusal/reluctance to sleep alone.
Table 2 presents a complete list of the most
common physiological symptoms associated with
The behavioral component of anxiety refers to
the action that individuals take to prevent exposure
to feared stimuli or to reduce anxiety associated
with exposure to the feared stimuli. Among the
most common behavioral symptoms associated
with the anxiety disorders is avoidance, in which
individuals avoid specific stimuli (e.g., bridges) or
situations (e.g., public speaking) to prevent antici-
pated harm. Avoidance often leads to impairment in
maintaining normal routines or in family, academic,
Table 1. Content of Anxious Thoughts for
Specific Anxiety Disorders
Anxiety DisorderSample Worries Anticipated Harm
SAD Being separated
Being unable to escape
the current situation
Negative social judgment
Harm to self or caretaker
PDDying, losing control,
or going crazy
the traumatic event
Contracting a disease
Wide range of possible
(e.g., failure, rejection)
PTSDPast traumatic event
Routine life issues such
as academic performance
or social interactions
Table 2. Somatic and Sleep-Related Symptoms of
Anxiety Included in the DSM-IV-TR
Cardiac Accelerated heart rate
Shortness of breath
Shortness of breath
Cold, clammy hands
Reluctance/Refusal to sleep alone
Talks/Walks in sleep
Exaggerated startle response
2KEELEY AND STORCH
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and/or social domains of functioning. Another
behavioral symptom associated primarily with
obsessive–compulsive disorder (OCD) is the
engagement of rituals (e.g., hand washing) that
serve to reduce anxiety. These rituals are either
excessive or unrealistic strategies for preventing
the feared situation from occurring (Storch &
Several large, methodologically rigorous epide-
miological studies have indicated that anxiety
disorders are one of the most prevalent categories
of childhood and adolescent psychopathology
(Anderson, Williams, McGee, & Silva, 1987;
Chavira, Stein, Bailey, & Stein, 2004; Kashani &
Orvaschel, 1990; McGee et al., 1990). The most
recent prevalence estimates from a pediatric
primary care sample including more than 700
families suggest that approximately 20% of chil-
dren (ages 8–17 years) were above the clinical
cutoff on a brief anxiety screen measure (Chavira et
al., 2004). In this study, 28% of the children with an
anxiety disorder diagnosis had an additional
comorbid diagnosis. In a follow-up sample of 190
families, 1-year prevalence rates for Diagnostic
and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) child anxiety disorders were as
follows: 10% for specific phobia, 6.8% for social
phobia, and 3.2% for GAD (Chavira et al., 2004).
Recent epidemiological studies of pediatric OCD
show that by late adolescence (age 18 years), the
lifetime prevalence rate of OCD is between 1%
and 4% (Douglass et al., 1995; Zohar, 1999), and
studies of SAD indicate prevalence rates of
approximately 4–5% of youth (Masi, Mucci, &
Millepiedi, 2001). Although no large-scale epide-
miological studies of childhood posttraumatic stress
disorder (PTSD) or panic disorder (PD) exist,
community-based studies indicate lifetime preva-
lence for PTSD ranging from 1% to 14% (Kessler,
Sonnega, Bromet, Hughes, & Nelson, 1995) and
lifetime prevalence for PD ranging from 1% to 5%
(Grant et al., 2006).
Althoughcomorbidity rates vary depending upon
the primary diagnosis, there exists a strong comor-
bidity among anxiety disorders in youth (Verduin &
Kendall, 2003). For example, an epidemiological
study of pediatric OCD revealed that 84% of youth
diagnosed with OCD had comorbid disorders,
including major depression (62%), social phobia
(38%), alcohol dependence (24%), and dysthymia
(22%; Douglass et al., 1995). The most common
comorbid diagnoses include other anxiety disorders
and depressive disorders (Kovacs & Devlin, 1998).
Additionally, children with anxiety disorders
frequently experience other psychiatric conditions,
including attention-deficit/hyperactivity disorder
and disruptive disorders (Anderson, 1994).
The etiology of child and adolescent anxiety may
be of a biological and/or learned nature. Indeed,
researchers posit that anxiety arises from a complex
interaction of specific characteristics related to the
child (e.g., biological, psychological, and genetic
factors) and his or her environment (e.g., con-
ditioning, observational learning, family relations,
traumatic events; Weems & Stickle, 2005). There
are an abundance of theoretical models that would
define child and adolescent anxiety within their
frame of reference.
Withina biologicalmodel of etiology,researchers
have investigated genetic influences as well as
neurobiological structures and circuits. A recent
meta-analysis of the genetic epidemiology of
anxiety disorders demonstrated that PD, phobias,
thatgeneticfactors havea moderate influenceonthe
development of anxiety disorders (Hettema, Neale,
& Kendler, 2001). Researchers have suggested that,
although clearly not the only contributing influ-
ences, genetic factors may help us understand why
certain individuals exposed to similar experiences
have different responses and outcomes concerning
the development of pathological anxiety (National
Institute of Mental Health, 1999).
Research aimed at identifying specific brain
areas and circuits underlying anxiety disorders has
provided support for neurobiological influences in
anxiety. The most support for neuroanatomical
influences has come from research investigating the
amygdala's role in fear conditioning. Research
in this area has implicated the amygdala in the
pathophysiology of anxiety disorders (Rauch, Shin,
& Wright, 2003). Neurochemical factors have also
been implicated in the development of anxiety
symptoms. Abnormal function of serotonin, nor-
epinephrine, dopamine, and γ-aminobutyric acid
systems as well as abnormal chemoreceptor
reactivity have all been implicated in anxiety
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Within a cognitive–behavioral model, abnormal
thoughts, feelings, and behaviors are described as
reactions that have been learned as a result of
conditioning and observation. Wolpe (1958), a
behavioral theorist, highlighted behavioral condi-
tioning as an important etiological factor in the
development and maintenance of anxiety and
posited that an individual associates a threatening
stimulus with a nonthreatening stimulus so that the
latter by itself triggers anxiety. Once the fearful or
anxious reaction has been learned through classical
conditioning, the fear or anxiety is maintained
through the operant mechanism of negative rein-
forcement (Mowrer, 1947). Negative reinforcement
is manifested by avoidance learning, escape learn-
ing, or both. Escape learning involves terminating
an aversive situation, whereas avoidance learning
involves avoiding fear- or anxiety-provoking situa-
tions. Consequently, without opportunities for new
learning provided by exposure, the fear or anxiety
does not extinguish. This process of acquisition and
maintenance of fears is known as Mowrer's two-
factor theory (Mowrer, 1947).
In addition to the two-factor theory, observa-
tional learning influences the development of
anxiety. Children learn about anxiety-provoking
situations by observing others experience such
situations or by acquiring information through
activities like reading or watching the news on
television (Rachman, 2004). Furthermore, they are
capable of retaining and reproducing event mem-
ories acquired via observational learning (Murach-
ver, Pipe, Gordon, Owens, & Fivush, 1996).
Finally, cognitive theorists posit that cognitive
biases, including attentional biases toward threat-
related information, distorted judgments of risk,
and selective memory processing, impact the
development of anxiety (Craske & Pontillo, 2001).
Ecological models focus on the impact of the
family system and other environmental influences
on the development of anxiety disorders and
particularly highlight the bidirectional relationships
among child, family, and other environmental
contributions to anxiety. For example, research
has revealed relationships among levels of child
temperamental characteristics (i.e., behavioral inhi-
bition), insecure parent–child attachment, and
anxious and controlling parenting styles (Elizabeth
et al., 2006; van Brakel, Muris, Bogels, &
Thomassen, 2006). Parental modeling of fearful
and anxious expressions and behaviors has also
been found to contribute to the development of
anxiety in children (Muris, Steerneman, Merck-
elbach, & Meesters, 1996). Additionally, environ-
mental factors outside the family system, such as
poverty and community violence, directly and
indirectly (through influence on family functioning
and relationships) contribute to the development of
anxiety (Cicchetti & Lynch, 1993; Lynch &
Cicchetti, 2002; Samaan, 2000).
DSM-IV-TR ANXIETY DISORDERS
The core symptoms for six anxiety disorders
are listed in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revi-
sion (DSM-IV-TR; APA, 2000) and are described
below. In keeping with the understanding of the
importance of developmental issues when diag-
nosing disorders, the DSM-IV-TR provides notes
when criteria specifically relate to children. For
example, it is noted in DSM-IV-TR that in
children, the anxiety may be expressed by crying,
tantrums, freezing, or clinging. Unlike adults,
children are not required to acknowledge that
their fears are unreasonable or excessive (with
respect to specific phobias, social phobia, and
OCD). Finally, persistence of a diagnosis for at
least 6 months is required for specific and social
phobias in children to minimize the overdiagnosis
of transitory, normal developmental fears (APA,
Separation Anxiety Disorder
SAD is characterized by excessive worry about
separation from another person who represents
safety for the affected child, typically a parent. In
new, unfamiliar, or feared situations, youth with
SAD are often dependent on their safety figure.
Common features of the disorder include excessive
demonstration of distress upon real or threatened
separation (e.g., tantrums, crying, somatic com-
plaints), fear of harm or permanent separation from
caretaker, and fear of getting lost, kidnapped, or
dying. School refusal is a common symptom of
SAD, occurring in approximately 75% of children
with the diagnosis (Masi et al., 2001). When
separated from the person representing safety,
significant worry about self or the person represent-
ing safety results in both distress and interference
with functioning (APA, 2000). For example, the
child may resist participating in social or academic
4KEELEY AND STORCH
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activities, resulting in a disruption of the develop-
ment of competency in these domains.
Within the clinical setting, children with SAD
may present with sleep problems, such as night-
mares (often with a theme of separation from, or
harm to, the attachment figure). Furthermore, these
children may experience a number of somatic
complaints (e.g., stomachache) related to the
distress associated with SAD. The presence of
clingy and whiny behavior within the clinical
setting may also be an indicator of SAD. The
clinical presentation of SAD may vary with age,
with younger children exhibiting excessive crying
and temper tantrums upon separation from the
attachment figure and older children displaying
social withdrawal and manipulative behavior to
avoid school or separation (Francis, Last, &
PD is characterized by both the actual occurrence
of panic attacks and persistent worry and vigilance
about prospective symptoms of another panic
attack. Panic attacks involve an overwhelming
fear of being in danger for no apparent reason as
well as physiological symptoms such as pounding
heart or chest pain, sweating, trembling or shaking,
shortness of breath or choking sensation, nausea,
dizziness, feelings of unreality or depersonaliza-
tion, and fear of going crazy or dying (APA, 2000).
Panic is, by definition, severe distress. PD can be
quite disabling because of efforts to avoid particular
situations or stimuli believed by the individual to
trigger panic attacks (Biederman et al., 1997). The
most common symptoms reported are palpitations,
shortness of breath, sweating, faintness, and weak-
ness. In adolescence, chest pain, flushes, trembling,
headache, and vertigo are also commonly reported
symptoms. In youth, cognitive symptoms are less
common, with the most frequent cognitive symp-
toms being a fear of losing control (Masi, Favilla,
Mucci, & Millepiedi, 2000). As with adults, there is
a strong association between PD and agoraphobia
in youth (Masi et al., 2000). Individuals with
agoraphobia experience anxiety related to being in
places or situations from which escape might be
difficult or in which help may not be available in the
event of having a panic attack. As a result, they
often avoid such situations or endure them with
severe distress (APA, 2000).
The presenting problem for youth with PD will
pertain to one or more of the many physiological
symptoms of panic attacks. Parents of youth with
PD may also report agoraphobic symptoms related
to their child's panic attacks. Unlike in adulthood,
catastrophic interpretations of physiological symp-
toms may not be part of the clinical presentation
(Ollendick, 1998). PD is less common in childhood
than in adolescence, and the clinical presentation
of PD varies across the developmental span (Diler
et al., 2004). Specifically, younger children's panic
attacks are often related to particular triggering
events whereas adolescent's panic attacks are more
often reported as unexpected and not linked to a
particular antecedent event (Ollendick, 1998).
Social phobia, or the fear of embarrassment or
negative evaluation in social or performance
situations, is manifested by the avoidance of
situations in which the child fears acting in a
humiliating or embarrassing manner (APA, 2000).
The DSM-IV-TR notes that, in children, there must
be evidence of the capacity for age-appropriate
social relationships with familiar people, and the
anxiety must not be limited to interactions with
adults but must occur in peer settings as well (APA,
2000). Three main factors in the development and
maintenance of social phobia are highlighted: (a)
cognitive biases (e.g., beliefs that individuals will
predictably interact with others in a manner that will
elicit rejection and/or negative evaluation from
others), (b) deficits in social skills, and (c) operant
conditioning (e.g., negative reinforcement for
avoidance behaviors; Kashdan & Herbet, 2001).
Researchers describe a vicious cycle, in which
anticipatory anxiety of a perceived threatening
social situation leads to negatively biased cogni-
tions and anxiety symptoms in the feared situations,
which consequently leads to actual or perceived
poor performance in the feared situations, which
then leads to embarrassment and increased antici-
patory anxiety about the feared situations (Hirsh &
Clark, 2004). Children and adolescents with social
phobia have been found to experience greater
sensitivity to rejection, report fewer friendships
and close relationships, and perceive less social
support and acceptance from peers (LaGreca &
Within the clinical setting, youth with social
phobia may present as shy and socially withdrawn
and may exhibit noticeable anxious–somatic
symptoms, including blushing, sweating, and
shaking, when interacting with unfamiliar people.
Limited eye contact is also quite common. In
extreme presentations, youth may have difficulty
5 ANXIETY DISORDERS
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with articulation or may become mute. Interperso-
nal deficits may be evident when interacting with
socially phobic youth, who often report having few
close friendships with their peers. Whereas
younger children with social phobia tend to hide
behind adults or attempt to physically escape from
a social situation, older children tend to remain in
the social situation but with few efforts to engage
or participate (Kronenberger & Meyer, 2001).
OCD is characterized by recurring intrusive
thoughts or excessive worries (obsessions) and/or
activities or rituals the person feels driven to
perform to reduce anxiety (compulsions). The
obsessions and/or compulsions are distressing,
time-consuming (more than 1 hour per day), or
debilitating (interfere with normal functioning;
APA, 2000). The most common obsessive themes
in the pediatric population include fears of
contamination (e.g., dirt, germs, toxins); preoccu-
pations about harm to self or others; the need for
symmetry, exactness, and order; concerns with
religious or moral conduct (e.g., being concerned
with committing a sin); lucky or unlucky
numbers; and preoccupations concerning forbid-
den sexual or aggressive thoughts (Masi et al.,
2005; Swedo, Rapoport, Leonard, Lenane, &
Cheslow, 1989). The most common compulsive
themes include cleaning or decontamination rituals
(e.g., excessive washing, bathing, or grooming);
checking, counting, repeating, straightening, and
routinized behaviors (e.g., doors, locks, home-
work, appliances); confessing, praying, and reas-
surance seeking; touching, tapping, and rubbing;
measures to prevent harm to self or others; and
hoarding and collecting (Masi et al., 2005; Swedo
et al., 1989). Although rituals may provide a
temporary reduction in anxiety, they do not result
in long-term relief due to the persistent and
recurrent nature of intrusive thoughts and images.
Consequently, youth with OCD become trapped in
a time-consuming and unrelenting cycle of obses-
sions and compulsions that leads to significant
distress and impairment in functioning (Carter &
Youth with OCD may present to health profes-
sionals with a number of physical or behavioral
complaints that are consequences of obsessive–
compulsive symptoms (Snider & Swedo, 2000).
For example, dermatological problems may arise
secondary to compulsive hand washing or skin
picking. Weight loss may occur due to refusal to eat
certain foods that are perceived as contaminated.
Compulsive avoidance of bathrooms due to con-
tamination fears may lead to the development of
secondary encopresis or enuresis. Additionally,
youth may present to their dentists with bleeding
gums as a result of excessive teeth cleaning (Snider
& Swedo, 2000).
Research has supported a distinction between
early- and late-onset OCD, such that early-onset
(i.e., prepubertal) OCD is more likely to occur in
males, to be characterized by symptom presenta-
tions characteristic of compulsions without obses-
sions and more primitive compulsions (i.e.,
touching, tapping, rubbing), to have comorbid tic
symptomatology, and to involve family members in
their rituals (Freeman et al., 2003; Geller et al.,
1998; Storch, Geffken, Merlo, Jacob, et al., 2007).
Furthermore, youth, especially young children, may
lack insight into the senselessness of their OCD
symptoms and, therefore, may not report their
symptoms to their parents (AACAP, 1998).
Posttraumatic Stress Disorder
PTSD is characterized by recurrent symptoms of
anxiety related to past trauma, such as physical
abuse or natural disasters (APA, 2000). Cognitive,
autonomic, and behavioral symptoms of anxiety are
typically involved. The main manifestations of
traumatic reactions include repetitive and intrusive
thoughts about the trauma, flashbacks or night-
mares in which the child reexperiences the trauma,
heightened arousal, avoidance of stimuli associated
with the trauma, sleep disturbances, and separation
difficulties (Yule, 2001). Cognitive changes, such
as difficulties in concentration and memory pro-
blems, are also common. Additionally, a child may
report a sense of foreshortened future or a
premature awareness of his or her own mortality
(Yule, 2001). This disorder always involves
significant distress and can result in marked
interference with functioning (APA, 2000).
Primary complaints of youth with PTSD in the
clinical setting may involve physiological arousal
symptoms such as difficulty sleeping or exagger-
ated startle response. Parents of youth with PTSD
may report a temporal association between a
particular traumatic event and the onset of atypical
behavior such as sexual acting out or aggression
(Kronenberger & Meyer, 2001). It is common for
youth with PTSD to be reluctant about discussing
the traumatic event, and their descriptions of the
traumatic event often lack a discussion of their
associated emotional experience.
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Generalized Anxiety Disorder
GAD involves diffuse excessive worry over a
wide variety of routine daily activities such as
school performance, social concerns, or family
interaction. It is characterized by 6 months or more
of chronic, exaggerated worry and tension that are
unfounded or much more severe than the anxiety
that most people experience. The excessively
anxious thoughts generally involve thoughts related
to negative, uncontrollable, or catastrophic out-
comes. Studies of youth with GAD have demon-
strated that youth selectively attend to negative and
threat-related information (Taghavi, Dalgleish,
Moradi, Neshat-Doost, & Yule, 2003). Avoidant
behavior is common for situations that provoke
anxiety. GAD may be accompanied by physiologi-
cal or somatic symptoms, including trembling,
twitching, muscle tension, headaches, irritability,
hot flashes, nausea, frequent urination, and fatigue
(Kendall & Pimentel, 2003). Symptoms must
interfere with some aspect of daily functioning to
meet the diagnostic criteria of GAD (APA, 2000).
As compared to children without GAD, children
with GAD experience higher levels of generalized
tension (Ginsburg, Riddle, & Davies, 2006), which
may be described as a chronic inability to relax.
Parents of children with GAD may describe their
child as a “worrier” with few coping skills to
effectively handle concerns. Within the clinical
setting, nurses may observe children with GAD
engage in excessive attempts to seek approval from
their parents or other adults. Whereas younger
children report anxiety pertaining to specific
situations, older children increasingly report “gen-
eralized” anxiety about a number of different
situations (Kronenberger & Meyer, 2001).
The psychological and behavioral assessment of
anxiety disorders is a well-studied area. It is beyond
the scope of this article to conduct a comprehensive
review of this topic. However, we will provide a
brief overview of some of the most common
assessment methods and measures in the diagnosis
of anxiety disorders. Evidence-based methods of
assessment include diagnostic interview schedules,
rating scales, observations, and self-monitoring
forms (Silverman & Ollendick, 2005). When
assessing symptoms, it is important to note that an
isolated behavior may not be an indicator of
psychopathology. Often, psychopathology can be
diagnosed when a cluster of abnormal behaviors
and symptoms have been reported.
Diagnostic interviews are reliable and valid
measures designed to facilitate diagnostic decisions
consistent with the DSM-IV-TR classification sys-
tem (APA, 2000). The most common diagnostic
interviews employed in the diagnosis of anxiety
disorders include the Anxiety Disorders Interview
Schedule for DSM-IV: Child and Parent Versions
(Silverman & Albano, 1996), Schedule for Affec-
tive Disorders and Schizophrenia for School-Age
Children—Present and Lifetime Version (Kaufman,
Birmaher, Brent, & Rao, 1997), and Structured
Clinical Interview for DSM-IV (First, Gibbon,
Spitzer, & Williams, 1996). These measures are
clinician-administered structured interviews that
assess for anxiety disorders as well as for the
presence of other psychiatric disorders (i.e., dis-
ruptive behavior disorders, mood disorders, psy-
chotic disorders). Although comprehensive and
methodical, these interviews require trained admin-
istrators, are often time-consuming (lasting
approximately 60–120 minutes), and can be
expensive to conduct. Therefore, within clinical
settings such as hospital- or school-based clinics, it
may be more feasible to administer screening
instruments (see below) to assess for the need to
refer patients for additional, more comprehensive
Self-report or parent-report rating scales are
relatively easy to administer (i.e., require minimal
training for clinicians), can be completed quickly
Additionally, these measures can be easily read-
ministered throughout the course of treatment to
capture clinical change over time. Screening
methods, such as the Screen for Child Anxiety
R; Muris, Merckelbach, Schmidt, & Mayer, 1999),
are helpful to provide a quick assessment of general
anxiety symptoms. The SCARED has five factor-
derived subscales (Panic/Somatic, Separation Anxi-
ety, Social Phobia, General Anxiety, and School
Phobia) that permit the identification of specific
problem areas related to anxiety. The Multidimen-
sional Anxiety Scale for Children (March, 1997) is
another commonly used measure of general anxiety
symptoms that consists of four factor-derived
subscales (Physical Symptoms, Harm Avoidance,
Social Anxiety, and Separation/Panic) and an
Anxiety Disorders Index, which includes items
found to differentiate children with and without
an anxiety disorder diagnosis. The Fear Survey
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Schedule for Children—Revised (Ollendick, 1983)
is a commonly used measure to assess childhood
fears, and factor analytic research has identified five
subscales: Fear of Failure/Criticism, Fear of the
Unknown, Fear of Injury and Small Animals, Fear
of Danger/Death, and Fear of Medical Situations.
In addition to general anxiety measures, syn-
drome-specific measures exist to assess for parti-
cular anxiety symptoms and are often utilized when
clinicians have hypotheses about specific anxiety
disorder diagnoses. The Social Anxiety Scale for
Children—Revised (LaGreca & Stone, 1993) is
used for the assessment of symptoms related to
social phobia and includes items that evaluate
avoidance/distress in new social situations, fear
of evaluation, and general social distress. The
Children's Yale–Brown Obsessive–Compulsive
Scale—Child Report and Parent Report (Storch
et al., 2006), a measure of symptoms related to
OCD, evaluates the severity of obsessions and
compulsions based on the following criteria:
distress, frequency, interference, resistance, and
symptom control. Finally, the Trauma Symptom
Checklist for Children (Briere, 1996) assesses
symptoms related to PTSD and yields six clinical
subscales: Anxiety, Depression, Anger, Posttrau-
matic Stress, Dissociation, and Sexual Concerns.
These self-report and parent-report measures are
paper-and-pencil instruments that may be adminis-
tered in a number of different settings, including
school, hospital, and home environments. These
measures come with easy-to-use manuals that
provide instructions regarding the scoring of the
responses as well as information pertaining to the
norms and clinical cutoff scores for different ages to
permit the identification of youth in need of further
Both observational and self-monitoring methods
have been used less frequently in the assessment
of child anxiety. Direct observation tasks include
(a) social evaluative tasks in which a child is
observed performing in a social situation (e.g.,
public speaking), (b) behavioral avoidance tasks in
which a child's response to being exposed to a fear-
or anxiety-provoking stimuli is observed, and (c)
parent–child interaction tasks in which parent and
child are observed in a problem-solving task
(Silverman & Ollendick, 2005). Self-monitoring
procedures identify and quantify symptoms and
behaviors via diary-like entries. Although useful in
evaluating and monitoring treatment outcome,
compliance with self-monitoring procedures is an
obstacle in youth (Saelens & McGrath, 2003). With
both observational and self-monitoring procedures,
further information regarding their feasibility,
reliability, and validity is needed to ensure the
utility of these assessment methods (Silverman &
Depending on the clinical setting, nurses may be
able to acquire additional assessment information
that may be useful for diagnosis and treatment
planning purposes. For example, nurses working in
the school setting may have the advantage of
obtaining information from the child's teachers
regarding the child's anxiety symptoms as com-
pared to his or her peers (Fisher, Masia-Warner, &
Klein, 2004). Additionally, school nurses may be
able to identify specific precipitating factors (e.g.,
classroom presentations, group work) by observing
the child in his or her natural school environment.
Nurses working within the child's home will have
the opportunity to observe parent–child interactions
within their natural setting and may also be able to
assess for parental modeling of anxious coping
styles. Furthermore, the nurse working in the
home environment can evaluate neighborhood
risk factors (e.g., community violence) that may
be contributing to the child's anxiety. Finally,
within a doctor's office or hospital setting,
nurses may have the advantage of conducting a
more thorough physical examination that may rule
out medical explanations for somatic symptom
complaints that may or may not be a function
Practice guidelines for the treatment of anxious
youth recommend a multimodal approach to
treatment, and comprehensive care should include
consideration of psychoeducation, cognitive–beha-
vioral interventions, school consultation, family
therapy, psychodynamic psychotherapy, and phar-
macotherapy (AACAP, 2007). To date, behavioral
and cognitive–behavioral interventions have
received the most empirical support for the
treatment of childhood anxiety (Kazdin & Weisz,
1998; Ollendick & King, 1998; McClellan &
Werry, 2003), whereas there is no documented
support for psychodynamic or family psychothera-
pies. The evidence base for pharmacotherapy
approaches is growing (Kutcher, Reiter, & Gardner,
1995), and there are particularly promising results
for the use of selective serotonin reuptake inhibitors
(SSRIs) in the short-term treatment of childhood
anxiety (AACAP, 2007). It is recommended that
8 KEELEY AND STORCH
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medications be considered in moderate to severe
cases, in cases in which anxiety-related impairment
prevents participation in psychotherapy, or when
the child only partially responds to psychotherapy
Behavioral interventions for the treatment of
anxiety include exposure, systematic desensitiza-
tion, contingency management methods, and
modeling techniques (Werry & Wollersheim,
1991). With exposure exercises, an individual fear
hierarchy is established, in which the child and
therapist work together, using the Subjective Levels
of Distress Scale (Wolpe, 1969), to rate the level of
distress associated with feared situations or objects
on a scale (0 [no distress] to 100 [severe distress]).
Once the hierarchy is developed, the child is
exposed in a stepwise fashion to identified fear-
provoking stimuli and is instructed to focus on the
anxiety. Exposure initially raises anxiety and
distress levels; however, repeated exposure results
in increased tolerance of stimuli and progressively
reduced levels of anxiety upon repeated exposure.
In systematic desensitization, the child is exposed
to fear-provoking stimuli but is also taught to
engage in an activity or response (e.g., relaxation,
distraction) incompatible with anxiety. Contin-
gency management methods serve to identify and
modify the rewards that the child receives that
maintain anxiety. Parents are taught to provide
positive reinforcement when the child confronts
fears and to remove positive reinforcement when
the child engages in avoidance behaviors. Finally,
modeling is a form of social learning treatment in
which the child observes a participant model
gradually confronting the feared situation with
Cognitive–Behavioral Therapy (CBT)
Cognitive–behavioral interventions aim to
teach the child to identify anxiety cues, utilize
specific coping responses, and challenge anxiety-
related cognitive distortions. Kendall (1994) has
developed an evidence-based cognitive–behavioral
treatment for anxiety in which children learn to
recognized somatic reactions and anxious feelings,
become aware of anxiety-related cognitions,
develop a coping plan (i.e., self-talk and problem
solving), evaluate coping responses, and apply self-
reinforcement for adaptive coping responses. Addi-
tional cognitive–behavioral interventions include
self-monitoring of anxiety symptoms, cognitive
restructuring, and relaxation techniques (i.e., deep
breathing, progressive relaxation; Kronenberger &
There is strong empirical support for behavioral
and cognitive–behavioral interventions for child-
hood anxiety delivered in individual, group, and
family-based formats (Compton et al., 2004;
James, Soler, & Weatherall, 2005; Silverman
et al., 1999). A recent meta-analysis reported a
large effect size (0.86) for CBT for childhood
anxiety disorders (excluding PTSD and OCD),
and results indicated that treatment gains were
maintained several years following active treat-
ment, suggesting the durability of CBT effects
(In-Albon & Schneider, 2006). Randomized,
controlled studies have indicated that, compared
to control conditions, CBT results in significantly
greater symptom improvement for social phobia
(Barrett, 1998; Kendall, 1994; Kendall et al.,
1997; Manassis et al., 2002; Wood, Piacentini,
Southam-Gerow, Chu, & Sigman, 2006),
GAD (Barrett, 1998; Kendall, 1994; Kendall
et al., 1997; Manassis et al., 2002; Wood et al.,
2006), SAD (Barrett, 1998; Kendall, 1994;
Kendall et al., 1997; Manassis et al., 2002;
Wood et al., 2006), PD (Manassis et al., 2002),
OCD (Barrett, Healy-Farrell, & March, 2004;
Pediatric OCD Treatment Study [POTS] Team,
2004; Storch, Geffken, Merlo, Mann, et al., 2007),
and PTSD (King et al., 2000).
A recent review of pharmacological treatment for
childhood anxiety disorders concluded that there is
good evidence to support the efficacy of SSRIs in
the treatment of anxiety disorders in children
(Reinblatt & Riddle, 2007). Several recent rando-
mized, placebo-controlled trials of SSRIs have
provided evidence for the short-term efficacy of
these medications in the treatment of childhood
anxiety disorders, including GAD (Birmaher et al.,
2003; Research Units on Pediatric Psychopharma-
cology Anxiety Study Group [RUPP], 2001;
Rynn, Siqueland, & Rickels, 2001), social phobia
(Birmaher et al., 2003; RUPP, 2001; Wagner
et al., 2004), SAD (Birmaher et al., 2003; RUPP,
2001), and OCD (POTS Team, 2004). No rando-
mized, placebo-controlled trials of SSRIs exist for
pediatric PD or PTSD. Uncontrolled trials of SSRIs
for pediatric PD suggest that SSRI treatment results
in clinically significant reductions in symptoms
(Masi et al., 2000; Renaud, Birmaher, Wassick, &
Bridge, 1999). Although there are limited data
9 ANXIETY DISORDERS
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regarding the pharmacological treatment of pedia-
tric PTSD, most clinical treatments consist of SSRIs
or adrenergic agents (e.g., clonidine, propranolol)
that are derived from data in adult studies (Reinblatt
& Riddle, 2007). Although these studies provide
promising results for the efficacy of SSRIs, there
are limited data pertaining to which SSRI is most
efficacious, as few trials evaluate the relative
efficacy of different SSRIs.
Despite the empirical support for the efficacy of
SSRIs in the reduction of anxiety symptoms, it is
important to consider the side-effect profiles and
other potential risks associated with the use of
medication for childhood anxiety. Overall, SSRIs
are generally well tolerated by patients and
relatively safe if overdosing occurs (Williams &
Miller, 2003). Side effects associated with SSRIs
in clinical trials for pediatric anxiety disorders
include gastrointestinal problems (e.g., abdominal
pain, diarrhea), headaches, and insomnia (Reinblatt
& Riddle, 2007). “Activation syndrome” represents
another potential side effect of SSRI treatment.
Activation syndrome is a term used to describe
several side effects of SSRIs that commonly
occur together, including irritability, somatic man-
ifestations of anxiety, restlessness, aggressivity,
disinhibition, emotional lability, impulsivity, hypo-
mania/mania, and social withdrawal (Goodman,
Murphy, & Storch, 2007). Additionally, recent
reviews of the use of SSRIs in pediatric patients
with anxiety disorders and major depressive
disorder have indicated that SSRIs are associated
with an increased risk of suicidality (Goodman
et al., 2007; Hammad, Laughren, & Racoosin,
2006). Given this increased risk, the U.S. Food and
Drug Administration Advisory Committee has
recommended that a black box warning regarding
the risk of suicidality for all antidepressants in
pediatric patients be included as part of the product
labeling (U.S. Food and Drug Administration,
2007). Psychoeducation regarding these adverse
side effects is necessary, and parents should be
advised to closely monitor their child's response to
medication (Hammerness, Vivas, & Geller, 2006).
Factors to consider when selecting medication and
dosage include age, body weight, pubertal status,
neurological status, and family history of medica-
tion response (Hammerness et al., 2006).
For short-term and more immediate relief, the
high-potency benzodiazepines may be used,
although these medications are habit forming
and many patients report discontinuation diffi-
culties with long-term use (Williams & Miller,
2003). Side effects of this class of drug include
sedation, dizziness, and cognitive blunting. In
addition, reports of behavioral disinhibition have
been reported (Graae, Milner, Rizzotto, & Klein,
1994; Walkup, Labellarte, & Ginsburg, 2002).
Given the potential for abuse and dependence in
benzodiazepines, clinicians should have caution
when considering this medication as a treat-
ment option for pediatric populations. Currently,
research is exploring the combination of CBT
and psychopharmacological approaches (e.g.,
SSRIs) in the treatment of pediatric anxiety with
Family therapy for child anxiety disorders is
suggested if dysfunctional family interactional
patterns (e.g., overcontrol, overprotection, conflict)
or parental anxiety symptoms are posited to be
contributing to the development or maintenance of
the child's anxiety problems. Key interventions
include psychoeducation regarding the nature and
maintenance of anxiety symptoms, contingency
management plans, reduction of parental anxiety,
cognitive restructuring techniques, improvement of
the parent–child relationship, and relapse preven-
tion (Ginsburg & Schlossberg, 2002). Studies have
demonstrated the effectiveness of family-based
CBT in the treatment of a number of childhood
anxiety disorders (Barrett et al., 2004; Ginsburg &
There is limited empirical support for psycho-
dynamic therapy for anxious youth (AACAP,
2007). This type of intervention targets children's
underlying fears and anxieties through nondirective
or minimally directed play (Bernstein, Rapoport, &
Leonard, 1997). Goals of psychodynamic
therapy include mastering themes of separation,
autonomy, self-esteem, and age-appropriate beha-
vior (Bernstein et al., 1997).
Although the previously described interventions
may be useful in the treatment of all childhood
anxiety disorders, certain diagnosis-specific inter-
ventions have been established as well. Social
skills training (LeCroy, 1994) for children with
social phobia, in which children learn specific
social skills (e.g., smiling, initiating a conversation,
being assertive), assists the child in acquiring and
applying social skills in social situations. For
10 KEELEY AND STORCH
ARTICLE IN PRESS
youth diagnosed with OCD, research has demon-
strated strong support for CBT with a particular
focus on exposure with response prevention (E/
RP) techniques. E/RP techniques involve (a)
placing the child in anxiety-provoking situations
associated with obsessions (exposure) and (b)
preventing the individual from engaging in anxi-
ety-reducing compulsions (response prevention;
IMPLICATIONS FOR NURSES
Given the considerable range of involvement that
nurses may have in the care of their patients and
families (e.g., on inpatient units, as prescribing
practitioners), they serve an important role in the
recognition of childhood anxiety symptoms. The
implementation of nurse care for children with
anxiety disorders should be guided by a model that
includes a systematic approach to assessing and
treating symptoms. Within this model, the impor-
tance of establishing a calm and safe therapeutic
environment is emphasized. Additionally, main-
taining a nonjudgmental and empathic perspective
may be particularly helpful for youth who struggle
with understanding and coping with their anxiety.
The assessment process should be guided by an
evaluation of the patient's presenting problems.
Given the variable nature of anxiety, it is important
to assess for cognitive, physiological, and beha-
vioral symptoms. For example, a child with PTSD
may present with intrusive thoughts related to harm,
sleep-related problems, and avoidance behaviors.
Obtaining information from multiple informants is
critical for the assessment process, as discrepant
data from different informants may facilitate the
development of hypotheses regarding the nature
of the child's anxiety. For example, if a teacher
describes significant anxiety in the child but
the parent denies observing any noticeable dis-
comfort, it may be possible that a particular
stimulus within the school environment is con-
tributing to the child's anxiety. When evaluating the
chief complaint, it is also important to gather
information regarding how the child's anxiety
interferes with his or her functioning. Anxiety
symptoms may cause impairment in academic,
social, and family domains.
Following a discussion of the presenting pro-
blems, the next step is to rule out potential medical
causes for the child's symptoms. Due to the
multitude of somatic symptoms associated with
anxiety disorders (see Table 2), a thorough physical
and/or neurological examination may be needed to
determine whether the child's symptoms are
psychological in nature. For example, although
sleep-related problems are common features of
anxiety, they may also be due to other medical
conditions, such as sleep apnea.
Once the presenting problem has been deemed
psychological in nature, the nurse should then
assess for precipitating factors that trigger anxiety.
Examples of precipitating factors include a trau-
matic event, exposure to social situations that may
entail an evaluative component (e.g., public speak-
ing), a physiological sensation (e.g., rapid heart
rate), prevention of a compulsive ritual, or intrusive
thoughts. The process of evaluating anxiety triggers
may be difficult for young children who lack insight
or who may not have the cognitive skills to evaluate
antecedents of anxiety. However, recognition of
triggers is a critical component to helping the
child de-escalate anxiety symptoms.
Given the potential impact of family influences
on the development and maintenance of anxiety,
careful attention should also be paid to the
interaction between the patient and his or her
family members. Nurses should observe whether
family members are reinforcing or accommodating
the child's anxiety symptoms. Furthermore, it is
important to assess whether parents are modeling
fearful or anxious reactions for their children. This
may be especially critical if there is a history of
family psychosocial problems.
Finally, it is important to screen for other
psychological problems and to assess for their
potential influence on the child's anxiety. For
example, a child's oppositionality may exacerbate
anxiety-related sleep problems if the child refuses
to go to bed. Given high rates of comorbid
psychopathology among anxiety disorders, it is
also important for nurses to be aware of common
comorbid conditions and their impact on treatment
response. For example, a child with social phobia
who also suffers from major depressive disorder
may have little motivation and/or energy to engage
in social interactions. Diagnosing comorbid dis-
orders and recognizing their influence on the
development and maintenance of anxiety symp-
toms are critical for comprehensive care.
Nurses play a critical role in facilitating the
treatment planning process. Information obtained
ARTICLE IN PRESS
by nurses during the assessment process will guide
the selection of intervention methods. For example,
if the nurse discovers that parental modeling of
involvement of the parent in treatment may enhance
the effectiveness of treatment. If previous trials of
CBT have reportedly resulted in only partial
response, the nurse may recommend an additional
or alternative approach (e.g., SSRI) to treatment.
Features of anxiety disorders, such as embarrass-
ment, avoidance, resistance, and secretive behavior,
may increase the complexity of the case and may
have significant implications for the selection
of intervention methods. For example, a patient
unwilling to disclose the details of a traumatic
experience may prevent clinicians from implement-
ing proper treatment to reduce anxiety associated
with the experience and accompanying distress.
Additionally, a patient with limited insight into
obsessive–compulsive symptoms (i.e., unable to
recognize obsessive thoughts as irrational) will be
particularly resistant to cognitive restructuring
and may require pharmacotherapy prior to psy-
chotherapy for CBT to be effective.
Finally, acquiring information regarding the
child's coping skills will help to identify specific
targets for intervention. It is important to obtain
information regarding the frequency with which the
child utilizes specific coping strategies and how
well the selected coping strategies are implemented.
Examples of coping strategies include problem
solving, acceptance, distraction, social support
seeking, escape, denial, and emotional expression.
If the child presents with mainly avoidance coping
strategies (e.g., escape, denial) or a limited coping
repertoire, he or she may benefit from instruction in
more approach-oriented coping strategies (e.g.,
problem solving, social support seeking). Children
facing uncontrollable stressors may require assis-
tance with emotion-focused coping strategies (e.g.,
acceptance, emotional expression).
Interventions for Acute Anxiety
There are several intervention strategies that can
be implemented within the clinical setting that
may provide relief from acute anxiety. Labeling
the child's symptoms in a nonthreatening manner
will help the child to recognize his or her anxiety
and to feel comfortable in the clinical setting.
Instructing the child to take slow, deep breaths
may prevent the escalation of physiological
symptoms. Progressive muscle relaxation exer-
cises, in which the child is taught to tense and
relax muscles from head to toes, may also
facilitate a reduction in symptoms. Talking in a
calm, soothing voice or playing relaxation tapes
may also provide relief from acute anxiety.
Encouraging the child to focus on a single object
or person in the room may help the child to
disengage from potentially anxiety-provoking
stimuli. Finally, instructing the child to visualize
a peaceful place (e.g., the beach) may also
facilitate a reduction in acute anxiety.
The complexity of the characteristics associated
with childhood anxiety disorders calls for clinicians
with detailed knowledge concerning anxiety symp-
tomatology as well as proper understanding of
assessment and intervention techniques. This article
provides an introduction to evidence-based practice
in the area of childhood anxiety disorders. Nurses
interested in learning specific techniques regarding
assessment and intervention may gain expertise
through formal training. Nurses with prescriptive
privileges are encouraged to stay up-to-date regard-
ing evidence-based recommendations for childhood
anxiety disorders (both psychosocial and medica-
of treatment medications. Those without formal
training should consider referring patients with
suspected anxiety disorders to an experienced,
licensed psychologist or psychiatrist for compre-
hensive assessment and treatment.
Childhood anxiety disorders are one of the most
prevalent categories of psychopathology in chil-
dren and adolescents. They often cause significant
distress and are characterized by broad impair-
ments in academic, social, and family functioning.
It is essential for clinicians to be aware of the
clinical presentation of child anxiety disorders as
well as proper assessment techniques for accurate
diagnosis. A comprehensive assessment of child-
hood anxiety should capitalize on the multiple
assessment techniques available, including diag-
nostic interviews, rating scales, and observational
methods. Fortunately, evidence-based therapies
exist for treatment of anxiety disorders in youth
(AACAP, 2007). These include behavioral inter-
ventions, cognitive–behavioral interventions,
psychopharmacology, family therapy, and psycho-
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