Mental Health: Anxiety - The Silent Elephant in the Room

The word “anxiety” carries a wide variety of meanings for both clinicians and patients. Understanding the mosaic of anxiety disorders and their varied presentations is essential for treating one of the most common psychiatric impairments in children and adolescents.

Generally, the younger the child, the more common the symptoms of anxiety manifest as physical symptoms, rather than reported symptoms of stress. Some common physical presentations include stomachaches, headaches and nausea. These physical symptoms are especially common during stressful periods (such as having to go to school, performances, sports practices and games). Other sensations, such as restlessness, shaking and fidgeting, can be related to anxiety, but also carry significant overlaps with attention-deficit/hyperactivity disorder. As children get older, they may describe their anxiety as feeling worried, scared, on edge, or that their mind is heavy.

Certain types of anxiety appear at earlier ages than others. According to the median age of onset date by Solmi et al., the earliest manifestations of pathological anxiety (approximately 8 years or younger) are phobias and separation anxiety. In early teenagers (13 years old), social anxiety commonly manifests. While the median age of onset of generalized anxiety disorder is in one’s 30s, the range of onset is wide.

Although anxiety is a normal emotional experience in certain situations, the hallmark of pathological anxiety is anxiety that causes significant distress or impairment in a person’s life. The different types of anxiety disorder are related to the underlying thought processes that categorize the disorder. For detailed explanations of each psychiatric disorder, I refer to the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-5. Here are some brief ways of categorizing common types of anxiety:

• Phobias: intense fear and avoidance of certain people, places, things or situations. The person’s fear is out of proportion to the actual danger of the situation and causes a response above and beyond that of most others in the same situation. For example, a child may run out of the clinician’s office due to seeing a needle.
• Separation Anxiety: significant fear of being away from major attachment figures due to fear of harm occurring to those people or themselves. This is a common source of school avoidance. A way to ask about it is to see if the patient can spend time away from their family (including with friends) without significant distress.
• Social Anxiety: significant worry about meeting and talking to people due to fear of saying the wrong thing or being judged or scrutinized. A subset of social anxiety is performance anxiety, which is related to presentations or other performative tasks, such as sports or theater.
• Generalized Anxiety Disorder: persistent anxiety every day, or on most days of the week, for months at a time (at least six months per DSM-5). These patients worry about many different things over the course of the day, and may have signs of physical or emotional distress (restlessness, irritability, etc.).

Treatment

In terms of therapy, cognitive behavioral therapy (CBT) is an excellent evidence-based method to treat anxiety. Play therapy is also an effective method for young children or individuals who struggle with the cognitive processes of CBT. Psychologytoday.com is a good resource to find therapists. In terms of medications, selective serotonin reuptake inhibitors (SSRIs) are the evidence-based recommendation for moderate to severe anxiety. While the efficacy of therapy versus medication is similar over the long term, the combination of therapy and SSRIs helps reduce anxiety symptoms the quickest. Of SSRIs, fluoxetine, sertraline or escitalopram are our preferred medications. Hydroxyzine is also a commonly used medication as needed to help with anxiety. For further information regarding commonly prescribed medications for anxiety, please refer to Up-to-Date or Lexicomp.

References:

1. Solmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. 2022;27(1):281-295. PMID: 34079068. PMCID: PMC8960395. doi:10.1038/s41380-021-01161-7
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
3. Zhou Y, Lu Y, Wu Y, et al. Safety of antidepressants commonly used in 6-17-year-old children and adolescents: A disproportionality analysis from 2014-2023 on the basis of the FAERS database. PLoS One. 2025;20(8):e0330025. PMID: 40802817. PMCID: PMC12349705. doi:10.1371/journal.pone.0330025