210  Part III  ◆  Behavioral and Psychiatric Disorders

prevalence rates comparable to physical disorders such as asthma and

diabetes. Anxiety disorders are often comorbid with other psychiatric
and medical disorders (including a second anxiety disorder); significant
impairment in day-to-day functioning is common. High levels of fear
in adolescence are also a significant risk factor for experiencing later
episodes of major depression in adulthood. Anxiety and depressive
disorder in adolescence predict increased risk of anxiety and depressive
symptoms (including suicide attempts) in adulthood, underscoring
the need to diagnose and treat these underreported, yet prevalent,
conditions early.
Because anxiety is both a normal phenomenon and, when highly
activated, strongly associated with impairment, the pediatrician must
be able to differentiate normal anxiety from abnormal anxiety across
development (Fig. 38.1 and Table 38.1). Anxiety has an identifiable
developmental progression for most children; most infants exhibit
Chapter 38  stranger wariness or anxiety beginning at 7-9 mo of age. Behavioral
inhibition to the unfamiliar (withdrawal or fearfulness to novel stimuli
Anxiety Disorders associated with physiologic arousal) is evident in approximately 10–15%
of the population at 12 mo of age and is moderately stable. Most children
who show behavioral inhibition do not develop impairing levels of
David R. Rosenberg and anxiety. A family history of anxiety disorders and maternal overinvolve-
Jennifer A. Chiriboga ment or enmeshment predicts later clinically significant anxiety in
behaviorally inhibited infants. The infant who is excessively clingy and
difficult to calm during pediatric visits should be followed for signs of
Anxiety, defined as dread or apprehension, is not considered pathologic, increasing levels of anxiety.
is seen across the life span, and can be adaptive (e.g., the anxiety one Preschoolers typically have specific fears related to the dark, animals,
might feel during an automobile crash). Anxiety has both a cognitive- and imaginary situations, in addition to normative separation anxiety.
behavioral component, expressed in worrying and wariness, and a
physiologic component, mediated by the autonomic nervous system.
Anxiety disorders are characterized by pathologic anxiety, in which
Table 38.1  Differential Diagnosis of Anxiety Disorders
anxiety becomes disabling, interfering with social interactions, develop-
ment, and achievement of goals or quality of life, and can lead to low Shyness
self-esteem, social withdrawal, and academic underachievement. The Substance use
average age of onset of anxiety disorder is 11 yr. Diagnosis of a particular Substance use withdrawal
anxiety disorder in a child requires significant interference in the child’s Hyperthyroidism
psychosocial and academic or occupational functioning, which can Arrhythmias
occur even with subthreshold symptoms that do not meet criteria in Pheochromocytoma
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Mast cell disorders
Carcinoid syndrome
(DSM-5). Anxiety may have physical manifestations such as weight Anaphylaxis
loss, pallor, tachycardia, tremors, muscle cramps, paresthesias, hyper- Hereditary angioedema
hidrosis, flushing, hyperreflexia, and abdominal tenderness. Lupus
Separation anxiety disorder (SAD), childhood-onset social phobia Autoimmune encephalitis
or social anxiety disorder, generalized anxiety disorder (GAD), obsessive- Body dysmorphic disorder
compulsive disorder (OCD), phobias, posttraumatic stress disorder Autism spectrum disorder
(PTSD), and panic disorder (PD) are all defined by the occurrence of Major depressive disorder
either diffuse or specific anxiety, often related to predictable situations Delusional disorder
or cues. Anxiety disorders are the most common psychiatric disorders Oppositional defiant disorder
Embarrassing medical condition
of childhood, occurring in 5–18% of all children and adolescents,

Dying and death of others Fear of negative evaluation

School anxiety,
Separation performance anxiety
Normative fears

Thunder, lightning, fire

water, darkness, nightmares,
animals, imaginary
Stranger creatures
shyness Germs, getting ill, natural
disasters, traumatic events, Peer rejection
harm to self or others

0 Infancy and 3 Childhood 6 School age 12 Adolescence

toddlerhood
Age (years)
Fig. 38.1  Normative fears throughout childhood and adolescence. (From Craske MG, Stein MB: Anxiety. Lancet 388:3048–3058, 2016.)

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210.e2  Part III  ◆  Behavioral and Psychiatric Disorders

Keywords
separation anxiety disorder
childhood-onset social phobia
social anxiety disorder
social effectiveness therapy for children (SET-C)
school refusal
selective mutism
panic disorder
generalized anxiety disorders
OCD
PTSD
CBT
SSRI safety
SSRI efficacy

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 Chapter 38  ◆  Anxiety Disorders  211

Preoccupation with orderliness and routines (just right phenomena) harm befalling the affected child or the child’s primary caregivers,
often takes on a quality of anxiety for preschool children. Parents’ reluctance to go to school or to sleep without being near the parents,
reassurance is usually sufficient to help the child through this period. persistent avoidance of being alone, nightmares involving themes of
Although most school-age children abandon the imaginary fears of separation, numerous somatic symptoms, and complaints of subjective
early childhood, some replace them with fears of bodily harm or other distress. The first clinical sign might not appear until 3rd or 4th grade,
worries (Table 38.2). In adolescence, general worrying about school typically after a holiday or a period where the child has been home
performance and worrying about social competence are common and because of illness, or when the stability of the family structure has been
remit as the teen matures. threatened by illness, divorce, or other psychosocial stressors.
Genetic or temperamental factors contribute more to the development Symptoms vary depending on the child’s age: Children <8 yr often
of some anxiety disorders, whereas environmental factors are closely have associated school refusal and excessive fear that harm will come
linked to the cause of others. Specifically, behavioral inhibition appears to a parent; children 9-12 yr have excessive distress when separated
to be a heritable tendency and is linked with social phobia, generalized from a parent; and those 13-16 yr often have school refusal and physical
anxiety, and selective mutism. OCD and other disorders associated complaints. SAD may be more likely to develop in children with lower
with OCD-like behaviors, such as Tourette syndrome and other tic levels of psychosocial maturity. Parents are often unable to be assertive
disorders, tend to have high genetic risk as well (see Chapter 37.1). in returning the child to school. Mothers of children with SAD often
Environmental factors, such as parent–infant attachment and exposure have a history of an anxiety disorder. In these cases the pediatrician
to trauma, contribute more to SAD and PTSD. Parental anxiety disorder should screen for parental depression or anxiety. Often, referral for
is associated with an increased risk of anxiety disorder in offspring. parental treatment or family therapy is necessary before SAD and
Differences in the size of the amygdala and hippocampus are noted in concomitant school refusal can be successfully treated.
patients with anxiety symptoms. Comorbidity is common in SAD. In children with comorbid tic
Separation anxiety disorder is one of the most common childhood disorders and anxiety, SAD is especially associated with tic severity.
anxiety disorders, with a prevalence of 3.5–5.4%. Approximately 30% SAD is a predictor for early onset of PD. Children with SAD compared
of children presenting to an outpatient anxiety disorder clinic have to those without SAD are 3 times more likely to develop PD in
SAD as a primary diagnosis. Separation anxiety is developmentally adolescence.
normal when it begins about 10 mo of age and tapers off by 18 mo. By When a child reports recurring acute severe anxiety, antidepressant
3 yr of age, most children can accept the temporary absence of their or anxiolytic medication is often necessary. Controlled studies of tricyclic
mother or primary caregiver. antidepressants (TCAs, imipramine) and benzodiazepines (clonazepam)
SAD is more common in prepubertal children, with an average age show that these agents are not generally effective. Data support the use
of onset of 7.5 yr. Girls are more frequently affected than boys. SAD is of cognitive-behavioral therapy (CBT) and selective serotonin reuptake
characterized by unrealistic and persistent worries about separation inhibitors (SSRIs) (see Chapter 33, Table 33.4). Adverse events with
from the home or a major attachment figure. Concerns include possible SSRI treatment, including suicidal and homicidal ideation, are uncom-
mon. CBT alone is associated with less insomnia, fatigue, sedation, and
restlessness than SSRIs. Combining SSRIs with CBT may be the best
approach to achieving a positive response; long-term SSRI treatment
Table 38.2  DSM-5 Diagnostic Criteria for Specific Phobia can provide additional benefit.
Childhood-onset social phobia (social anxiety disorder) is character-
A. Marked fear or anxiety about a specific object or situation (e.g., ized by excessive anxiety in social settings (including the presence of
flying, heights, animals, receiving an injection, seeing blood). unfamiliar peers, or unfamiliar adults) or performance situations, leading
Note: In children, the fear or anxiety may be expressed by crying, to social isolation, and is associated with social scrutiny and fear of
tantrums, freezing, or clinging. doing something embarrassing (Table 38.3). Fear of social settings can
B. The phobic object or situation almost always provokes also occur in other disorders, such as GAD. Avoidance or escape from
immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured
the situation usually dissipates anxiety in social phobia (SP), unlike
with intense fear or anxiety. GAD, where worry persists.
D. The fear or anxiety is out of proportion to the actual danger Children and adolescents with SP often maintain the desire for
posed by the specific object or situation and to the sociocultural involvement with family and familiar peers. When severe, the anxiety
context. can manifest as a panic attack. SP is associated with a decreased quality
E. The fear, anxiety, or avoidance is persistent, typically lasting for of life, with increased likelihood of having failed at least 1 grade, and
6 mo or more. a 38% likelihood of not graduating from high school. Its onset is typically
F. The fear, anxiety, or avoidance causes clinically significant during or before adolescence and is more common in girls. A family
distress or impairment in social, occupational, or other important history of SP or extreme shyness is common. Approximately 70–80%
areas of functioning.
G. The disturbance is not better explained by the symptoms of
of patients with SP have at least 1 comorbid psychiatric disorder. Most
another mental disorder, including fear, anxiety and avoidance shy patients do not have SP.
or situations associated with panic-like symptoms or other Social effectiveness therapy for children (SET-C), alone or with
incapacitating symptoms (as in agoraphobia); objects or SSRIs, is considered the treatment of choice for SP (see Table 33.4).
situations related to obsessions (as in obsessive-compulsive SSRI and SET-C are superior to placebo in reducing social distress and
disorder); remainders of traumatic events (as in posttraumatic behavioral avoidance and increasing general functioning. SET-C may
stress disorder); separation from home or attachment figures (as be better than SSRI in reducing these symptoms. SET-C, but not SSRI,
in separation anxiety disorder); or social situations (as in social may be superior to placebo in improving social skills, decreasing anxiety
anxiety disorder). in specific social interactions, and enhancing social competence. SSRIs
Specify if:
Code based on the phobic stimulus: have a maximum effect by 8 wk; SET-C provides continued improvement
Animal (e.g., spiders, insects, dogs). through 12 wk. A combination of SSRI and CBT is superior to either
Natural environment (e.g., heights, storms, water). treatment alone in reducing severity of anxiety in children with SP and
Blood-injection-injury (e.g., needles, invasive medical other anxiety disorders. β-Adrenergic blocking agents are used to treat
procedures). SP, particularly the subtype with performance anxiety and stage fright.
Situational (e.g., airplanes, elevators, enclosed places). β-Blockers are not approved by the U.S. Food and Drug Administration
Other (e.g., situations that may lead to choking or vomiting; in (FDA) for SP.
children, e.g., loud sounds or costumed characters). School refusal, which occurs in approximately 1–2% of children, is
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, associated with anxiety in 40–50% of cases, depression in 50–60% of
(Copyright 2013). American Psychiatric Association, pp 197–198. cases, and oppositional behavior in 50% of cases. Younger anxious

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212  Part III  ◆  Behavioral and Psychiatric Disorders

Table 38.3  DSM-5 Diagnostic Criteria for Social Anxiety Table 38.4  DSM-5 Diagnostic Criteria for Panic Disorder
Disorder (Social Phobia)
A. Recurrent unexpected panic attacks. A panic attack is an abrupt
A. Marked fear or anxiety about 1 or more social situations in which surge of intense fear or intense discomfort that reaches a peak
the individual is exposed to possible scrutiny by others. within minutes, and during which time 4 (or more) of the
Examples include social interactions (e.g., having a conversation, following symptoms occur:
meeting unfamiliar people), being observed (e.g., eating or Note: The abrupt surge can occur from a calm state or an anxious
drinking), and performing in front of others (e.g., giving a state.
speech). 1. Palpitations, pounding heart, or accelerated heart rate.
B. The individual fears that he or she will act in a way or show 2. Sweating.
anxiety symptoms that will be negatively evaluated (i.e., will be 3. Trembling or shaking.
humiliating or embarrassing; will lead to rejection or offend 4. Sensations of shortness of breath or smothering.
others). 5. Feelings of choking.
C. The social situations almost always provoke fear or anxiety. 6. Chest pain or discomfort.
Note: In children, the fear or anxiety may be expressed by crying, 7. Nausea or abdominal distress.
tantrums, freezing, clinging, shrinking, or failing to speak in social 8. Feeling dizzy, unsteady, light-headed, or faint.
situations. 9. Chills or heart sensations.
D. The social situations are avoided or endured with intense fear or 10. Paresthesias (numbness or tingling sensations).
anxiety. 11. Derealizations (feeling or unreality) or depersonalization
E. The fear or anxiety is out of proportion to the actual threat (being detached from one-self).
posed by the social situation and to the sociocultural context. 12. Fear of losing control or “going crazy.”
F. The fear, anxiety, or avoidance is persistent, typically lasting for 13. Fear of dying.
6 mo or more. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness,
G. The fear, anxiety, or avoidance causes clinically significant headache, uncontrollable screaming or crying) may be seen.
distress or impairment in social, occupational, or other important Such symptoms should not count as 1 of the 4 required
areas of functioning. symptoms.
H. The fear, anxiety, or avoidance is not attributable to the B. At least 1 of the attacks has been followed by 1 mo (or more) of
physiologic effects of a substance (e.g., a drug of abuse, a 1 or both of the following:
medication) or another medical condition. 1. Persistent concern or worry about additional panic attacks or
I. The fear, anxiety, or avoidance is not better explained by the their consequences (e.g., losing control, having a heart attack,
symptoms of another mental disorder, such as panic disorder, “going crazy”).
body dysmorphic disorder, or autism spectrum disorder. 2. A significant maladaptive change in behavior related to the
J. If another medical condition (e.g., Parkinson disease, obesity, attacks (e.g., behaviors designed to avoid having panic
disfigurement from burns or injury) is present, the anxiety or attacks, such as avoidance of exercise or unfamiliar situations).
avoidance is clearly unrelated or is excessive. C. The disturbance is not attributable to the physiologic effects of
Specify if: a substance (e.g., a drug of abuse, a medication) or another
Performance only: If the fear is restricted to speaking or performing medical condition (e.g., hyperthyroidism, cardiopulmonary
in public. disorders).
D. The disturbance is not better explained by another mental
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, disorder (e.g., the panic attacks do not occur only in response to
(Copyright 2013). American Psychiatric Association, pp 202–203. feared social situations, as in social anxiety disorder; in response
to circumscribed phobic objects or situations, as in specific
phobia; in response to obsessions, as in obsessive-compulsive
disorder; or in response to reminders of traumatic events, as in
children who refuse to attend school are more likely to have SAD, posttraumatic stress disorder; or in response to separation from
whereas older anxious children usually refuse to attend school because attachment figures, as in separation anxiety disorder).
of SP. Somatic symptoms, especially abdominal pain and headaches,
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,
are common. There may be increasing tension in the parent–child (Copyright 2013). American Psychiatric Association, pp 208–209.
relationship or other indicators of family disruption (domestic violence,
divorce, or other major stressors) contributing to school refusal.
Management of school refusal typically requires parent management
training and family therapy. Working with school personnel is always
indicated; anxious children often require special attention from teachers, Panic disorder is a syndrome of recurrent, discrete episodes of marked
counselors, or school nurses. Parents who are coached to calmly send fear or discomfort in which patients experience abrupt onset of physical
the child to school and to reward the child for each completed day of and psychological symptoms called panic attacks (Table 38.4). Physical
school are usually successful. In cases of ongoing school refusal, referral symptoms can include palpitations, sweating, shaking, shortness of
to a child and adolescent psychiatrist and psychologist is indicated. SSRI breath, dizziness, chest pain, and nausea. Children can present with
treatment may be helpful. Young children with affective symptoms have acute respiratory distress but without fever, wheezing, or stridor, ruling
a good prognosis, whereas adolescents with more insidious onset or out organic causes of the distress. The associated psychological symptoms
with significant somatic complaints have a more guarded prognosis. include fear of death, impending doom, loss of control, persistent
Selective mutism is conceptualized as a disorder that overlaps with concerns about having future attacks, and avoidance of settings where
SP. Children with selective mutism talk almost exclusively at home, attacks have occurred (agoraphobia, Table 38.5).
although they are reticent in other settings, such as school, daycare, or PD is uncommon before adolescence, with the peak age of onset at
even relatives’ homes. The mutism must be present for ≥1 mo. Often, 15-19 yr, occurring more often in girls. The postadolescence prevalence
one or more stressors, such as a new classroom or conflicts with parents of PD is 1–2%. Early-onset PD and adult-onset PD do not differ in
or siblings, drive an already shy child to become reluctant to speak. It symptom severity or social functioning. Early-onset PD is associated
may be helpful to obtain history of normal language use in at least one with greater comorbidity, which can result from greater familial loading
situation to rule out any communication disorder (fluency disorder), for anxiety disorders in the early-onset subtype. Children of parents
neurologic disorder, or pervasive developmental disorder (autism, with PD are much more likely to develop PD. A predisposition to
schizophrenia) as a cause of mutism. Fluoxetine in combination with react to autonomic arousal with anxiety may be a specific risk factor
behavioral therapy is effective for children whose school performance leading to PD. Twin studies suggest that 30–40% of the variance is
is severely limited by their symptoms (see Chapter 52). Other SSRIs attributed to genetics. The increasing rates of panic attack are also directly
may also be effective. related to earlier sexual maturity. Cued panic attacks can be present in

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 Chapter 38  ◆  Anxiety Disorders  213

Table 38.5  DSM-5 Diagnostic Criteria for Agoraphobia Table 38.6  DSM-5 Diagnostic Criteria for Generalized
Anxiety Disorder
A. Marked fear or anxiety about 2 (or more) if the following 5
situations: A. Excessive anxiety and worry (apprehensive expectation),
1. Using public transportation (e.g., automobiles, buses, trains, occurring more days than not for at least 6 mo, about a number
ships, planes). of events or activities (such as work or school performance).
2. Being in open spaces (e.g., parking lots, marketplaces, B. The individual finds it difficult to control the worry.
bridges). C. The anxiety and worry are associated with 3 (or more) of the
3. Being in enclosed places (e.g., shops, theaters, cinemas). following 6 symptoms (with at least some symptoms having
4. Standing in line or being in a crowd. been present for more days than not for the past 6 mo):
5. Being outside of the home alone. Note: Only 1 item is required in children.
B. The individual fears or avoids these situations because of 1. Restlessness or feeling keyed up or on edge.
thoughts that escape might be difficult or help might not be 2. Being easily fatigued.
available in the event of a developing panic-like symptoms or 3. Difficulty concentrating or mind going blank.
other incapacitating or embarrassing symptoms (e.g., fear or 4. Irritability.
falling in the elderly, fear of incontinence). 5. Muscle tension.
C. The agoraphobic situations almost always provoke fear or 6. Sleep disturbance (difficulty falling or staying asleep, or
anxiety. restless, unsatisfying sleep).
D. The agoraphobic situations are actively avoided, require the D. The anxiety, worry, or physical symptoms cause clinically
presence of a companion, or are endured with intense fear or significant distress or impairment in social, occupational, or
anxiety. other important areas of functioning.
E. The fear or anxiety is out of proportion to the actual danger E. The disturbance is not attributable to the physiologic effects of
posed by the agoraphobic situations and to the sociocultural a substance (e.g., a drug of abuse, a medication) or other
context. medical condition (e.g., hyperthyroidism).
F. The fear, anxiety, or avoidance is persistent, typically lasting for F. The disturbance is not better explained by another mental
6 mo or more. disorder (e.g., anxiety or worry about having panic attacks in
G. The fear, anxiety, or avoidance causes clinically significant panic disorder, negative evaluation in social anxiety disorder
distress or impairment in social, occupational, or other important [social phobia], contamination or other obsessions in obsessive-
area of functioning. compulsive disorder, separation from attachment figures in
H. If another medical condition (e.g., inflammatory bowel disease, separation anxiety disorder, remainders of traumatic events in
Parkinson disease) is present, the fear, anxiety, or avoidance is posttraumatic stress disorder, gaining weight in anorexia
clearly excessive. nervosa, physical complaints in somatic symptom disorder,
I. The fear, anxiety, or avoidance is not better explained by the perceived appearance flaws in body dysmorphic disorder,
symptoms or another mental disorder—for example, the having a serious illness in illness anxiety disorder, or the content
symptoms are not confined to specific phobia, situational type; of delusional beliefs in schizophrenia or delusional disorder).
do not involve only social situations (as in social anxiety
disorder); and are not related exclusively to obsessions (as in From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,
obsessive-compulsive disorder), reminders or traumatic events (Copyright 2013). American Psychiatric Association, p 222.
(as in posttraumatic stress disorder), or fear of separation (as in
separation anxiety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of
panic disorder. If an individual’s presentation meets criteria for
simple phobia and PD. Onset may be gradual or sudden, although GAD
panic disorder and agoraphobia, both diagnoses should be seldom manifests until puberty. Boys and girls are equally affected before
assigned. puberty, when GAD becomes more prevalent in girls. The prevalence
of GAD ranges from 2.5–6% of children. Hypermetabolism in frontal
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, precortical area and increased blood flow in the right dorsolateral
(Copyright 2013). American Psychiatric Association, pp 217–218.
prefrontal cortex may be present.
Children with GAD are good candidates for CBT, an SSRI, or their
combination (see Table 33.4). Buspirone may be used as an adjunct to
other anxiety disorders and differ from the uncued “out-of-the-blue” SSRI therapy. The combination of CBT and SSRI often results in a
attacks in PD. superior response in pediatric patients with anxiety disorders, including
No randomized controlled trials (RCTs) have evaluated the effective- GAD. The recovery rate is approximately 80%.
ness of antidepressant medication in youth with PD. Open-label studies It is important to distinguish children with GAD from those who
with SSRIs appear to show effectiveness in the treatment of adolescents present with specific repetitive thoughts that invade consciousness
(see Table 33.4). CBT may also be helpful. The recovery rate is approxi- (obsessions) or repetitive rituals or movements that are driven by anxiety
mately 70%. (compulsions). The most common obsessions are concerned with bodily
Generalized anxiety disorder occurs in children who often experience wastes and secretions, the fear that something calamitous will happen,
unrealistic worries about different events or activities for at least 6 mo or the need for sameness. The most common compulsions are handwash-
with at least 1 somatic complaint (Table 38.6). The diffuse nature of the ing, continual checking of locks, and touching. At times of stress (bedtime,
anxiety symptoms differentiates it from other anxiety disorders. Worries preparing for school), some children touch certain objects, say certain
in children with GAD usually center around concerns about competence words, or wash their hands repeatedly.
and performance in school and athletics. GAD often manifests with Obsessive-compulsive disorder is diagnosed when the thoughts or
somatic symptoms, including restlessness, fatigue, problems concentrat- rituals cause distress, consume time, or interfere with occupational or
ing, irritability, muscle tension, and sleep disturbance. Given the somatic social functioning (Table 38.7). In the DSM-5, OCD and related disorders,
symptoms characteristic of GAD, the differential diagnosis must consider such as trichotillomania, excoriation, body dysmorphic disorder, and
other medical causes. Excessive use of caffeine or other stimulants in hoarding, are listed separately and are no longer included under anxiety
adolescence is common and should be determined with a careful history. disorders.
When the history or physical examination is suggestive, the pediatrician OCD is a chronically disabling illness characterized by repetitive,
should rule out hyperthyroidism, hypoglycemia, lupus, pheochromo- ritualistic behaviors over which the patient has little or no control. OCD
cytoma, and other disorders (see Table 38.1; Fig. 38.2). has a lifetime prevalence of 1–3% worldwide, and as many as 80% of
Children with GAD are extremely self-conscious and perfectionistic all cases have their onset in childhood and adolescence. Common
and struggle with more intense distress than is evident to parents or obsessions include contamination (35%) and thoughts of harming loved
others around them. They often have other anxiety disorders, such as ones or oneself (30%). Washing and cleaning compulsions are common

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214  Part III  ◆  Behavioral and Psychiatric Disorders

What is the primary symptom?

Worry Fear Panic

Are there unusual behaviors Do fears arise from Panic disorder

with the worry trauma exposure? Agoraphobia

No Yes

Generalized anxiety Obsessive-compulsive

disorder disorder
Adjustment disorder PANDAS
with anxiety

Yes No

Acute stress disorder Specific phobias

Posttraumatic stress Social anxiety disorder
disorder Separation anxiety disorder
Selective mutism

Fig. 38.2  Evaluation of worry, fear, and panic. PANDAS, Pediatric autoimmune neuropsychiatric disorders associated with Streptococcus pyogenes.
(From Kliegman RM, Lye PS, Bordini B, et al, editors: Nelson pediatric symptom-based diagnosis, Philadelphia, 2018, Elsevier, p 429).

Table 38.7  DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder

A. Presence of obsessions, compulsions, or both: D. The disturbance is not better explained by the symptoms of
Obsessions are defined by (1) and (2): another mental disorder (e.g., excessive worries, as in generalized
1. Recurrent and persistent thoughts, urges, or images that are anxiety disorder; preoccupation with appearance, as in body
experienced, at some time during the disturbance, as intrusive dysmorphic disorder; difficulty discarding or parting with
and unwanted, and that in most individuals cause marked possessions, as in hoarding disorder; hair pulling, as in
anxiety or distress. trichotillomania [hair-pulling disorder]; skin picking, as in
2. The individual attempts to ignore or suppress such thoughts, excoriation [skin-picking] disorder; stereotypies, as in stereotypic
urges, or images, or to neutralize them with some other movement disorder; ritualized eating disorder, as in eating
thought or action (i.e., by performing a compulsion). disorders; preoccupation with substances or gambling, as in
Compulsions are defined by (1) and (2): substance-related and addictive disorders; preoccupation with
1. Repetitive behaviors (e.g., hand washing, ordering, checking) having an illness, as in illness anxiety disorder; sexual urges or
or mental acts (e.g., praying, counting, repeating words silently) fantasies, as in paraphilic disorders; impulses, as in disruptive,
that the individual feels driven to perform in response to an impulse-control, and conduct disorders; guilty ruminations, as in
obsession or according to rules that must be applied rigidly. schizophrenia spectrum and other psychotic disorders; or
2. The behaviors or mental acts are aimed at preventing or repetitive patterns of behavior, as in autism spectrum disorder).
reducing anxiety or distress, or preventing some dreaded Specify if:
event or situation; however, these behaviors or mental acts are With good or fair insight: The individual recognizes that obsessive-
not connected in a realistic way with what they are designed to compulsive disorder beliefs are definitely or probably not true or
neutralize or prevent, or are clearly excessive. that they may or may not be true.
B. The obsessions or compulsions are time-consuming (e.g., take With poor insight: The individual thinks obsessive-compulsive
more than 1 hr per day) or cause clinically significant distress or disorder beliefs are probably true.
impairment in social, occupational, or other important areas of With absent insight/delusional beliefs: The individual is completely
functioning. convinced that obsessive-compulsive disorder beliefs are true.
C. The obsessive-compulsive symptoms are not attributable to the Specify if:
physiologic effects of a substance (e.g., a drug of abuse, a Tic-related: The individual has a current or past history of a tic
medication) or another medical condition. disorder.
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 237.

in children (75%), as are checking (40%) and straightening (35%). Many with SSRI, when symptoms are moderate to severe (YBOCS >21). In
children are observed to have visuospatial irregularities, memory OCD patients with comorbid tics, SSRIs are no more effective than
problems, and attention deficits, causing academic problems not explained placebo, and the combination of CBT and SSRI is superior to CBT;
by OCD symptoms alone. CBT alone is superior to placebo. Pediatric OCD patients with comorbid
The Children’s Yale-Brown Obsessive-Compulsive Scale (C-YBOCS) tics should begin treatment with CBT alone or combined CBT and
and the Anxiety Disorders Interview Schedule for Children (ADIS-C) SSRI. Pediatric patients with OCD who have a family history of OCD
are reliable and valid methods for identifying children with OCD. The may be significantly less responsive to CBT alone than patients without
C-YBOCS is helpful in following the progression of symptoms with a family history.
treatment. The Leyton Obsessional Inventory (LOI) is a self-report measure There are 4 FDA-approved medications for pediatric OCD: fluoxetine,
of OCD symptoms that is quite sensitive. Patients with OCD have sertraline, fluvoxamine, and clomipramine. Clomipramine, a heterocyclic
consistently identified abnormalities in the frontostriatal-thalamic antidepressant and nonselective serotonin and norepinephrine reuptake
circuitry associated with severity of illness and treatment response. inhibitor, is only indicated when a patient has failed 2 or more SSRI
Comorbidity is common in OCD, with 30% of patients having comorbid trials. There may be a role for glutamate-modulating medications in
tic disorders, 26% comorbid major depression, and 24% comorbid the treatment of OCD. The glutamate inhibitor riluzole (Rilutek) is FDA
developmental disorders. approved for amyotrophic lateral sclerosis (see Chapter 630.3) and has
Consensus guidelines recommend that children and adolescents with a good safety record. The most common adverse event with riluzole is
OCD begin treatment with either CBT alone or CBT in combination transient increase in liver transaminases. Riluzole in children with

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 Chapter 38  ◆  Anxiety Disorders  215

treatment-resistant OCD may be beneficial and is well tolerated. Other by calmly noting that phobias are not unusual and rarely cause impair-
glutamate-modulating agents, such as memantine, N-acetylcysteine, ment. The prevalence of specific phobias in childhood is 0.5–2%.
and D-cycloserine, have been used with some success in patients with Systematic desensitization is a form of behavior therapy that gradually
OCD. Referral of patients with OCD to a mental health professional is exposes the patient to the fear-inducing situation or object, while
always indicated. simultaneously teaching relaxation techniques for anxiety management.
In 10% of children with OCD, symptoms are triggered or exacerbated Successful repeated exposure leads to extinguishing anxiety for that
by group A β-hemolytic streptococcal infection (see Chapter 210). Group stimulus. When phobias are particularly severe, SSRIs can be used with
A β-hemolytic streptococci trigger antineuronal antibodies that cross- behavioral intervention. Low-dose SSRI treatment may be especially
react with basal ganglia neural tissue in genetically susceptible hosts, effective for some children with severe, refractory choking phobia.
leading to swelling of this region and resultant obsessions and compul- Posttraumatic stress disorder is typically precipitated by an extreme
sions. This subtype of OCD, called pediatric autoimmune neuropsy- stressor (see Chapter 14). PTSD is an anxiety disorder resulting from
chiatric disorder associated with streptococcal infection (PANDAS), the long- and short-term effects of trauma that cause behavioral and
is characterized by sudden and dramatic onset or exacerbation of OCD physiologic sequelae in toddlers, children, and adolescents (Table 38.8).
or tic symptoms, associated neurologic findings, and a recent streptococcal Another diagnostic category, acute stress disorder, reflects that traumatic
infection. Increased antibody titers of antistreptolysin O and antide- events often cause acute symptoms that may or may not resolve. Previous
oxyribonuclease B correlates with increased basal ganglia volumes. trauma exposure, a history of other psychopathology, and symptoms
Plasmapheresis is effective in reducing OCD symptoms in some patients of PTSD in parents predict childhood-onset PTSD. Many adolescent
with PANDAS and also decreasing enlarged basal ganglia volume. OCD and adult psychopathologic conditions, such as conduct disorder,
has also followed episodes of acute disseminated encephalomyelitis (see depression, and some personality disorders, might relate to previous
Chapter 618.4) The pediatrician should be aware of the infectious cause trauma. PTSD is also linked to mood disorders and disruptive behavior.
of some cases of tic disorders, and OCD and follow management Separation anxiety is common in children with PTSD. The lifetime
guidelines (see Chapter 37). prevalence of PTSD by age 18 yr is approximately 6%. Up to 40% show
Children with phobias avoid specific objects or situations that reliably symptoms, but do not fulfill the diagnostic criteria.
trigger physiologic arousal (e.g., dogs, spiders) (see Table 38.2). The Events that pose actual or threatened physical injury, harm, or death
fear is excessive and unreasonable and can be cued by the presence or to the child, child’s caregiver, or others close to the child, and that
anticipation of the feared trigger, with anxiety symptoms occurring produce considerable stress, fear, or helplessness, are required to make
immediately. Neither obsessions nor compulsions are associated with the diagnosis of PTSD. Three clusters of symptoms are also essential
the fear response; phobias only rarely interfere with social, educational, for diagnosis: reexperiencing, avoidance, and hyperarousal. Persistent
or interpersonal functioning. Assault by a relative and verbal aggression reexperiencing of the stressor through intrusive recollections, nightmares,
between parents can influence the onset of specific phobias. The parents and reenactment in play are typical responses in children. Persistent
of phobic children should remain calm in the face of the child’s anxiety avoidance of reminders and numbing of emotional responsiveness,
or panic. Parents who become anxious themselves may reinforce their such as isolation, amnesia, and avoidance, constitute the 2nd cluster of
children’s anxiety, and the pediatrician can usefully interrupt this cycle behaviors. Symptoms of hyperarousal, such as hypervigilance, poor

Table 38.8  DSM-5 Diagnostic Criteria for Posttraumatic Stress Disorder

POSTTRAUMATIC STRESS DISORDER reactions may occur on a continuum, with the more extreme
Note: The following criteria apply to adults, adolescents, and expression being a complete loss or awareness of present
children older than 6 yr. For children 6 yr and younger, see surroundings.)
corresponding criteria below. Note: In children, trauma-specific reenactment may occur in play.
A. Exposure to actual or threatened death, serious injury, or sexual 4. Intense or prolonged psychological distress at exposure to
violence in 1 (or more) of the following ways: internal or external cues that symbolize or resemble an aspect
1. Directly experiencing the traumatic event(s). of the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others. 5. Marked physiologic reactions to internal or external cues that
3. Learning that the traumatic event(s) occurred to a close family symbolize or resemble an aspect of the traumatic event(s).
member or close friend. In cases of actual or threatened death C. Persistent avoidance of stimuli associated with the traumatic
of a family member or friend, the event(s) must have been event(s), beginning after the traumatic event(s) occurred, as
violent or accidental. evidenced by 1 or both of the following:
4. Experiencing repeated or extreme exposure to aversive details 1. Avoidance of or efforts to avoid distressing memories,
of the traumatic event(s) (e.g., 1st responders collecting human thoughts, or feelings about or closely associated with the
remains; police officers repeatedly exposed to details of child traumatic event(s).
abuse). 2. Avoidance of or efforts to avoid external reminders (people,
Note: Criterion A4 does not apply to exposure through electronic places, conversations, activities, objects, situations) that arouse
media, television, movies, or pictures, unless this exposure is work distressing memories, thoughts, or feelings about or closely
related. associated with the traumatic event(s).
B. Presence of 1 (or more) of the following intrusion symptoms D. Negative alterations in cognitions and mood associated with the
associated with the traumatic event(s), beginning after the traumatic event(s), beginning or worsening after the traumatic
traumatic event(s) occurred: event(s) occurred, as evidenced by 2 (or more) of the following:
1. Recurrent, involuntary, and intrusive distressing memories of the 1. Inability to remember an important aspect of the traumatic
traumatic event(s). event(s) (typically due to dissociative amnesia and not to other
Note: In children older than 6 yr, repetitive play may occur in which factors such as head injury, alcohol, or drugs).
themes or aspects of the traumatic event(s) are expressed. 2. Persistent and exaggerated negative beliefs or expectations
2. Recurrent distressing dreams in which the content and/or effect about oneself, others, or the world (e.g., “I am bad,” “No one
of the dream are related to the traumatic event(s). can be trusted,” “The world is completely dangerous,” “My
Note: In children, there may be frightening dreams without whole nervous system is permanently ruined”).
recognizable content. 3. Persistent, distorted cognitions about the cause or
3. Dissociative reactions (e.g., flashbacks) in which the individual consequences of the traumatic event(s) that lead the individual
feels or acts as if the traumatic event(s) were recurring. (Such to blame himself/herself or others.

Continued

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216  Part III  ◆  Behavioral and Psychiatric Disorders

Table 38.8  DSM-5 Diagnostic Criteria for Posttraumatic Stress Disorder—cont’d

4. Persistent negative emotional state (e.g., fear, horror, anger, Note: It may not be possible to ascertain that the frightening
guilt, or shame). content is related to the traumatic event.
5. Markedly diminished interest or participation in significant 3. Dissociative reactions (e.g., flashbacks) in which the child feels
activities. or acts as if the traumatic event(s) were recurring. (Such
6. Feelings of detachment or estrangement from others. reactions may occur on a continuum, with the most extreme
7. Persistent inability to experience positive emotions (e.g., expression being a complete loss of awareness of present
inability to experience happiness, satisfaction, or loving surroundings.) Such trauma-specific reenactment may occur
feelings). in play.
E. Marked alterations in arousal and reactivity associated with the 4. Intense or prolonged psychological distress at exposure to
traumatic event(s), beginning or worsening after the traumatic internal or external cues that symbolize or resemble an aspect
event(s) occurred, as evidenced by 2 (or more) of the following: of the traumatic event(s).
1. Irritable behavior and angry outbursts (with little or no C. One (or more) of the following symptoms, representing either
provocation) typically expressed by verbal or physical persistent avoidance of stimuli associated with the traumatic
aggression toward people or objects. event(s) or negative alterations in cognitions and mood associated
2. Reckless or self-destructive behavior. with the traumatic event(s), must be present, beginning after the
3. Hypervigilance. event(s) or worsening after the event(s):
4. Exaggerated startle response. Persistent Avoidance of Stimuli
5. Problems with concentration. 1. Avoidance of or efforts to avoid activities, places, or physical
6. Sleep disturbance (e.g., difficulty falling or staying asleep or reminders that arouse recollections or the traumatic event(s).
restless sleep). 2. Avoidance of or efforts to avoid people, conversations, or
F. Duration of the disturbance (Criteria B, C, D, and E) is more than interpersonal situations that around recollections of the
1 mo. traumatic event(s).
G. The disturbance causes clinically significant distress or impairment Negative Alterations in Cognitions
in social, occupational, or other important areas of functioning. 3. Substantially increased frequency of negative emotional states
H. The disturbance is not attributable to the physiologic effects of a (e.g., fear, guilt, sadness, shame, confusion).
substance (e.g., medication, alcohol) or another medical condition. 4. Markedly diminished interest or participation in significant
Specify whether: activities, including constriction of play.
With dissociative symptoms: The individual’s symptoms meet the 5. Socially withdrawn behavior.
criteria for posttraumatic stress disorder, and in addition, in 6. Persistent reduction in expression of positive emotions.
response to the stressor, the individual experiences persistent or D. Alterations in arousal and reactivity associated with the traumatic
recurrent symptoms of either of the following: event(s), beginning or worsening after the traumatic event(s)
1. Depersonalization: Persistent or recurrent experiences of occurred, as evidenced by 2 (or more) of the following:
feeling detached from, and as if one were an outside observer 1. Irritable behavior and angry outbursts (with little or no
of, one’s mental processes or body (e.g., feeling as though one provocation), typically expressed as verbal and physical
were in a dream; feeling a sense of unreality of self or body or aggression toward people or objects (including extreme temper
of time moving slowly). tantrums).
2. Derealization: Persistent or recurrent experiences of unreality of 2. Hypervigilance.
surroundings (e.g., the world around the individual is 3. Exaggerated startle response.
experienced as unreal, dreamlike, distant, or distorted). 4. Problems with concentration.
Note: To use this subtype, the dissociative symptoms must not be 5. Sleep disturbance (e.g., difficulty falling asleep or staying asleep
attributable to the physiologic effects of a substance (e.g., or restless sleep).
blackouts, behavior during alcohol intoxication) or another E. The duration of the disturbance is more than 1 mo.
medical condition (e.g., complex partial seizures). F. The disturbance causes clinically significant distress or impairment
Specify if: in relationships with parents, siblings, peers, or other caregivers or
With delayed expression: If the full diagnostic criteria are not met with school behavior.
until at least 6 mo after the event (although the onset and G. The disturbance is not attributable to the physiologic effects of a
expression of some symptoms may be immediate). substance (e.g., medication or alcohol) or another medical
condition.
POSTTRAUMATIC STRESS DISORDER FOR CHILDREN Specify whether:
6 YR AND YOUNGER With dissociative symptoms: The individual’s symptoms meet the
A. In children 6 yr and younger, exposure to actual or threatened criteria for posttraumatic stress disorder, and the individual
death, serious injury, or sexual violence in 1 (or more) of the experiences persistent or recurrent symptoms of either of the
following ways: following:
1. Directly experiencing the traumatic event(s). 1. Depersonalization: Persistent or recurrent experiences of
2. Witnessing, in person, the event(s) as it occurred to others, feeling detached from, and as if one were an outside observer
especially primary caregivers. of, one’s mental processes or body (e.g., feeling as though one
Note: Witnessing does not include events that are only in electronic were in a dream; feeling a sense of unreality of self or body or
media, television, movies, or pictures. of time moving slowly).
3. Learning that the traumatic event(s) occurred to a parent or 2. Derealization: Persistent or recurrent experiences of unreality of
caregiving figure. surroundings (e.g., the world around the individual is
B. Presence of 1 (or more) of the following intrusion symptoms experienced as unreal, dreamlike, distant, or distorted).
associated with the traumatic event(s), beginning after the Note: To use this subtype, the dissociative symptoms must not be
traumatic event(s) occurred: attributable to the physiologic effects of a substance (e.g.,
1. Recurrent, involuntary, and intrusive distressing memories of the blackouts, behavior during alcohol intoxication) or another
traumatic event(s). medical condition (e.g., complex partial seizures).
Note: Spontaneous and intrusive memories may not necessarily Specify if:
appear distressing and may be expressed as play reenactment. With delayed expression: If the full diagnostic criteria are not met
2. Recurrent distressing dreams in which the content and/or effect until at least 6 mo after the event (although the onset and
of the dream is related to the traumatic event(s). expression of some symptoms may be immediate).
From the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, pp 271–274.

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concentration, extreme startle responses, agitation, and sleep problems, The experiences of the siblings of children with chronic illness are
complete the symptom profile of PTSD. Occasionally, children regress often forgotten, with familial resources focused on medical-financial
in some of their developmental milestones after a traumatic event. consequences and the emotional and physical functioning of the ill
Avoidance symptoms are usually observable in younger children, whereas child. It is not uncommon for the siblings of ill children to experience
older children may better describe reexperiencing and hyperarousal depression and anxiety as well. Assessing their social support systems,
symptoms. Repetitive play involving the event, psychosomatic symptoms, communication opportunities with parents and emotional outlets are
and nightmares may also be observed. critical to maintaining healthy functioning. Maintaining a redefined
Initial interventions after a trauma should focus on reunification schedule of after-school activities and social engagements are helpful
with a parent and attending to the child’s physical needs in a safe place. in allowing siblings to continue in school.
Aggressive treatment of pain, and facilitating a return to comforting
routines, including regular sleep, is indicated. Long-term treatment SAFETY AND EFFICACY CONCERNS ABOUT SSRIS
may include individual, group, school-based, or family therapy, as well No empirical evidence suggests the superiority of one SSRI over another.
as pharmacotherapy, in selected cases. Individual treatment involves Data are limited on combining medications. SSRIs are usually well
transforming the child’s concept of himself or herself as victim to that tolerated by most children and adolescents. The FDA issued a “black
of survivor and can occur through play therapy, psychodynamic therapy, box” warning of increased agitation and suicidality among adolescents
or CBT. Group work is also helpful for identifying which children might and children taking SSRIs. This warning was based on review of studies
need more intensive assistance. Goals of family work include helping in children and adolescents with major depression and not anxiety
the child establish a sense of security, validating the child’s emotions, disorders. Close monitoring is always warranted.
and anticipating situations when the child will need more support from
the family. Bibliography is available at Expert Consult.
Clonidine or guanfacine may be helpful for sleep disturbance, persistent
arousal, and exaggerated startle response. Recent RCTs in children and
adolescents with PTSD found no significant difference between SSRI
and placebo. SSRIs may be considered in pediatric patients with PTSD
who have comorbid conditions responsive to SSRIs, including depression,
affective numbing, and anxiety (see Table 33.4). As for many other
anxiety disorders, CBT is the psychotherapeutic intervention with the
most empirical support.

ANXIETY ASSOCIATED WITH

MEDICAL CONDITIONS
It is prudent to rule out organic conditions such as hyperthyroidism,
caffeinism (carbonated beverages), hypoglycemia, central nervous system
disorders (delirium, encephalopathy, brain tumors), migraine, asthma,
lead poisoning, cardiac arrhythmias, and rarely, pulmonary embolism,
hyperparathyroidism, systemic lupus erythematosus, anaphylaxis,
porphyria, or pheochromocytoma, before making a diagnosis of an
anxiety disorder (see Table 38.1). Some prescription drugs with side
effects that can mimic anxiety include antiasthmatic agents, corticoster-
oids, sympathomimetics, SSRIs (initiation), anticholinergic agents, and
antipsychotics. Nonprescription drugs causing anxiety include diet pills,
antihistamines, stimulant drugs of abuse, drug withdrawal, and cold
medicines.
Chronic illness is also an underlying cause of anxiety. Children are
not often emotionally and cognitively competent to understand the
implications of a serious and prolonged illness. In addition to the
physiologic implications of illness, they must also attend to the hospi-
talizations, procedures, and medications that permeate their everyday
schedule. This experience affects their schooling, friendships, activities,
and dynamics of the nuclear family, including the experiences of their
well siblings.
School issues surrounding both prolonged absences and school reentry
following a medical condition can cause or reinforce and escalate existing
anxiety. School is a foundation not only for learning, but it is central
to children’s social experiences and feelings of normalcy. It is often
impeded and stunted by illness. Academic struggles can result from
missing classes, medication use, and emotional status. Children with
chronic conditions are also socially disadvantaged, with friendship
networks hampered by unstable attendance or social rejection for being
different. Consulting with the school psychologist can be beneficial in
preparing teachers and classmates before the child returns to school.
An agreement between the student and school staff should be imple-
mented, outlining a plan for taking medication, needing rest, or consulting
on other needs. If the child and family agree, an informational meeting
with students and teachers can normalize the situation. Explaining the
condition makes it less scary for children who catastrophize or worry
about contagion. Classmates and teachers are a natural accessible resource
and can be a valuable support community. Medication may also be
warranted to supplement social supports.

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 Chapter 38  ◆  Anxiety Disorders  217.e1

Bibliography Hirschritt ME, Bloch MH, Mathews CA: Obsessive-compulsive disorder: advances
American Psychiatric Association: Diagnostic and statistical manual of mental disorders, in diagnosis and treatment, JAMA 317(13):1358–1367, 2017.
ed 5, Washington, DC, 2013, American Psychiatric Association. Hoge EA, Ivkovic A, Fricchione GL: Generalized anxiety disorder: diagnosis and
Baldwin D, Woods R, Lawson R, et al: Efficacy of drug treatments for generalized treatment, BMJ 345:37–42, 2012.
anxiety disorder: systematic review and meta-analysis, BMJ 342:637, 2011. Kurlam R, Johnson D, Kaplan EL: Streptococcal infection and exacerbations of child-
Beidel DC, Turner SM, Sallee FR, et al: SET-C versus fluoxetine in the treatment of hood tics and obsessive-compulsive symptoms: a prospective blinded cohort study,
childhood social phobia, J Am Acad Child Adolesc Psychiatry 46:1622–1632, 2007. Pediatrics 121:1188–1197, 2008.
Bridge JA, Iyengar S, Salary CB, et al: Clinical response and risk for reported suicidal Leichsenring F, Leweke F: Social anxiety disorder, N Engl J Med 376(23):2255–2264, 2017.
ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis March JS, Franklin ME, Leonard H, et al: Tics moderate treatment outcome with
of randomized controlled trials, JAMA 297:1683–1696, 2007. sertraline but not cognitive-behavior therapy in pediatric obsessive-compulsive
Brezo J, Barker ED, Paris J, et al: Childhood trajectories of anxiousness and disruptive- disorder, Biol Psychiatry 61:344–347, 2007.
ness as predictors of suicide attempts, Arch Pediatr Adolesc Med 162:1015–1021, 2008. Muir KE, McKenney KS, Connolly MB, et al: A case report of obsessive-compulsive
Burstein M, Ameli-Grillon L, Merikangas KR: Shyness versus social phobia in US disorder following acute disseminated encephalomyelitis, Pediatrics 132:e771–e774,
youth, Pediatrics 128:917–925, 2011. 2013.
Craske MG, Stein MB: Anxiety, Lancet 388:3028–3058, 2016. Nicholson TRJ, Ferdinando S, Krishnaiah RB, et al: Prevalence of anti-basal ganglia
Dougherty LR: Tolep MR: Preschool anxiety disorders: comprehensive assessment antibodies in adult obsessive-compulsive disorder cross-sectional study, Br J
of clinical, demographic, temperamental, familial, and life stress correlates, J Clin Psychiatry 200(5):381–386, 2012.
Child Adolesc Psychol 42:577–589, 2013. Pavone P, Parano E, Rizzo R, et al: Autoimmune neuropsychiatric disorders associated
Forman-Hoffman VL, Zolotor AJ, McKeeman JL, et al: Comparative effectiveness of with streptococcal infection: sydenham chorea, PANDAS, and PANDAS variants,
interventions for children exposed to nonrelational traumatic events, Pediatrics J Child Neurol 21:727–736, 2006.
131(3):526–539, 2013. Ramsawh HJ, Chavira DA, Stein MB: Burden of anxiety disorders in pediatric medical
Franklin ME, Sapyta J, Freeman JB, et al: Cognitive behavior therapy augmentation of settings, Arch Pediatr Adolesc Med 164:965–972, 2010.
pharmacotherapy in pediatric obsessive-compulsive disorder, JAMA 306:1224–1232, Rockhill C, Kodish I, DiBattisto C, et al: Anxiety disorders in children and adolescents,
2011. Curr Probl Pediatr Adolesc Health Care 40(4):65–100, 2010.
Freeman J, Sapyta J, Garcia A, et al: Family-based treatment of early childhood Rosenberg DR, Gershon S, editors: Pharmacotherapy of child and adolescent psychiatric
obsessive-compulsive disorder. The Pediatric Obsessive-Compulsive Disorder disorders, I, ed 3, Chichester, West Sussex, UK, 2012, John Wiley & Sons, pp 1–475.
Treatment Study for Young Children (POTS Jr): a randomized clinical trial, JAMA Roy-Byrne PP, Craske MG, Stein MB: Panic disorder, Lancet 368:1023–1032, 2006.
Psychiatry 71:689–698, 2014. Scahill L, Riddle MA, McSwiggin-Hardin M, et al: Children’s Yale-Brown obsessive
Garcia AM, Sapyta JJ, Moore PS, et al: Predictors and moderators of treatment outcome compulsive scale: reliability and validity, J Am Acad Child Adolesc Psychiatry
in the Pediatric Obsessive Compulsive Treatment Study (POTS I), J Am Acad Child 36:844–852, 1997.
Adolesc Psychiatry 49:1024–1033, 2010. Shalev A, Liberzon I, Marmar C: Post-traumatic stress disorder, N Engl J Med 376(25):
Ginsburg GS, Drake KL, Tein JY, et al: Preventing onset of anxiety disorders in offspring 2459–2468, 2017.
of anxious parents: a randomized controlled trial of a family-based intervention, Stein MB, Sareen J: Generalized anxiety disorder, N Engl J Med 373(21):2059–2068, 2015.
Am J Psychiatry 172(12):1207–1214, 2015. Thirlwall K, Cooper PJ, Karalus J, et al: Treatment of child anxiety disorders via guided
Grant JE: Obsessive-compulsive disorder, N Engl J Med 371:646–652, 2014. parent-delivered cognitive-behavioural therapy: randomized controlled trial, Br J
Grant P, Lougee L, Hirschtritt M, et al: An open-label trial of riluzole, a glutamate Psychiatry 203:436–444, 2013.
antagonist, in children with treatment-resistant obsessive-compulsive disorder, Tyrer P, Baldwin D: Generalized anxiety disorder, Lancet 368:2156–2166, 2006.
J Child Adolesc Psychopharmacol 17:761–767, 2007. Veale D, Roberts A: Obsessive-compulsive disorder, BMJ 348:31–34, 2014.
Herr NR, Williams JW Jr, Benjamin S, et al: Does this patient have generalized Weersing VR, Brent DA, Rozenman MS, et al: Brief behavioral therapy for pediatric
anxiety or panic disorder? The rational clinical examination systematic review, anxiety and depression in primary care: a randomized clinical trial, JAMA Psychiatry
JAMA 312:78–84, 2014. 74(6):571–578, 2017.

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