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Anxiety Evaluation and Management

Clinical Pearls Video Series

Part 1: Assessment

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

  • What causes anxiety? How common is it? (0:13–2:51)
  • How do I differentiate normal stress from an anxiety disorder? (2:52–4:27)
  • What are common comorbidities that exist with anxiety disorders? (4:28–5:07)
  • What is the relationship between anxiety and depression? (5:08–6:28)
  • How might I distinguish anxiety from traumatic stress or PTSD? (6:29–8:26)
  • How might anxiety present in youth with intellectual disability or autism? (8:27–10:21)
  • How do I think about anxiety in the context of familial risk of anxiety? Does caregiver anxiety impact a child’s presentation of an anxiety disorder? (10:22–12:06)
  • How might anxiety disorders first present in the primary care setting, and what should I consider on the differential? (12:07–13:45)

Part 2: Management

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

  • What is the role of psychotherapy in patients with anxiety & what types of evidence-based psychotherapy are used? (0:13–2:27)
  • Are there environmental strategies or accommodations, at home or at school, that can be offered to support a child with anxiety? (2:28–5:29)
  • How do I manage anxiety when the patient also has concurrent depression? Substance use? Suicidal thoughts or behaviors? (5:30–6:54)
  • What is the role of group therapy and family therapy in managing anxiety disorders? (6:55–7:58)
  • Should I start with medications, therapy, or both? (7:59–9:16)
  • What medications may be considered to manage anxiety? How are they started and managed over time? What side effects should I be monitoring? (9:17–11:54)
  • What other medications might be utilized to manage anxiety if there is partial or no response to an SSRI? (11:55–14:48)
  • What is an effective strategy for choosing a medication for a specific patient? (14:49–17:27)
  • Key Takeaways (17:28–18:56)
Emily Bilek

Emily Bilek, Ph.D., Child Psychologist, University of Michigan

Jessica Pierce

Jessica Pierce, M.D., M.Sc., Child & Adolescent Psychiatrist, University of Michigan

Anxiety is an evolutionarily conserved threat-response which gets triggered by perceived or future-oriented threats. When anxiety is pervasive across settings and functionally impairing, it may meet criteria for an anxiety disorder. An estimated 10–15% of youth under age 18 have an anxiety disorder, with the most common types being Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder.

When avoidance causes impairment or when “emotional avoidance” behaviors emerge (such as excessive screen use, acting out, self-harm, or substance use), anxiety should be evaluated. Screening tools including SCARED and GAD-7 can support assessment. Common comorbidities include depressive disorders, OCD, trauma-related disorders, ADHD, Autism Spectrum Disorder, and substance use. Psychotherapy, particularly Cognitive Behavioral Therapy, is the first-line treatment for anxiety in youth, with exposure-based interventions being the most effective component for reducing avoidance and increasing functioning. When symptoms are severe or psychotherapy access is limited, medication such as SSRIs may be added.

Resources

Steinsbekk, S., Ranum, B., & Wichstrøm, L. (2022). Prevalence and course of anxiety disorders and symptoms from preschool to adolescence: A 6‐wave community study. Journal of Child Psychology and Psychiatry, 63(5), 527–534. https://doi.org/10.1111/jcpp.13487

Effective Child Therapy: Evidence-based mental health treatment for children and adolescents. From the Society of Clinical Child and Adolescent Psychology. https://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/fear-worry-and-anxiety/

Wolitzky-Taylor, K., Zimmermann, M., Arch, J. J., De Guzman, E., & Lagomasino, I. (2015). Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings? Behaviour Research and Therapy, 72, 9–17. https://doi.org/10.1016/j.brat.2015.06.010

Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, Ripperger-Suhler J, Rockhill C. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry. 2020 Oct;59(10):1107-1124. doi: 10.1016/j.jaac.2020.05.005. Epub 2020 May 18. PMID: 32439401.

Melton TH, Croarkin PE, Strawn JR, McClintock SM. Comorbid Anxiety and Depressive Symptoms in Children and Adolescents: A Systematic Review and Analysis. J Psychiatr Pract. 2016 Mar;22(2):84-98. doi: 10.1097/PRA.0000000000000132. PMID: 27138077; PMCID: PMC6267783.

Spinhoven P, Penninx BW, van Hemert AM, de Rooij M, Elzinga BM. Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors. Child Abuse Negl. 2014 Aug;38(8):1320-30. doi: 10.1016/j.chiabu.2014.01.017. Epub 2014 Mar 13. PMID: 24629482.

Green SA, Berkovits LD, Baker BL. Symptoms and development of anxiety in children with or without intellectual disability. J Clin Child Adolesc Psychol. 2015;44(1):137-44. doi: 10.1080/15374416.2013.873979. Epub 2014 Feb 14. PMID: 24528099; PMCID: PMC4133315.

Vasa RA, Mazurek MO, Mahajan R, Bennett AE, Bernal MP, Nozzolillo AA, Arnold LE, Coury DL. Assessment and Treatment of Anxiety in Youth With Autism Spectrum Disorders. Pediatrics. 2016 Feb;137 Suppl 2:S115-23. doi: 10.1542/peds.2015-2851J. PMID: 26908467.

Eley TC, McAdams TA, Rijsdijk FV, Lichtenstein P, Narusyte J, Reiss D, Spotts EL, Ganiban JM, Neiderhiser JM. The Intergenerational Transmission of Anxiety: A Children-of-Twins Study. Am J Psychiatry. 2015 Jul;172(7):630-7. doi: 10.1176/appi.ajp.2015.14070818. Epub 2015 Apr 23. PMID: 25906669; PMCID: PMC8515953.

American Academy of Child and Adolescent Psychiatry. “Anxiety: Parents’ Medication Guide.” https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/resources/med_guides/anxiety-parents-medication-guide.pdf  

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

/5

Anxiety Quiz

1. Which anxiety disorder is characterized by a marked fear of performance situations or negative evaluation by others?

2. Which symptom is often the first apparent indication of anxiety in children presenting to primary care?

3. What is the most common comorbid mental health disorder with anxiety in youth?

4. A patient takes a therapeutic dose of fluoxetine for over 6 months with no clear benefit but no obvious adverse effects. The patient is well engaged with a CBT therapist. What is the best next step in medication management?

5. What behaviors are associated with maintaining anxiety in youth?

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