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Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course

Shannon Bennett, PhD
John T Walkup, MD
Section Editor
David Brent, MD
Deputy Editor
Richard Hermann, MD


Worries and fears are a natural and adaptive part of childhood development. Anxiety and fear meet the criteria for a clinical anxiety disorder when the concerns are persistent and excessive, causing notable distress or impairment in day-to-day life.

Anxiety disorders are the most common childhood-onset psychiatric disorders. Anxiety disorders in children (up to 12 years old) and adolescents (13 to 18 years old) are associated with educational underachievement and co-occurring psychiatric conditions, as well as functional impairments that can extend into adulthood.

This topic describes the epidemiology, pathogenesis, clinical manifestations, and course of anxiety disorders in children and adolescents. Assessment and diagnosis of anxiety disorders in children and adolescents are discussed separately. Pharmacotherapy and psychotherapy for anxiety disorders in children and adolescents are also discussed separately. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis" and "Pharmacotherapy for anxiety disorders in children and adolescents" and "Psychotherapy for anxiety disorders in children and adolescents".)


The DSM-5 includes seven anxiety disorders seen in children [1]. The diagnosis of these disorders in children is discussed below; their epidemiology, pathogenesis, clinical manifestations, course and diagnosis in adults are described separately. (See "Anxiety disorders in children and adolescents: Assessment and diagnosis", section on 'Assessment'.)

Generalized anxiety disorder (See 'Generalized anxiety disorder' below and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

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Literature review current through: Dec 2017. | This topic last updated: Jan 20, 2016.
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  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Achenbach TM, Howell CT, McConaughy SH, Stanger C. Six-year predictors of problems in a national sample of children and youth: I. Cross-informant syndromes. J Am Acad Child Adolesc Psychiatry 1995; 34:336.
  3. Kessler RC, Avenevoli S, Costello EJ, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry 2012; 69:372.
  4. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2010; 49:980.
  5. Costello EJ, Angold A, Burns BJ, et al. The Great Smoky Mountains Study of Youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Arch Gen Psychiatry 1996; 53:1129.
  6. Birmaher B, Ollendick TH. Childhood-onset panic disorder. In: Phobic and Anxiety Disorders in Children and Adolescents, Ollendick TH, March JS (Eds), Oxford University Press, New York 2004.
  7. Ollendick TH. Panic disorder in children and adolescents: new developments, new directions. J Clin Child Psychol 1998; 27:234.
  8. Essau CA, Conradt J, Petermann F. Frequency of panic attacks and panic disorder in adolescents. Depress Anxiety 1999; 9:19.
  9. Birmaher B, Ollendick TH, March JS. Childhood-onset panic disorder. In: Phobic and Anxiety Disorders in Children and Adolescents, Ollendick TH, March JS (Eds), 2004.
  10. Wittchen HU, Nocon A, Beesdo K, et al. Agoraphobia and panic. Prospective-longitudinal relations suggest a rethinking of diagnostic concepts. Psychother Psychosom 2008; 77:147.
  11. Shear K, Jin R, Ruscio AM, et al. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163:1074.
  12. Bergman RL, Piacentini J, McCracken JT. Prevalence and description of selective mutism in a school-based sample. J Am Acad Child Adolesc Psychiatry 2002; 41:938.
  13. Kearney CA, Albano AM. The functional profiles of school refusal behavior. Diagnostic aspects. Behav Modif 2004; 28:147.
  14. Kearney CA. School absenteeism and school refusal behavior in youth: a contemporary review. Clin Psychol Rev 2008; 28:451.
  15. King NJ, Ollendickm TH, Tonge B. School Refusal: Assessment and Treatment, Allyn and Bacon, Boston, MA 1995.
  16. Copeland WE, Angold A, Shanahan L, Costello EJ. Longitudinal patterns of anxiety from childhood to adulthood: the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry 2014; 53:21.
  17. Compton SN, Walkup JT, Albano AM, et al. Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health 2010; 4:1.
  18. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 2008; 359:2753.
  19. Costello EJ, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 2003; 60:837.
  20. Kendall PC, Brady EU, Verduin TL. Comorbidity in childhood anxiety disorders and treatment outcome. J Am Acad Child Adolesc Psychiatry 2001; 40:787.
  21. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry 1999; 40:57.
  22. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol 2005; 56:235.
  23. Kagen J. Galen’s Prophecy: Temperament in human nature, Basic Books, New York 1994.
  24. Biederman J, Rosenbaum JF, Bolduc-Murphy EA, et al. A 3-year follow-up of children with and without behavioral inhibition. J Am Acad Child Adolesc Psychiatry 1993; 32:814.
  25. Pérez-Edgar K, Fox NA. Temperament and anxiety disorders. Child Adolesc Psychiatr Clin N Am 2005; 14:681.
  26. Rapee RM. Preschool environment and temperament as predictors of social and nonsocial anxiety disorders in middle adolescence. J Am Acad Child Adolesc Psychiatry 2014; 53:320.
  27. Bar-Haim Y, Lamy D, Pergamin L, et al. Threat-related attentional bias in anxious and nonanxious individuals: a meta-analytic study. Psychol Bull 2007; 133:1.
  28. Ranta K, Tuomisto MT, Kaltiala-Heino R, et al. Cognition, imagery and coping among adolescents with social anxiety and phobia: testing the Clark and Wells model in the population. Clin Psychol Psychother 2014; 21:252.
  29. LeDoux JE. Emotion circuits in the brain. Annu Rev Neurosci 2000; 23:155.
  30. Phelps EA. Emotion and cognition: insights from studies of the human amygdala. Annu Rev Psychol 2006; 57:27.
  31. Casey BJ, Ruberry EJ, Libby V, et al. Transitional and translational studies of risk for anxiety. Depress Anxiety 2011; 28:18.
  32. Caouette JD, Guyer AE. Gaining insight into adolescent vulnerability for social anxiety from developmental cognitive neuroscience. Dev Cogn Neurosci 2014; 8:65.
  33. Xu K, Ernst M, Goldman D. Imaging genomics applied to anxiety, stress response, and resiliency. Neuroinformatics 2006; 4:51.
  34. Klumpp H, Fitzgerald DA, Cook E, et al. Serotonin transporter gene alters insula activity to threat in social anxiety disorder. Neuroreport 2014; 25:926.
  35. Merikangas KR, Lieb R, Wittchen HU, Avenevoli S. Family and high-risk studies of social anxiety disorder. Acta Psychiatr Scand Suppl 2003; :28.
  36. Black DW, Gaffney GR, Schlosser S, Gabel J. Children of parents with obsessive-compulsive disorder -- a 2-year follow-up study. Acta Psychiatr Scand 2003; 107:305.
  37. Eley TC, Gregory AM. Behavioral genetics: Anxiety disorders in children and adolescents., Guilford Press, New York 2004.
  38. Trzaskowski M, Eley TC, Davis OS, et al. First genome-wide association study on anxiety-related behaviours in childhood. PLoS One 2013; 8:e58676.
  39. Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry 2001; 158:1568.
  40. Scaini S, Belotti R, Ogliari A. Genetic and environmental contributions to social anxiety across different ages: a meta-analytic approach to twin data. J Anxiety Disord 2014; 28:650.
  41. Kendler KS, Gardner CO, Lichtenstein P. A developmental twin study of symptoms of anxiety and depression: evidence for genetic innovation and attenuation. Psychol Med 2008; 38:1567.
  42. Rutter M, Moffitt TE, Caspi A. Gene-environment interplay and psychopathology: multiple varieties but real effects. J Child Psychol Psychiatry 2006; 47:226.
  43. Binder EB. The genetic basis of mood and anxiety disorders - changing paradigms. Biol Mood Anxiety Disord 2012; 2:17.
  44. Wilson J, Markie D, Fitches A. Analysis of associations for candidate genes with anxiety disorders. Psychiatry Res 2011; 189:324.
  45. Smoller JW, Yamaki LH, Fagerness JA, et al. The corticotropin-releasing hormone gene and behavioral inhibition in children at risk for panic disorder. Biol Psychiatry 2005; 57:1485.
  46. Soliman F, Glatt CE, Bath KG, et al. A genetic variant BDNF polymorphism alters extinction learning in both mouse and human. Science 2010; 327:863.
  47. Barlow DH. Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. Am Psychol 2000; 55:1247.
  48. Barlow DH. Anxiety and Its Disorders: The nature and treatment of anxiety and panic, 2nd ed., Guilford, Philadelphia, PA 2002.
  49. Mineka S, Cook M, Miller S. Fear conditioned with escapable and inescapable shock: Effects of a feedback stimulus. J Exp Psychol Anim Behav Process 1984; 10:307.
  50. Mineka S, Kihlstrom JF. Unpredictable and uncontrollable events: a new perspective on experimental neurosis. J Abnorm Psychol 1978; 87:256.
  51. Coplan JD, Paunica AD, Rosenblum LA. Neuropsychobiology of the variable foraging demand paradigm in nonhuman primates. In: Fear and Anxiety: The benefits of translational research, Gorman JM (Ed), American Psychiatric Publishing, Washington DC 2004.
  52. Coplan JD, Rosenblum LA, Gorman JM. Primate models of anxiety. Longitudinal perspectives. Psychiatr Clin North Am 1995; 18:727.
  53. Eley TC, McAdams TA, Rijsdijk FV, et al. The Intergenerational Transmission of Anxiety: A Children-of-Twins Study. Am J Psychiatry 2015; 172:630.
  54. Dadds MR. A brief parent-focused intervention reduces anxiety disorders in socially inhibited children. Evid Based Ment Health 2011; 14:49.
  55. Asselmann E, Wittchen HU, Lieb R, Beesdo-Baum K. The role of the mother-child relationship for anxiety disorders and depression: results from a prospective-longitudinal study in adolescents and their mothers. Eur Child Adolesc Psychiatry 2015; 24:451.
  56. Moller EL, Majdandzic M, Vriends N, Bogels SM. Social referencing and child anxiety: The evolutionary based role of fathers/versus mothers’ signals. J Child Fam Stud 2014; 23:1268.
  57. Borelli JL, Rasmussen HF, St. John HK, et al. Parent reactivity and the link between parent and child anxiety symptoms. J Child Fam Stud 2015; 24:3130.
  58. Bruce LC, Heimberg RG, Goldin PR, Gross JJ. Childhood maltreatment and response to cognitive behavioral therapy among individuals with social anxiety disorder. Depress Anxiety 2013; 30:662.
  59. Kuo JR, Goldin PR, Werner K, et al. Childhood trauma and current psychological functioning in adults with social anxiety disorder. J Anxiety Disord 2011; 25:467.
  60. Ollendick TH, Vasey MW, King NJ. Operant conditioning influences in childhood anxiety. In: The Developmental Psychopathology of Anxiety, Vasey MW, Dadds MR (Eds), Oxford University Press, New York 2001. p.231.
  61. Equit M, Pälmke M, Becker N, et al. Eating problems in young children -- a population-based study. Acta Paediatr 2013; 102:149.
  62. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th, text revision, American Psychiatric Association, Washington, DC 2000.
  63. Garcia AM, Freeman JB, Francis G, et al. Selective mutism. In: Phobic and Anxiety Disorders in Children and Adolescents: A clinician’s guide to effective psychosocial and pharmacological interventions, Ollendick TH, March JS (Eds), Oxford University Press, New York 2004.
  64. Ressler KJ, Rothbaum BO, Tannenbaum L, et al. Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear. Arch Gen Psychiatry 2004; 61:1136.
  65. Ollendick TH, Mayer JA. School phobia. In: Behavioral Theories and Treatment of Anxiety, Plenum Press, New York 1984.
  66. Rapee RM, Schniering CA, Hudson JL. Anxiety disorders during childhood and adolescence: origins and treatment. Annu Rev Clin Psychol 2009; 5:311.
  67. Woodward LJ, Fergusson DM. Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry 2001; 40:1086.
  68. Pine DS, Cohen P, Gurley D, et al. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 1998; 55:56.
  69. Kaplow JB, Curran PJ, Angold A, Costello EJ. The prospective relation between dimensions of anxiety and the initiation of adolescent alcohol use. J Clin Child Psychol 2001; 30:316.
  70. Boden JM, Fergusson DM, Horwood LJ. Anxiety disorders and suicidal behaviours in adolescence and young adulthood: findings from a longitudinal study. Psychol Med 2007; 37:431.
  71. Kendall PC, Compton SN, Walkup JT, et al. Clinical characteristics of anxiety disordered youth. J Anxiety Disord 2010; 24:360.
  72. Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch Pediatr Adolesc Med 2010; 164:965.
  73. Bittner A, Egger HL, Erkanli A, et al. What do childhood anxiety disorders predict? J Child Psychol Psychiatry 2007; 48:1174.
  74. Kossowsky J, Pfaltz MC, Schneider S, et al. The separation anxiety hypothesis of panic disorder revisited: a meta-analysis. Am J Psychiatry 2013; 170:768.
  75. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2635.