Clinical Care Guideline: Generalized Anxiety Disorder (GAD) in Children and Adolescents

Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. (5) This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of GAD in children/adolescents. 

Diagnostic Considerations for GAD in Children/Adolescents

Over the past 6 months (or longer), has your patient been experiencing the following for at least 6 months:

• Excessive anxiety and worry about a number of different things? 
• Is it difficult for the client to control the worry?
• As a result of the anxiety and worry, does the patient experience at least 3 symptoms such as:
  • Feeling restless or often “on edge”
  • Irritability
  • Muscle tension
  • Sleep difficulties
  • Trouble concentrating 
  • Easily fatigued
• Has the anxiety, worry, and/or physical symptoms negatively impacted the patient’s ability to function in important areas of life, such as relationships, work, and school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc.)?

It’s important to note that the above symptoms and experiences may also be attributable to an alternate disorder such as OCD, separation anxiety, somatization disorder, a neurological cause, a medical condition, medication side effect (bronchodilators, steroids, stimulants, dietary supplements), or the direct physiologic effects of a substance (caffeine, nicotine, drugs of abuse). Please evaluate for potential underlying causes and document a thorough history and assessment of your HPI.

For complete diagnostic criteria of Generalized Anxiety Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787.

When documenting care, be sure to include the specific symptoms of GAD experienced by the patient in your HPI. This ensures your note reflects alignment between the diagnosis and the DSM-5 criteria for the condition.

Symptom Screening and Monitoring

The GAD-7 (Generalized Anxiety Disorder - 7 item) is a brief validated, patient self-report screening tool used to assess the frequency and severity of anxiety symptoms. Please use this MIC tool to monitor your patient’s progress. The GAD-7 is appropriate for adolescents; however, if you are seeing younger patients or would like to use an alternative screening tool SCARED is an appropriate alternative.

Routine use of these measures is foundational to providing effective care for individuals who experience anxiety, as it supports accurate diagnoses, identification of treatment plan goals based on symptom severity, and can guide effective clinical interventions.

Evidence-Based Approaches to Treatment 

Research demonstrates that children and adolescents with GAD can be effectively treated through psychotherapy, medication management, or a combination of the two. Evidence suggests that utilizing medication as a complementary approach alongside therapy is likely more effective than either treatment alone. (2)

Medication

There are two FDA-approved medications to treat GAD in children/adolescents. The two are shown below out of two classes of medication: selective serotonin reuptake inhibitors (SSRIs)  and selective norepinephrine reuptake inhibitors (SNRIs) specifically Duloxetine They are approved by the U.S. Food and Drug Administration (FDA) for this indication. (2)  Here is a brief summary of FDA-approved SSRIs in children and adolescents.

• Escitalopram (Lexapro) - FDA approval for 7+ in GAD
• Duloxetine (Cymbalta) - FDA approval for 7+ in GAD

In children/adolescents, we may use other SSRIs or SNRIs to help treat anxiety symptoms. However, these are not FDA-approved for GAD in children/adolescents so we must make the patient and legal guardian aware of off-label prescribing. The research is limited to SSRIs and children/adolescents with various anxiety disorders; however, many of these medications are safe and effective according to numerous studies.  Some examples that could be used include but are not limited to:

• Fluoxetine (Prozac) - FDA approval for 7+ in OCD
• Sertraline (Zoloft) - FDA approval for 6+ in OCD

Avoid prescribing benzodiazepines (ex. alprazolam, clonazepam, lorazepam) whenever possible due to concerns for abuse and/or dependence. These medications are not approved for children/adolescents. 

Remember to start low and go slow with medications in children/adolescents.  If you are going to use a medication that is considered ‘off label’ for children/adolescents make sure to document that this was discussed with a legal guardian and that treatment was consented to.

It is important to discuss/document the SSRI FDA black box warning for all patients aged 24 years or younger. The Food and Drug Administration (FDA) requires a "black box" warning that antidepressant medications may sometimes increase suicidal ideation in children, adolescents, and young adults (aged 18–24) during initial treatment (generally the first 1–2 months) and at times of dose changes.   Families and caregivers of patients being treated with antidepressants should be alerted about the need to monitor patients daily for the emergence of agitation, irritability, and unusual changes in behavior.  Note: The overall rate of suicidal ideation is lower in patients treated with antidepressants compared to those given placebo, and this should be considered when discussing the risks and benefits of antidepressant therapy.

Psychotherapy

Cognitive behavior therapy (CBT) is the most well-studied and effective form of psychotherapy to treat GAD. (1) Common evidence-based CBT interventions include: (5)

• Psychoeducation
• Thought Monitoring 
• Cognitive Restructuring 
• Relaxation, Mindfulness, and Grounding
• Exposure
• Behavior modification 

You can assist your patient to get connected with a Rula therapist by reaching out to our VA support team through AMD or you can provide your patient with this link during your session so they can browse individual therapists on their own.

Assessing Risk and Higher Level of Care Needs

It is important for providers to engage in (and document) regular assessment of risk, complete a safety plan (if applicable), and evaluate the need for additional services (such as IOP, PHP, Group therapy, etc) as clinically indicated. 

If your patient does not seem to be improving with the interventions you are providing (within a reasonable amount of time) or if they are decompensating, consider consulting a clinical colleague or placing a referral for additional interventions as needed. 

Rula’s team of care coordinators can help provide your patient with information regarding IOP/PHP and neuropsych referrals. Use this Care Coordination request form found in AMD under “web links” to request assistance with an HLOC referral for your patient.

Cultural Considerations

The expression of anxiety symptoms is often influenced by cultural contexts, including perceptions of illness and symptoms (including their causes), ideas related to shame and what shaming is, gender and racial identification, what life experiences are considered typical in a particular cultural environment as well as whether a person's response to those stimuli is considered “unreasonable” or “excessive”. (7)  As a result, it is important to always consider the social and cultural contexts of a client's treatment needs as part of the diagnostic process. 

“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.” (8)

Resources:

• Parent's Medication Guide
• Anxiety resource for patients and parents
• Using Medications Without FDA Approval - Child Mind Institute

References

1. Child Mind Institute https://childmind.org/article/generalized-anxiety-disorder-in-kids/#treatment-options

2. American Academy of Child and Adolescent Psychiatry https://www.jaacap.org/action/showPdf?pii=S0890-8567%2820%2930280-X

3. Journal of Clinical Psychiatry. https://www.psychiatrist.com/wp-content/uploads/2021/02/18304_treating-generalized-anxiety-disorder-cognitive-behavioral.pdf 

4. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders

5. American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2022/1200/anxiety-disorders-children-adolescents.html

6. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

7. National Institute of Health.  Hofmann SG, Anu Asnaani MA, Hinton DE. Cultural aspects in social anxiety and social anxiety disorder. Depress Anxiety. 2010 Dec;27(12):1117-27. https://doi.org/10.1002/da.20759

8. National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/ 

9. ECRI Guidelines Trust. Guidelines.ecri.org. (n.d.). https://guidelines.ecri.org/ 

Updated August 13, 2024 17:19