Management of Anxiety in the Pediatric Population


Since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

At the 2020 Virtual Conference on Pediatric Health Care, Susan Van Cleve, DNP, RN, CPNP-PC, PMHS, FAANP, FAAN, discussed identifying and treating anxiety in children and teens, especially in relation to the high incidence of comorbidity in that population.

According to Van Cleve, approximately 15% to 20% of children and teens in the United States suffer from either a mental, emotional, or behavioral disorder. Of that population, 3 of 4 children aged 3 to 17 years who have depression also have anxiety (73.8%), while approximately 1 of 3 children in that age range have behavior problems (37.9%), and depression (32.3%).

“There's so much comorbidity in terms of children and teens who have either depression with anxiety or ADHD, mostly inattentive ADHD, and anxiety, that it really requires that the clinician conduct a comprehensive assessment and evaluation for all these different disorders so that we don't miss a disorder,” said Van Cleve, in an interview with Contemporary Clinic.

Van Cleve explained that since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

“Diagnosis of anxiety requires a fair amount of time. It requires asking a lot of questions and getting information from teachers, parents, kids, the children themselves, as well as looking at their symptoms, and how much those symptoms are interfering with the child’s functioning. We then need to come up with an appropriate diagnosis and treatment plan,” Van Cleve said.

Van Cleve explained that a key term in this evaluation process is the functional impairment of the child in relation to their symptoms. Functional impairment, which occurs when a child does not function in a typical way for his or her age, is a major criteria when considering whether to look into an issue that a child or teen may be having because without that element, a diagnosis of anxiety may not be helpful or relevant.

“So, if a child comes to us with a complaint of inattention in school and we go through our whole evaluation process and determine that the child may have inattentive ADHD but also anxiety, we have to decide what treatment is going to be appropriate because that diagnosis will affect the treatment, and so by doing a thorough evaluation and really looking at the symptoms that are interfering with that child's level of functioning, we can choose the appropriate treatment plan,” Van Cleve said.

She explained further that many times in her practice, she will sit down with parents and children to see what is causing the most harm in the child’s life right now: Is it the anxiety, or is it the inattentive ADHD? Once those needs are made clear by the parent and the child, they are able to determine an appropriate treatment plan based on the right diagnosis.

Screening tools also are a critical tool available for diagnosis of children and teens due to the tools’ ability to provide objectivity, according to Van Cleve. They allow providers the opportunity to hear from people that are not present during the visit, such as a teacher, a daycare worker, a counselor, or a therapist. Furthermore, screening tools allow children to self-report their symptoms in order to inform the provider of exactly what their feeling and their struggles.

“The use of screening tools when diagnosing a child is invaluable, and I really think that we should recommend their use for every practice when screening for depression and anxiety. We screen for all kinds of behavioral issues with our patients; it's very important.”

From this point of diagnosis, since children’s brains are more pliable than adults, Van Cleve explained that children often respond very well to treatment. She added that currently, the strongest evidence-based treatment option available is cognitive behavioral therapy (CBT). CBT is able to act as a method for cognitive restructuring that allows children to change how they think about their lives, how they behave, and how they feel about themselves and their behaviors.

“It's very interesting. Cognitive behavioral therapy does work and children's brains are very pliable, so it's a wonderful thing to see when children can learn these skills and really reframe how they think about things,” Van Cleve said.

Since the FDA has not yet approved any drugs for anxiety in children and teens, CBT is the first option when treating patients, as any pharmaceutical treatments available for children are off-label, according to Van Cleve. She explained that CBT acts either as an adjunct to be used with medication or a treatment before medication is considered.

Van Cleve added that one of the benefits of approaching medication cautiously is the opportunity to build trust with the parents of the child, as they will feel that the provider is not just throwing a medication at a child’s issue.

“I think we have to use medication really carefully,” Van Cleve said. “We have to start at low doses, we have to go slowly, and we need to include the family as part of the decision-making, and as we progress with dosages.”


Van Cleve S. Worrying, Fear and Angst: How to Identify and Treat Anxiety in Children and Teens. Presented at: 2020 Virtual Conference on Pediatric Health Care; June 4 – 6, 2020; virtual. Accessed June 11, 2020.

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