Pediatric anxiety disorders: screening, criteria, CBT and SSRIs

Main decision tree

Anxiety in school-age children and teens: which fear?

Key points

USPSTF 2022: screen all children and teens aged 8–18 years for anxiety (for example SCARED or GAD-7).
First-line treatment for every anxiety disorder: CBT with graded exposure.
Moderate–severe anxiety or poor CBT response: add an SSRI; CBT plus an SSRI works best.
After response, continue the medicine 6–12 months, then taper; avoid benzodiazepines.
Duration: separation anxiety ≥4 weeks; GAD, social anxiety and specific phobia ≥6 months.
GAD in children needs only 1 physical symptom (adults need 3).
Selective mutism: silent outside home for >1 month, not counting the first month of school.

Screening and the general approach

Anxiety disorders are the most common mental health problems in adolescents. The USPSTF recommends screening all children and teens aged 8–18 years, even with no complaints, using a tool such as SCARED or GAD-7. A positive screen is followed by an interview.

Rule out medical causes and substances that mimic anxiety, such as hyperthyroidism, caffeine and stimulants. Then ask what the fear is about: that decides the diagnosis.

First-line: CBT, built on gradual exposure to the feared situation.
Add an SSRI for moderate–severe symptoms or when CBT alone is not enough.
Benzodiazepines are not recommended for childhood anxiety disorders.

Generalized anxiety disorder

Decision tree: Generalized anxiety: management — Generalized anxiety: management · from Pedemy's flashcards. Tap to open full size.

Many everyday worries (school, health, family money) on most days for ≥6 months.
The worry is hard to control.
Children need only 1 associated symptom, such as poor sleep, restlessness, fatigue, poor focus, irritability or muscle tension.
Moderate–severe GAD: CBT plus an SSRI; the combination works better than either alone.
FDA-approved for pediatric GAD from age 7: escitalopram and duloxetine (an SNRI).
After response, continue 6–12 months, then taper slowly.
Venlafaxine (an SNRI) is used after 2 SSRI trials have failed.

Decision tree: Social anxiety disorder — Social anxiety disorder · from Pedemy's flashcards. Tap to open full size.

	Social anxiety disorder	Panic disorder
Core fear	Being judged or embarrassed	Sudden, unexpected panic attacks (racing heart, fear of dying)
Key detail	Occurs with peers, not only with adults; avoids class talks, cafeteria, parties	≥1 month of worry about the next attack or avoidance after it
Duration	≥6 months	Recurrent attacks plus ≥1 month of worry
Before diagnosing	Fine at home with family	Normal ECG and TSH; no drugs or caffeine
Treatment	CBT with exposure; SSRI if moderate–severe	CBT; SSRI if moderate–severe

Separation anxiety disorder

Decision tree: Anxiety in young children: separation anxiety — Anxiety in young children: separation anxiety · from Pedemy's flashcards. Tap to open full size.

Excessive fear of losing or being apart from a caregiver: worry that the parent will die or be hurt, or that the child will be lost or kidnapped.
Signs: school refusal, refusing sleepovers or sleeping alone, nightmares about separation, morning stomachaches or vomiting.
Duration: at least 4 weeks in children.
Strongest family risk factor: a parent with an anxiety disorder, especially with overprotective, accommodating parenting; family conflict also adds risk.

Treating separation anxiety

Decision tree: Separation anxiety: management — Separation anxiety: management · from Pedemy's flashcards. Tap to open full size.

CBT first. The exposure ladder practices stepwise, manageable separations from the caregiver.
Keep the child in school. Homeschooling or staying home keeps the avoidance going and prolongs impairment.
Parents should stop accommodating (for example, picking the child up whenever worried texts arrive); accommodation raises anxiety and blunts treatment response.
Treat the parent's own anxiety.
Add an SSRI for moderate–severe symptoms or when CBT is not enough.

Specific phobia and selective mutism

Decision tree: Anxiety in young children: specific phobia — Anxiety in young children: specific phobia · from Pedemy's flashcards. Tap to open full size.

	Specific phobia	Selective mutism
Picture	Fear of one object or situation (dogs, storms), out of proportion, with avoidance	Speaks normally at home but not at school or with others
Duration	≥6 months	>1 month; the first month of school does not count
Check first	Fear is beyond the real danger, not a normal developmental fear	Hearing and language are normal
Treatment	CBT with graded exposure	CBT with graded speaking tasks, a school plan; SSRI if severe

Common questions

At what age should children be screened for anxiety?

The USPSTF recommends anxiety screening for children and teens aged 8–18 years, even without symptoms.

What is the first-line treatment for anxiety in children?

Cognitive behavioral therapy with gradual exposure. An SSRI is added for moderate to severe symptoms or a poor response to CBT.

How long should an SSRI be continued for childhood anxiety?

Usually 6–12 months after a good response, then a slow taper.

Study this topic

Flashcards and practice questions Mental Health topics Tool: Childhood anxiety — notes Tool: Separation anxiety — notes For parents: Childhood anxiety

Sources

Written for Pedemy in our own words from the sources above; checked November 2026. For education only, not medical advice; check doses and local protocols before treating a patient. Pedemy is independent and not affiliated with or endorsed by the organizations cited.

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