Generalized Anxiety Disorder in Kids

For a lot of kids with anxiety, excessive worry is triggered by a specific situation, such as being away from their parents, public speaking, heights or a scary animal. But kids who worry excessively about numerous things may have generalized anxiety disorder.

Generalized anxiety disorder (GAD) is characterized as constant worry about lots of different things that aren’t really threats and/or overreacting to minor threats. It’s the most common type of anxiety disorder among children and teens.

Unlike with a phobia, which has a specific trigger — spiders, needles, dogs, airplanes, clowns, etc. — children with GAD worry about a variety of everyday situations.

“Kids with generalized anxiety disorder worry about all the same things that other kids worry about,” says Emily Gerber, PhD, a clinical psychologist, “but they worry more often and more intensely.”

There doesn’t even necessarily have to be anything that triggers it, adds Dr. Gerber. “It’s sort of always  there.”

“Kids with GAD are chronic worriers,” says Jerry Bubrick, PhD, a senior clinical psychologist at the Child Mind Institute. “There’s no area that they don’t worry about, but the typical areas of worry are usually around health of themselves or their family, money, and safety and stability.”

Kids with GAD worry about the “what ifs,” adds Dr. Bubrick.

“What if we run out of gas?”

“What if mom loses her job?”

“What if a hurricane blows away our house?”

“What if I get a bad grade?”

They tend to imagine the worst happening, and seek reassurance from parents that it won’t.

Dr. Bubrick has seen kids, for example, who are super worried if a big storm is coming in. Then, if nothing bad happens, they’re worried about another storm coming. What if we’re not as prepared next time? They’re glued to the weather reports with excessive worry.

Dr. Gerber describes a child who developed GAD during the pandemic. “His aunt was in the ICU for a while during COVID, and so he started to become overly concerned about everybody around him,” she says. “He was constantly asking, ‘Are they going to be OK?’ and didn’t want anyone to go out because he was so worried they would get sick.”

Other signs of GAD in children and teens include:

• Restlessness or feeling on edge
• Apprehensiveness
• Indecisiveness
• Being easily fatigued, especially at the end of the school day
• Irritability
• Trouble sleeping
• Difficulty concentrating or feeling their mind go “blank”
• Catastrophizing or always expecting the worst

Most kids feel anxious about their performance in school from time to time and may worry about an upcoming test or presentation. A child with GAD, however, is likely to take that worry to an extreme, and study obsessively even though they already know the material.

“There’s one 9-year-old in particular I’m thinking of whose parents are very ambitious and so he only wants to get A-pluses at school,” Dr. Gerber says. “He has this terrible fear that if he submits an assignment and it’s anything less than perfect, his life is going to be ruined. As a result, he’s developed some avoidant behaviors. He either is distressed or he’s so avoidant that he completely forgets about the assignment.”

Dr. Bubrick adds that some kids with GAD are such perfectionists that they don’t want to do anything unless they can be the best at it. “They will think, ‘If I can’t be the best at something, then why try? If I can’t be a rock star, then why take guitar lessons?’ “

They may have anxious stomachaches and headaches and spend a lot of time in the school nurse’s office.

GAD can develop in children as early as 5 but is most frequently diagnosed in adolescents. It tends to affect girls more than boys, but all genders can develop the disorder. Kids with sensitive temperaments are more likely than others to develop generalized anxiety.

The largest predictor of GAD in children and teens is family history. Kids who have one parent with any kind of anxiety disorder are more likely to have generalized anxiety than other kids; those with two parents with anxiety are significantly more at risk. Experts believe the risk stems from a combination of biology and learned behaviors — seeing how a parent deals with stress and worry and emulating that behavior.

And if there’s one thing kids today have an abundance of, it’s stress. Rates of anxiety had already been on the rise when COVID-19 hit the U.S. in March 2020. The pandemic accelerated the development of the disorder in many young people. Between 2016 and 2020, anxiety rates among kids had increased from 7.1% to 9.2%, according to a study published in JAMA Pediatrics whereas a review published just a year later in the Journal of Psychiatric Research reported rates of anxiety among kids were between 19% and 24%.

“The pandemic was a major anxiety trigger for a lot of Americans, especially kids, who rely on school for most of their socialization,” Dr. Gerber says. “And unfortunately, we have yet to see rates of GAD slow down. We’re still seeing kids with anxiety levels parents say they’ve not seen before.”

Without treatment, GAD typically worsens over time. If you suspect your child might have generalized anxiety disorder, it’s a good idea to get them evaluated. The sooner GAD is diagnosed and treated, the fewer long-term complications your child will develop.

“The danger is that if GAD isn’t treated and kids don’t learn how to cope with anxiety in safe and effective ways, it can continue to erode their functioning,” Dr. Gerber says. “It really can become chronic and is a strong predictor of depression and other disorders later in life.”

Another real concern, particularly for adolescents and teens, is substance use.

“There are a lot of kids — when they haven’t gotten treatment — who will self-medicate and start drinking alcohol or smoking pot to ease their anxiety,” Dr. Gerber says. “But a lot of times, the opposite happens. It might be a relief initially, but if they don’t learn to cope with the discomfort and develop skills for dealing with their feelings, then the anxiety will continue to increase and often so will the substance use.”

Most instances of GAD can be treated with psychotherapy in the form of cognitive behavior therapy (CBT) or acceptance and commitment therapy (ACT).

With CBT, children and teens are taught their worries are not based in fact and learn ways to cope with anxious thoughts when they arise. Exposure therapy, a CBT technique commonly used in the treatment of anxiety, involves triggering a child’s anxiety a little at a time, in a safe and controlled setting, until the anxiety subsides. Once a child has learned to tolerate the anxiety without avoiding it, the anxiety diminishes.

There’s a limit to what you can do with exposure therapy for kids with GAD, who are worried about so many things, notes Dr. Bubrick. “You can’t do exposures for everything all the time. So, we do a lot of cognitive work instead. We do a lot of challenging thinking, getting kids to recognize that irrational thinking and replacing it with more logical, rational versions of those thoughts. So, it’s really having the kids learn a different way to think.”

Teens, particularly those who have prior experience with CBT, may benefit from ACT, a form of mindfulness therapy closely related to CBT. With ACT, a teen would learn to acknowledge and accept the anxious thoughts they’re having and commit to moving forward despite them. ACT helps kids step back and observe their anxiety, Dr. Gerber adds. “Rather than trying to stop it, they’re, in a way, making friends with it, treating it like an uninvited guest who’s tolerable, if not exactly welcome.”

Mild-to-moderate GAD can often be treated in anywhere from 10 to 20 therapy sessions. Severe GAD is treated with combination psychotherapy and medication for anxiety disorders, usually an antidepressant called an SSRI.

“The medication might allow them to progress more quickly in the therapy because they can tolerate the intensity of the worry or the anxiety better,” Dr. Gerber adds.

While GAD tends to run in families, it’s important not to blame yourself for your child’s anxiety and instead focus on helping them work past their worries.

“A lot of times parents will feel like they did something wrong,” Dr. Gerber says. “In reality, many factors go into a kid developing GAD. I like to tell them ‘You’re not the problem, but you can be a big part of the solution.’”

That involves getting your child the treatment they need and working with your child’s therapist to learn how to best support your child outside of the clinician’s office. Step one is to avoid inadvertently reinforcing anxious behavior. Parents can unintentionally accommodate fears by providing reassurance or allowing kids to avoid things that trigger their anxiety.

“It’s quite natural for parents to want to provide reassurance or accommodate a child when they’re upset,” Dr. Gerber says. “But by doing that, you’re sending the message that there is something to be worried about.”

As an example, Dr. Gerber says she once had a patient who was scared to come downstairs for fear something bad would happen. His well-meaning parents “got a mini fridge and plugged it in next to his room so he only had to peek out and grab a juice box when he wanted something to drink,” she says. “But that’s not helpful in the long run.”

On the other hand, it can be equally harmful to ignore or dismiss anxious thoughts since, “the more you try to avoid or accommodate anxiety, the stronger it gets,” Dr. Gerber says.

One relatively new approach to helping kids with GAD or other kinds of anxiety involves a therapist working with parents alone — not directly with the children. It’s called Supportive Parenting for Anxious Child Emotions, or SPACE, and it teaches parents how to change their own behavior in order to help their child overcome anxiety.

If parents have anxiety themselves, it can also help for them to get support or treatment, she adds. In turn, they’ll be better equipped to help their child with it as well.