Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is excessive and ongoing worry that can cause unwanted worries that are hard to control and interfere with daily activities. It is called “generalized” because the child’s or teen’s anxiety and worries are usually related to many everyday things, such as health, family safety, social interactions, doing well in school or sports, being on time, etc. Children and teens with GAD usually worry a lot more than the actual chance of something bad happening. For example, a student with GAD might study much more than his classmates, even when he’s already doing well, or he may worry a lot about a party he is planning.

What are the symptoms of GAD?

The excessive anxiety or worries that children and teens with GAD experience are much more than what is normal for their age or situation. Specific symptoms of GAD include:

Core symptoms of GAD

– Restlessness or feeling “on edge,” being unable to relax

– Getting tired easily

– Trouble concentrating or mind “going blank”

– Irritability (e.g., getting easily annoyed or upset)

– Muscle aches or tension

– Sleep problems (e.g., trouble falling asleep, staying asleep, restless sleep)

Associated symptoms of GAD

– Behavior problems

– Physical symptoms, including stomachaches or headaches

– Mood swings, feeling sad, or hopeless

– Feeling easily overwhelmed

– Overthinking situations, decisions, plans, solutions, and worst-case scenarios

– Difficulty handling uncertainty

How is GAD diagnosed?

A child psychiatrist may diagnose a child or teen with GAD after deciding that their worries are not tied to a specific event; they worry about many different things, they have trouble controlling their anxiety or worries; their symptoms have lasted for at least six months; and their symptoms cause significant distress, as well as problems in everyday life (e.g., social, family, school, etc.).

The child-adolescent psychiatrist may interview and/or assess both the child or teen and a caregiver to figure out the specific nature of the child’s or teen’s anxiety. Many practitioners also use questionnaires or behavior/emotion rating forms to help with the diagnosis and measure how serious the problem is. The practitioner will also try to determine that the child’s or teen’s anxiety is not related to something unexpected.

GAD can be chronic, and the symptoms tend to come and go throughout life. It doesn’t go away completely very often.

GAD facts

Worldwide frequency of the condition:

GAD is estimated to affect 1.3% of the global population. Anxiety disorders, in general, affect approximately 6.5% of the global population. Estimates made during the COVID-19 pandemic are even higher.

Impact of the condition in Brazil:

Despite limited data, the estimated prevalence of anxiety disorders in Brazil is 2.9% in children (5-9 years) and 8.6% in adolescents (10-19 years). GAD is a type of anxiety disorder, and there is no nationally representative data on it alone.

Gender ratio:

Data on gender in relation to GAD vary greatly, depending on the severity of the condition and the presence of comorbidities. In general, girls are more frequently diagnosed than boys.

Peak age of onset:

The average age of onset of GAD is estimated to be 15.5 years, which is later than the average for anxiety disorders in general (5.5 years).

Proportion of cases arising before age 18

According to recent data, 20.4% of people with GAD will have been diagnosed by the age of 18.

What are the associated factors for GAD?

Some common factors linked with GAD are:

– Genetic and familial factors: A tendency toward an anxiety disorder most likely comes from a combination of multiple genes that interact in a complex way with multiple environmental factors.

– Environmental factors: These include bad experiences (e.g., trauma), parenting styles (e.g., overprotection, overcontrol, or encouraging avoidance behaviors), parental loss, and parental separation.

What other disorders co-occur with GAD?

Even though each child and teen is different, individuals who meet the criteria for GAD are likely to meet or have previously met the criteria for other anxiety disorders (such as Separation Anxiety Disorder, Social Anxiety Disorder, and Panic Disorder) or depression. It also often happens with Disruptive Mood Dysregulation Disorder.

How is GAD treated?

GAD is usually treated with therapy or a combination of therapy and medication. Caregivers and other family members are an important part of treatment, since they can help kids and teens practice the skills they learn in therapy.

There are many therapies that have been shown to effectively treat symptoms of GAD, but the one with the most evidence is called cognitive-behavioral therapy (CBT). CBT is an umbrella term that refers to a wide range of different cognitive and behavioral techniques. One technique is called exposure. Using this technique, a therapist exposes the child to something that triggers anxiety, starting with something very small. As the child becomes upset, the therapist teaches them ways to manage their anxiety. The therapist also works with the child to change their thinking about their anxiety by identifying unhelpful thoughts or beliefs, making the child aware of them, and helping to reframe them. They repeat this process with bigger and bigger stressors. Group CBT has been shown to be especially helpful for children and teens.

Children and teens with GAD tend to respond well to certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. Other medications called serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, are also effective for reducing anxiety in children and teens. Benzodiazepines (e.g., alprazolam, lorazepam, diazepam) and tricyclic antidepressants (e.g., clomipramine, amitriptyline) are not effective in children and adolescents and should not be used. That said, some clinicians might use benzodiazepines for a short time (e.g., 4 weeks) when starting SSRIs in specific cases in older teens, since SSRIs take some time to start working. Medications can have side effects, but they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or teen taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and SSRIs/SNRIs should also be considered, since some studies show evidence that the combination is the best choice compared to either treatment alone in children and teens.

References

Clinical description, symptoms, and diagnostic information

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Child Mind Institute. (2021, September 7). Quick guide to Generalized Anxiety Disorder. _https://childmind.org/guide/quick-guide-to-generalized-anxiety-disorder/_

– Flannery, S. (2023, January 3). Generalized Anxiety Disorder in Kids. _https://childmind.org/article/generalized-anxiety-disorder-in-kids/_

– World Health Organization. (n.d.). ICD-11 for mortality and morbidity statistics. 6B00 Generalised Anxiety Disorder. Retrieved January 27, 2023, from _https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1712535455_

Facts

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from _http://vizhub.healthdata.org/gbd-compare_. (Accessed 11/15/2022)

– Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. _https://doi.org/10.1038/mp.2013.50_

– Ohannessian, C. M., Milan, S., & Vannucci, A. (2017). Gender Differences in Anxiety Trajectories from Middle to Late Adolescence. Journal of Youth and Adolescence, 46(4), 826–839. _https://doi.org/10.1007/s10964-016-0619-7_

– Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365. _https://doi.org/10.1111/jcpp.12381_

– Racine, N., McArthur, B. A., Cooke, J. E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global Prevalence of Depressive and Anxiety Symptoms in Children and Adolescents During COVID-19: A Meta-analysis. JAMA Pediatrics, 175(11), 1142. _https://doi.org/10.1001/jamapediatrics.2021.2482_

– Sacco, R., Camilleri, N., Eberhardt, J., Umla-Runge, K., & Newbury-Birch, D. (2022). A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. European Child & Adolescent Psychiatry. _https://doi.org/10.1007/s00787-022-02131-2_

– Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. _https://doi.org/10.1038/s41380-021-01161-7_

– Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature. The Canadian Journal of Psychiatry, 51(2), 100–113. _https://doi.org/10.1177/070674370605100206_

Associated factors

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. _https://doi.org/10.1016/j.jad.2020.12.134_

– de Roo, M., Veenstra, R., & Kretschmer, T. (2022). Internalizing and externalizing correlates of parental overprotection as measured by the EMBU: A systematic review and meta‐analysis. Social Development, 31(4), 962–983. _https://doi.org/10.1111/sode.12590_

– Farhane-Medina, N. Z., Luque, B., Tabernero, C., & Castillo-Mayén, R. (2022). Factors associated with gender and sex differences in anxiety prevalence and comorbidity: A systematic review. Science Progress, 105(4), 003685042211354. _https://doi.org/10.1177/00368504221135469_

– Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in Clinical Neuroscience, 19(2), 159–168. _https://doi.org/10.31887/DCNS.2017.19.2/kdomschke_

– Lawrence, P. J., Murayama, K., & Creswell, C. (2019). Systematic Review and Meta-Analysis: Anxiety and Depressive Disorders in Offspring of Parents With Anxiety Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 58(1), 46–60. _https://doi.org/10.1016/j.jaac.2018.07.898_

– Moreno-Peral, P., Conejo-Cerón, S., Motrico, E., Rodríguez-Morejón, A., Fernández, A., García-Campayo, J., Roca, M., Serrano-Blanco, A., Rubio-Valera, M., & Ángel Bellón, J. (2014). Risk factors for the onset of panic and generalised anxiety disorders in the general adult population: A systematic review of cohort studies. Journal of Affective Disorders, 168, 337–348. _https://doi.org/10.1016/j.jad.2014.06.021_

– Ståhlberg, T., Khanal, P., Chudal, R., Luntamo, T., Kronström, K., & Sourander, A. (2020). Prenatal and perinatal risk factors for anxiety disorders among children and adolescents: A systematic review. Journal of Affective Disorders, 277, 85–93. _https://doi.org/10.1016/j.jad.2020.08.004_

– Yap, M. B. H., Pilkington, P. D., Ryan, S. M., & Jorm, A. F. (2014). Parental factors associated with depression and anxiety in young people: A systematic review and meta-analysis. Journal of Affective Disorders, 156, 8–23. _https://doi.org/10.1016/j.jad.2013.11.007_

Co-occurring disorders

– American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.

– Saha, S., Lim, C. C. W., Cannon, D. L., Burton, L., Bremner, M., Cosgrove, P., Huo, Y., & McGrath, J. (2021). Co‐morbidity between mood and anxiety disorders: A systematic review and meta‐analysis. Depression and Anxiety, 38(3), 286–306. _https://doi.org/10.1002/da.23113_

Interventions

– Carl, E., Witcraft, S. M., Kauffman, B. Y., et al. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): A meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, 49(1), 1-21. _https://doi.org/10.1080/16506073.2018.1560358_

– Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. _https://doi.org/10.1002/wps.20881_

– Cuijpers, P., Cristea, I. A., Karyotaki, E., Reijnders, M., & Huibers, M. J. H. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15(3), 245-258. _https://doi.org/10.1002/wps.20346_

– Gosmann, N. P., Costa, M. de A., Jaeger, M. de B., et al. (2021). Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis. Patel V, ed. PLoS Med, 18(6), e1003664. _https://doi.org/10.1371/journal.pmed.1003664_

– Mahdi, M., Jhawar, S., Bennett, S. D., & Shafran, R. (2019). Cognitive behavioral therapy for childhood anxiety disorders: What happens to comorbid mood and behavioral disorders? A systematic review. Journal of Affective Disorders, 251, 141–148. _https://doi.org/10.1016/j.jad.2019.03.041_

– Schopf, K., Mohr, C., Lippert, M. W., Sommer, K., Meyer, A. H., & Schneider, S. (2020). The role of exposure in the treatment of anxiety in children and adolescents: Protocol of a systematic review and meta-analysis. Systematic Reviews, 9(1), 96. _https://doi.org/10.1186/s13643-020-01337-2_

– Schwartz, C., Barican, J. L., Yung, D., Zheng, Y., & Waddell, C. (2019). Six decades of preventing and treating childhood anxiety disorders: A systematic review and meta-analysis to inform policy and practice. Evidence Based Mental Health, 22(3), 103–110. _https://doi.org/10.1136/ebmental-2019-300096_

– Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: An evidence-based treatment review. Expert Opinion on Pharmacotherapy, 19(10), 1057–1070. _https://doi.org/10.1080/14656566.2018.1491966_

– Wang, Z., Whiteside, S. P. H., Sim, L., et al. (2017). Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatrics, 171(11), 1049. _https://doi.org/10.1001/jamapediatrics.2017.3036_

– Zhou, X., Zhang, Y., Furukawa, T. A., Cuijpers, P., Pu, J., Weisz, J. R., Yang, L., Hetrick, S. E., Del Giovane, C., Cohen, D., James, A. C., Yuan, S., Whittington, C., Jiang, X., Teng, T., Cipriani, A., & Xie, P. (2019). Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: A network meta-analysis. JAMA Psychiatry, 76(1), 41. _https://doi.org/10.1001/jamapsychiatry.2018.3070_