Anxiety in Children & Adolescents: An Overview for Primary Care Providers (PCPs) in Nevada

Anxiety disorders are among the most common mental health conditions in young people and present frequently in pediatric primary care. Nevada’s primary care providers are well-positioned to identify anxiety disorders early, initiate first-line interventions, and coordinate stepped-up care when needed. 

This overview summarizes definitions, prevalence, screening, evidence-based treatment, safety considerations, and Nevada-specific referral options to help you manage pediatric anxiety effectively and safely.

What’s the difference between normal anxiety and an anxiety disorder? 

First, let’s address a common question: when is anxiety normal (or even beneficial) and when does anxiety cross the line into a clinical disorder?  

Normal anxiety: 

Normal anxiety motivates preparation and is part of healthy emotional development. For example, it’s normal for children to experience heightened anxiety about an upcoming school year, test, or game/competition. 

Features of normal anxiety:

• Linked to a specific, realistic stressor.
• Usually short-lived — symptoms fade once the situation passes.
• Mild to moderate intensity; doesn’t significantly interfere with functioning.
• Often accompanied by physical signs (racing heart, “butterflies,” etc,) that resolve quickly.

There are also developmentally normal anxieties that don’t fit neatly within the above definition. Examples: “stranger danger” in infants and fear of monsters in preschoolers. However, these types of anxiety lessen with age and mental development.

Anxiety disorder: 

An anxiety disorder is a maladaptive, persistent pattern that requires clinical assessment and possibly intervention.

In practice, clinicians look for impairment and persistence as the key red flags. If anxiety causes a young person to: 

• avoid normal activities,
• lose sleep, 
• decline academically, or 
• experience daily distress (which can manifest as aggression, tantrums, school refusal), 

it likely meets diagnostic thresholds of an anxiety disorder. (See diagnostic screens and criteria below.) 

How common is anxiety?

National surveys of children’s health published by the CDC show that roughly 11% of children ages 3–17 have a current, diagnosed anxiety problem. Diagnosed anxiety rates are higher in females than males (12% females versus 9% males). 

School-based surveys (e.g., YRBS) also show large proportions of teens reporting poor mental health and anxiety-related symptoms. 

Anxiety by age range in children relative to other common mental health disorders. Image courtesy of CDC report: Data and Statistics on Children’s Mental Health.

There are also different types of anxiety disorder. In AACAP’s Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders, the authors provide the following breakdown: 

“For specific anxiety disorders among youths 13 to 18 years old, lifetime prevalence rates approximate 20% for specific phobia, 9% for social anxiety, 8% for separation anxiety, and 2% each for agoraphobia, panic, and generalized anxiety. The median age of onset of anxiety disorders approximates 11 years…”

The authors also note the frequency of comorbidity in anxiety disorders as well as the need for better detection and treatment: 

“Anxiety disorders (especially generalized anxiety) are highly comorbid with each other and with other psychiatric disorders, particularly depression but also bipolar, attention-deficit/hyperactivity disorder (ADHD), learning/language, behavior, obsessive-compulsive, eating, and substance-related disorders. For comorbid occurrences, multifaceted treatment plans likely are necessary.”

Despite the availability of effective treatments for anxiety, less than one-half of youths needing mental health treatment receive any care, and fewer still receive evidence-based care. Better identification, assessment, and treatment of anxiety disorders by clinicians from multiple disciplines could have a substantial impact on the individual and public health burden of mental illness in children and adolescents.

These data underscore the importance of routine detection in Nevada primary care. 

Who to screen and with what tools

The U.S. Preventive Services Task Force recommends screening for anxiety in children and adolescents aged 8–18 years in clinical settings that can ensure accurate diagnosis and follow-up (grade B recommendation). There is insufficient evidence to support screening in children younger than eight years.

Typically, anxiety screenings occur after an initial psychosocial assessment is administered via a general screening tool such as the Pediatric symptoms checklist (PSC) or the Strengths and Difficulties Questionnaire (SDQ), with results indicating a potential problem requiring further evaluation via secondary screening tools. 

From there, practical, validated screening tools for assessing anxiety disorders that integrate well into clinic workflows include: 

• Preschool Anxiety Scale (PAS) - To be completed by parent/primary care giver(s) for preschool children, when clinician determines screening to be necessary. However, as previously mentioned, there is insufficient evidence to support proactive screening in children younger than eight years.
• SCARED (Screen for Child Anxiety Related Emotional Disorders) - For ages 8-18, SCARED is a two-part screening questionnaire, one to be completed by the child, the other by the parent. 
• A score of ≥ 25 on the 41-item screen may indicate the presence of an anxiety disorder, with subscale scores for specific anxiety disorders (example: social anxiety disorder).
• A score of ≥ 3 on the 5-item short form may indicate the presence of an anxiety disorder.
• GAD-7 - For ages 11-17, this screening is designed to be completed by the child upon receiving a diagnosis of generalized anxiety disorder (or clinically significant generalized anxiety disorder symptoms) and thereafter, prior to follow-up visits with the clinician. Clinicians are advised to calculate two scores:
• Total score (from 0-40), with higher scores indicating greater severity of generalized anxiety disorder; and
• Average total score (0-5), which allows the clinician to think of the child’s generalized anxiety disorder in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4).

General clinical screening recommendation: Screen at annuals, during behavioral-health concerns, and/or when academic, sleep, or somatic complaints arise.

Diagnostic approach & red flags

A positive screen is a prompt for a structured clinical interview with an aim to:

• clarify symptom duration, functional impairment (school, families, peers), and common comorbidities (depression, ADHD, substance use);
• evaluate for panic attacks, separation anxiety, social anxiety, and specific phobias; and
• assess sleep, appetite, and somatic complaints. 

Important: Always assess suicide risk when mood symptoms, hopelessness, or significant functional decline are present — acute safety concerns require immediate hospitalization or crisis team activation.

Evidence-based treatments: what works

For children and adolescents with diagnosed mild to moderate anxiety disorder, cognitive behavioral therapy (CBT) — especially models with exposure components and parent involvement — is the first-line psychosocial treatment. For moderate to severe anxiety, combined CBT and pharmacotherapy yields better short-term outcomes than either alone in some trials, however the data are nuanced and treatment protocols should be individualized on a case-by-case basis. 

Selective serotonin reuptake inhibitors (SSRIs) — specifically Fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro) — have the strongest medication evidence in pediatric anxiety. Serotonin-norepinephrine reuptake inhibitors (SNRIs) have also shown effectiveness. Duloxetine (Cymbalta), an SNRI, is the only medication approved by the FDA for generalized anxiety disorder in children seven years and older. 

The American Academy of Child & Adolescent Psychiatry’s (AACAP) ranks distinct treatment protocols for anxiety disorder as follows:

1. AACAP recommends (1C) that cognitive-behavioral therapy (CBT) be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, specific phobia, or panic disorder.
2. AACAP recommends (1B) that selective serotonergic reuptake inhibitors (SSRIs) be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.
3. AACAP suggests (2C) that combination treatment (CBT and an SSRI) could be offered preferentially over CBT alone or an SSRI alone to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.
4. AACAP suggests (2C) that serotonin norepinephrine reuptake inhibitors (SNRIs) could be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.

Note to general public: AACAP’s number and letter rating scale (above) utilizes a system for rating both the strength of the recommendation (number) and the quality of the evidence (letter). Their recommendations are then ranked accordingly. In coordination with their doctor, a patient may utilize one or multiple of the above treatment protocols based on their unique circumstances and diagnosis.    

Clinician note on medication side effects: Antidepressants such as SSRIs and SNRIs have an FDA boxed warning regarding the increased risk of suicidal thoughts and behaviors in children and adolescents. Primary care clinicians should discuss this risk with patients and their caregivers when obtaining informed consent and use medications selectively. (Kowalchuk et al., 2022)

In summary, any medication decisions should balance symptom severity, functional impairment, side-effect profiles, and family preferences. Collaborative care models (integrated behavioral health + care management + psychiatric consultation) improve access and outcomes in primary care settings and are worth implementing where feasible. 

Long-term prognosis

Child and adolescent anxiety disorders are challenging to overcome and often persist into adulthood. Early detection, evidence-based treatment, and family/community support are critical for improvement. 

As a 2022 analysis summarizes: 

“There is a sufficient body of empirical evidence that shows significant improvement in childhood anxiety disorders with psychotherapy or pharmacotherapy, with a combination of therapies providing the most benefits. Despite effective treatments, some childhood anxiety disorders persist into adulthood. In a longitudinal study examining the remission rates of anxiety among 319 youths, researchers found that after four years only 22% of study participants were in stable symptom remission, 48% had relapsed, and 30% were chronically ill. Evidence-based treatments, early intervention, caregiver support and modeling, professional collaboration, and care coordination are all important elements leading to a better prognosis.”

Practical clinic workflow (quick checklist)

• Screen ages 8–18 routinely (GAD-7/SCARED). Document scores and functional impact. 
• Triage positive screens: 
• mild → brief CBT/monitor with frequent follow-up; 
• moderate/severe → refer for CBT and consider SSRI or psychiatry co-management.
• Safety planning: assess suicidality, restrict lethal means, build a written safety plan, and provide 24/7 crisis contacts.
• Follow-up cadence: after medication start, see/phone within 1–2 weeks to assess tolerability and suicidality; then every 2–4 weeks until stable.

Leverage integrated care: embed behavioral health clinicians, use telepsychiatry consults, or employ collaborative care registries to track outcomes.

Nevada-specific resources

Below are key contacts and programs for Nevada clinicians:

• 988 Suicide & Crisis Lifeline — urgent/24/7 crisis support by call, text, or chat; include this with safety planning. 988 Lifeline 
• Crisis Support Services of Nevada (CSSNV) — regional 24/7 crisis contact center and Nevada’s 988 provider for northern Nevada; useful for warm handoffs and care coordination. cssnv.org 
• Nevada Division of Child & Family Services (DCFS) — Children’s Mental Health — state programs, treatment services, and care coordination for youth with significant needs. Use DCFS pathways for children who meet severe-emotional-disorder criteria. dcfs.nv.gov 
• NAMI Nevada & local peer supports — family education, teen and caregiver resources, and referral directories for outpatient services. Clinicians can give families links to local NAMI programs and support groups. NAMI Nevada 
• Nevada 2-1-1 and Nevada211.org — searchable directory of behavioral-health services, school-based programs, and community supports for referral. Nevada 211 
• Nevada Pediatric Access Line (NV PAL) — provides free, high quality mental health consultations/telehealth and ongoing education to Nevada’s primary care providers. NVPAL