Generalized Anxiety Disorder (GAD)

  • Generalized anxiety disorder (GAD) is characterized by excessive worrying that is not linked to any one event or situation. It causes a child to feel significantly distressed over any number of things—from the health of family members to tests at school and future events.

    The difference between these normal feelings of anxiety and the presence of GAD or another anxiety disorder is that a child with generalized anxiety disorder will experience an extended and extensive period of worry, and the degree of anxiety and fear is notably out of proportion to the reality of the situation. In summary, children and adolescents with GAD feel much more anxious, and for much longer periods of time, than other children do.

    GAD is common among children and adolescents and is treatable with the guidance of clinicians. Psychotherapy, for example, has proven to be an extremely effective method of overcoming the disproportionate anxiety that is the "calling card" of GAD. An experienced mental health professional will use psychotherapy to help your child’s brain practice healthy and constructive responses to anxiety.

    Your child will experience periods of anxiety throughout his or her life, just as anyone does. It’s possible that she will struggle from time to time with abnormal levels of anxiety due to the pre-existing tendency toward excessive worry. However, the tools learned in psychotherapy will provide your child with healthy coping techniques to carry into adulthood, and the majority of children with GAD have substantial improvement over the long term.

    How Boston Children’s Hospital approaches anxiety disorders

    Boston Children’s has long been at the forefront of providing expert, compassionate care to children and adolescents with mental and behavioral health issues. Our Department of Psychiatry team members are leaders in researching, diagnosing and treating GAD and other anxiety disorders, as well as mood disorders such as:

    Boston Children’s approach to mental health care is evidence-based—which means that our treatments have been tested and proven effective through scientific studies, both here at our hospital and by other leading institutions worldwide. We use “talk therapy” as our primary method of treatment for anxiety, focusing on teaching children helpful thinking and coping skills to overcome symptoms and adopt new, healthier thought patterns and behaviors.

    In certain instances, we might recommend that your child begin an anti-anxiety medication regimen—always in conjunction with talk therapy. Boston Children’s has a dedicated Psychopharmacology Clinic to help determine whether medication might be a helpful addition to your child’s treatment plan.

    Our team is always aware that your child is, first and foremost, a child—and not merely a recipient of care. You and your family are essential members of the treatment team, and our compassionate mental health professionals will include you in the therapeutic process every step of the way. 


    Generalized anxiety disorder: Reviewed by David R. DeMaso, MD
    © Boston Children’s Hospital, 2012

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  • All of us are born with the instinctive “fight or flight” response that helped our ancestors escape predators and other threats. When we are afraid, concerned or stressed, the part of our brain responsible for the fight or flight response will generate the nervous, fearful sensation we call anxiety. While everyone experiences anxiety at times, people with anxiety disorders contend with excessive worrying that does not subside the way normal anxiety does.

    Generalized anxiety disorder (GAD) is a type of anxiety disorder that is not tied to any single cause or reason. People with GAD worry excessively about multiple concerns and tend to feel anxious in almost any situation or setting, and are often unable to “put their worries aside” no matter how hard they try.

    What do children with GAD usually worry about?

    Children with GAD may worry about anything (and often worry about more than one topic at once).

    Examples of common worries experienced by children with GAD include:

    • future events (for example, “What’s going to happen to me when Mom and Dad die?”)

    • past behaviors and incidents (“I still feel sick when I remember tripping in front of the whole class last year and how everyone laughed at me.”)

    • social acceptance (“What if my friends are only pretending to like me?”)

    • family matters ("Now that Kathy’s parents are getting divorced, what if mine do too?”)

    • personal abilities (“Why can’t I climb the rope swing in gym class like everyone else?”)

    • perceived personal shortcomings (“I’m so dumb/fat/ugly.”)

    • school performance (“I’m feeling kind of confused in math class this semester. What if I fail?”)

    Children with GAD often worry about the same subjects as children who do not have an anxiety disorder. The difference is that for the child with GAD, there is no “on-off” switch for the worry: it is ever-present and so extreme that it interferes with the child’s ability to relax, concentrate and enjoy activities…even favorite hobbies and interests.    

    What causes GAD and other anxiety disorders in children?

    Anxiety disorders like GAD are linked to:                                           

    • Biological factors: The brain has special chemicals, called neurotransmitters, that send messages back and forth to control the way a person feels. Serotonin and dopamine are two important neurotransmitters that, when disrupted, can cause feelings of anxiety and depression.
    • Family factors: Anxiety and fear can be inherited. Just as a child can inherit a parent’s brown hair, green eyes and nearsightedness, a child can also inherit that parent’s tendency toward excessive anxiety. In addition, anxiety may be learned from family members and others who are noticeably stressed or anxious around a child. For example, a child whose parent displays perfectionist tendencies may become a perfectionist, too.
    • Environmental factors: A traumatic experience (such as a divorce, illness or death in the family, or major events outside of the family) may also trigger the onset of an anxiety disorder.

    Signs and symptoms

    What are the symptoms of GAD in children?

    Unlike adults, children may not realize how intense or abnormal their feelings of anxiety have become. It can be difficult for a child to determine that something is “wrong.”

    The hallmark of a child with GAD—as opposed to another type of anxiety disorder— is that they will worry about more than one topic and will experience anxiety in multiple situations and settings. If your child has GAD, she may need frequent reassurance from you or other family members, or from teachers or classmates at school.

    Other symptoms of GAD often include:

    • worrying about things before they happen
    • a need for everything to be “perfect”
    • ongoing worries about friends, school or activities
    • constant thoughts and fears about safety (of self or of others, such as parents and siblings)
    • reluctance or refusal to go to school
    • frequent stomachaches, headaches or other physical complaints
    • frequent muscle aches or tension
    • trouble sleeping at home and away
    • “clingy” behavior with parents
    • feeling the sensation of a “lump in the throat” or “pounding in their chest”
    • fatigue
    • inability to concentrate
    • being easily startled
    • irritability
    • inability to relax

    Your child may be diagnosed with generalized anxiety disorder if these symptoms:

    • are present for at least six months
    • cause significant distress for the child
    • do not subside, no matter how much the child tries to relax or stop worrying
    • impaired functioning at home, at school or with peers

    How can I tell if my child has GAD, or is just “going through a phase” of anxiety?

    Nearly all children experience short periods of anxiety and worry in their lives. For example, very young children tend to go through phases of fearing the dark, loud noises or large animals. Older children will experience periods of anxiety when separated from their parents for the first time, taking a difficult test or giving a presentation in front of the class.

    The difference between these normal feelings of anxiety and the presence of GAD or another anxiety disorder is that a child with generalized anxiety disorder will experience an extended and extensive period of worry, and the degree of anxiety and fear is notably out of proportion to the reality of the situation, and the child doesn’t respond to typical supportive measures.

    As an example, let’s say your child is anxious about an impending thunderstorm. If the feeling of anxiety is minor (your child may express some nervousness or trepidation, but is comforted by asking questions and receiving reassurance), lasts for only a short time leading up to the storm and is replaced by a return to calm and a normal routine immediately afterwards, this can be interpreted as a passing bout of anxiety.

    However, if your child begins to fret at the first sign of darkening clouds, is significantly distressed (to the point that she may feel physically ill, can’t focus on schoolwork or play and isn’t soothed by parents’ reassurance), this can be a warning sign of an anxiety disorder.

    What if my child has been diagnosed with another mental health issue, in addition to generalized anxiety disorder?

    A child with GAD often has another mental health condition, including:

  • How is generalized anxiety disorder diagnosed at Boston Children’s hospital?

    A Boston Children’s mental health clinician (typically a child and adolescent psychiatrist, child psychologist or psychiatric social worker) will make the diagnosis following a comprehensive psychiatric assessment, which will include a conversation and question-and-answer session with you and your child.

    During the assessment, parents are asked to talk about their child’s anxiety symptoms and the resulting behavior. You will also be asked to give an overview of your child’s family history, medical history, school life and social interactions. Sometimes parent or child questionnaires are used as well to help clarify the diagnosis.

    If my child is diagnosed with generalized anxiety disorder, what happens next?

    Our mental health clinician will help explain your child’s condition and answer any questions you or your child may have. The next step is developing a mutually agreed-upon treatment plan that works for you, your child and your family.

  • If you suspect your child may have generalized anxiety disorder (GAD), it is essential to speak with a qualified mental health professional as soon as possible.

    Children with anxiety disorders respond well to treatment that is administered by trained clinicians. By closely working with the treatment team, you can help your child go on to enjoy an active and fulfilling life.

    How is generalized anxiety disorder treated at Boston Children's?

    Our team of psychiatrists, psychologists and social workers can help you, your child and your family by:

    • tailoring therapy plans according to your child's age, specific symptoms, family and school situation and overall medical history
    • using psychotherapy (which is also referred to as “talk therapy”), or a combination of medication and therapy, to help your child feel and function better



    Talk therapy is always part of the treatment plan and the type of “talk” therapy that has the strongest evidence base and the one we use is cognitive behavioral therapy or CBT. CBT is designed to help children understand how their specific feelings of anxiety emerge. It will also teach them important new skills for overcoming those feelings and replacing them with healthier, more constructive behaviors.  

    Your child may receive individual therapy, or may participate in group sessions with other kids who are also working to overcome GAD. We also offer family counseling, which allows parents, siblings and other family members to take part in a child's therapy sessions and learn new strategies as a team.

    Coping strategies learned in therapy may include:

    • identifying and talking about worries and other feelings
    • stopping recurring negative thoughts as soon as they start
    • relaxing the mind and body during times of stress 
    • develop a “toolbox” of skills to handle anxiety wherever it occurs


    Anti-anxiety medications

    If your child's GAD does not adequately respond to psychotherapy, your clinician may recommend adding an anti-anxiety medication to his treatment plan. These medications can help your child feel more relaxed and comfortable while he is working on learning and practicing coping skills in therapy.

    Here at the Boston Children's Department of Psychiatry, we never prescribe mental health medication as a standalone treatment. Instead, we always consider medication as part of a two-pronged approach, with psychotherapy as a necessary component. Our Psychopharmacology Clinic can help determine whether medication might be a useful addition to your child's talk therapy.

    Commonly prescribed anti-anxiety medications that can immediately help include:

    • alprazolam (Xanax)
    • lorazepam (Ativan)
    • clonazepam (Klonopin)
    • diphenhydramine (Benadryl)
    • hydroxizine (Vistaril)
    • buspirone  (BuSpar)

    Quite often, if medications are needed, longer-term agents may also be prescribed. These include:

    • fluoxetine (Prozac)
    • sertraline (Zoloft)

    Learn more about psychiatric medications for children and adolescents.

    Can I prevent my child from developing an anxiety disorder?

    There is no way to prevent anxiety disorders like GAD, but early treatment can significantly reduce symptoms and improve your child's quality of life. If you notice your child is showing signs of an anxiety disorder, the best thing you can do is to seek professional help as soon as possible.

    Coping and support

    The ups and downs experienced by a child—and family—living with an anxiety disorder can feel overwhelming. In addition to the information about the condition provided here, you may find support from the following resources:

    • Boston Children's Center for Families is dedicated to helping families locate the information and resources they need to better understand their child's particular condition and take part in their care. All patients, families and health professionals are welcome to use the center's services at no extra cost. The Center for Families is open Monday through Friday from 8 a.m. to 7 p.m., and on Saturdays from 9 a.m. to 1 p.m. Please call 617-355-6279 for more information.
    • The Boston Children's chaplaincy is a source of spiritual support for parents and family members. Our program includes nearly a dozen clergy members—representing Episcopal, Jewish, Lutheran, Muslim, Roman Catholic, Unitarian and United Church of Christ traditions—who will listen to you, pray with you and help you observe your own faith practices during your child's treatment.
    • The Experience Journal was designed by Boston Children's psychiatrist-in-chief, David DeMaso, MD, and members of his team. This online collection features thoughts, reflections and advice from kids and caregivers dealing not only with physical illnesses like asthma and diabetes, but also with such mental health conditions as ADHD and depression.
    • Boston Children's Center for Young Women's Health and Center for Young Men's Health recognize that young men and young women have certain concerns that are specific to their genders, while other concerns are shared. These Boston Children's centers offer the latest general and gender-specific information about issues like fitness and nutrition, sexuality and reproductive health, physical development and emotional well-being.
  • At Boston Children’s Hospital, we’re dedicated to proving the effectiveness of our treatment approaches through rigorous scientific testing. Our research program is one of the largest and most active of any pediatric hospital in the world.

    Each day, our psychiatry and psychology researchers are working toward important discoveries to propel new advances in preventing, diagnosing and treating mental and behavioral disorders. This research reinforces our ongoing commitment to enhancing mental health care for all children and adolescents.

    Our research projects with potential implications for treating anxiety include:

    • Michelle Bosquet, PhD, staff psychologist at Boston Children’s, is examining how infants and children develop psychologically when their mothers are suffering from anxiety.
    • David Clapham, chief of Boston Children’s Basic Cardiology Research Laboratories, along with a team of collaborators, has discovered a molecular “on-off” switch for innate fear (the fear that is embedded in our genes). This breakthrough could potentially lead to more effective anti-anxiety drugs.
    • David DeMaso, MD, Boston Children’s psychiatrist-in-chief, is exploring the use of new media technologies to help physically ill children cope with—and communicate—their feelings of worry and stress.
    • Baruch Krauss, MD, attending physician in Boston Children’s Division of Emergency Medicine, is studying new treatments—both those that involve medication, and those that do not—to help relieve acute anxiety in children who are undergoing procedures in the Emergency Room.
    • Jennifer LeBovidge, PhD, and her colleagues in Boston Children’s Immunology Program are conducting a study of a group approach to treating children with food allergies. They aim to determine how best to help these children and their parents manage their allergies and cope with related feelings of anxiety.
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