Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about a variety of events. It is often accompanied by physical symptoms such as headaches, muscular tension, restlessness, heart palpitations, and stomach upset. Children and adolescents with GAD may worry excessively about their performance and competence at school or in sporting events, about personal safety and the safety of family members, or about natural disasters and future events.

The difference between normal feelings of anxiety and the presence of generalized anxiety disorder is that children with GAD worry more often and more intensely than other children in the same circumstances. Children with GAD tend to worry about the same things as their non-anxious peers, but they do so in excess. These worries and associated symptoms cause significant distress and impair daily functioning. Children with GAD are often overly self-critical and avoid activities in which they feel that may not be able to perform perfectly. They also tend to seek frequent reassurance from caregivers, teachers, and others about their performance, although this reassurance provides only fleeting relief from their worries.

GAD is relatively common disorder among children and adolescents. It begins gradually, often in childhood or adolescence, with symptoms that may worsen during times of stress. Worries may switch from one concern to another, and may change with time and age. GAD may result in significant academic, social, and familial impairment. If left untreated, the disorder may be chronic and predicative of adulthood anxiety and depression. However, early identification and effective management can help reduce the severity of symptoms. Psychotherapeutic approaches, including cognitive behavioral therapy, are among the most researched and promising treatments for childhood anxiety. In certain instances, medication, in combination with psychotherapy, may also recommended for treatment of generalized anxiety disorder.

As with many other mental health conditions, the exact cause of generalized anxiety disorder is unknown but may be linked to:

• Genetic factors: GAD may run in families. Just as a child can inherit parent’s brown hair, green eyes, and nearsightedness, a child can also inherit that parent’s tendency toward excessive anxiety. Current research suggests that one-third of the risk of experienced GAD is genetic.
• 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. Researchers have also found that several parts of the brain are involved in fear and anxiety.
• Temperament factors: A child whose temperament is timid or shy or who avoids anything dangerous may be more prone to generalized anxiety disorder than others are.
• 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. 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.

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, children with anxiety disorders contend with excessive worrying that does not subside the way normal anxiety does.

Children with generalized anxiety disorder experience excessive and uncontrollable worry about a number of events or activities. They feel anxious in multiple settings and are often unable to “put their worries aside” no matter how hard they try.

Examples of common worries experienced by children with GAD include:

• Future events (“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”)
• 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 a 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.

Symptoms of generalized anxiety disorder can vary. They may include:

• Restlessness or feeling keyed up or on edge
• Apprehensiveness
• Being easily fatigued, especially at the end of the school day
• Irritability
• Trouble sleeping
• Difficulty concentrating or the feeling that your mind "goes blank"
• Difficulty handling uncertainty or indecisiveness
• Expecting the worst, even when there is no apparent reason for concern

Physical signs and symptoms may include:

• Fatigue
• Muscle tension or muscle aches
• Trembling
• Twitching
• Sweating
• Nausea, diarrhea, or irritable bowel syndrome
• Headaches

Generalized anxiety disorder is diagnosed by a mental health clinician who can help determine whether the symptoms your child is experiencing is related to an anxiety disorder or another medical condition. The mental health clinician (such as a child and adolescent psychiatrist, child psychologist, psychiatric social worker, or psychiatric nurse practitioner) will make the diagnosis following a comprehensive assessment, which includes a diagnostic with you and your child. During the assessment, parents are asked to talk about their child’s anxiety symptoms and related behavior. You will also be asked to give an overview of your child’s family history, medical history, social history, and social interactions. Sometimes parent or child questionnaires are used to help clarify the diagnosis.

After the comprehensive assessment, a 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 GAD, it is essential to speak with a qualified mental health professional as soon as possible. Children with GAD respond well to treatment that is administered by trained mental health clinicians. By closely working with the treatment team, you can help your child go on to enjoy an active and fulfilling life.

Evidence-based treatments for GAD in children and adolescents includes cognitive behavioral therapy, medication, or a combination of medication and therapy. Here at Boston Children’s Hospital, medication is used in conjunction with therapy for treatment of GAD. Selective serotonin reuptake inhibitor (SSRI) antidepressants are currently first-line medications in the pharmacotherapy of anxiety disorders in children. These antidepressants are powerful anxiolytics with a broader spectrum that may improve comorbid affective disorders and symptoms of anxiety.

If left untreated, studies show that GAD is often a chronic illness with symptoms that tend to wax and wane across the lifespan. Earlier age of onset is also associated with greater risk for development of other anxiety and depressive disorders later in life.