Anxiety: identification and management

  • See also

    Acute behavioural disturbance: Acute management  
    Acute behavioural disturbance: Code response 
    Mental state examination 

    Key Points

    1. Consider whether anxiety is contributing to the presentation of all children
    2. Psychological therapy should be first line and ongoing treatment for anxiety
    3. If medication is being considered, this should be in conjunction with ongoing psychological therapy


    • Anxiety disorders are among the most common mental health conditions in children
    • While some degree of anxiety is recognised as a normal response to stress, anxiety disorders can be distinguished by their intensity, duration and impact on daily function
    • Anxiety disorders are characterised by excessive fear, apprehension and other behavioural disturbances in response to an anticipated potential threat
    • Care should be patient-centred, with respect given to children and their parents/carers, and with their involvement in decisions about their health



    • Assess for symptoms and signs of anxiety disorder, and determine whether the symptoms meet the diagnostic criteria in DSM-5 or ICD-11 (see below)
    • Consider the presence, severity and impact of anxiety in the context of all areas of the child’s life
    • Presentations of anxiety will differ across ages and developmental stages and may include:
      • Regularly avoiding everyday experiences and situations, eg school, social events, playing, sport, eating or sleeping
      • Frequent physical complaints, such as tummy aches and headaches
      • Sudden emotional or angry outbursts, tantrums or ‘meltdowns’
      • Difficulty sleeping
      • Changes in appetite
      • Seeking reassurance often
      • Being preoccupied or unable to concentrate
      • Overplanning situations and overthinking things
    • Assess for other medical, neurodevelopmental comorbidities or life experiences (see below) that may increase risk of anxiety, contribute to presentation, or impact on medication options
    • Medications eg prescription, over the counter, complementary

    Risk factors for anxiety in children

    • Mental health conditions eg eating disorders
    • Neurodevelopmental disorders eg autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), intellectual disability, communication disorders, developmental delay
    • Disturbances in sleep, behaviour, appetite/weight or somatic symptoms
    • Chronic illness that impacts daily functioning, quality of life, autonomy eg cystic fibrosis
    • Sensory impairment
    • Gender-related concerns
    • Experience of trauma eg family experience/history of violence, trauma, conflict, out of home care or traumatic event resulting in a disability
    • Family history of anxiety, depression, obsessive compulsive disorder (OCD) or substance use disorders
    • Substance misuse

    Note: this list is not exhaustive, and clinicians should also rely on professional judgement and clinical assessment


    • Baseline physical exam including cardiac exam, blood pressure, heart rate and growth parameters
    • Further targeted exam as indicated, to rule out organic causes that may mimic anxiety symptoms eg hyperthyroidism 
    • Assess for symptoms of anxiety disorder and determine whether symptoms meet diagnostic criteria in DSM-5 or ICD-11
    • Rating scales and screening tools may be useful in assessing anxiety but must be supplemented by clinical interview and observations when making a diagnosis. A variety of screening instruments are available including


    • Management of anxiety includes psychoeducation, psychological therapy, and medication with the aim of reducing anxiety symptoms, remission of anxiety diagnosis and improved functioning
    • Anxiety commonly co-occurs with other mental health, neurodevelopmental and physical conditions and it is important to consider these as part of assessment and management


    No investigations are required unless considering an alternative diagnosis


    A discussion of treatment and support options should always begin with psychoeducation, followed by consideration of the psychological and medication treatment options acceptable to the child and family


    Psychoeducation for children and carers is a core component of management and should include education and information on the following 

    • Symptoms of anxiety and perpetuating factors
    • Secondary impacts of anxiety on the family, individual’s quality of life and behavioural functioning
    • Possible negative impacts of receiving a diagnosis, including stigma and labelling

    To ensure shared and informed decision making when planning care, explore

    • Family and individual beliefs and understanding about methods to manage mental health conditions
    • The likelihood of the child adhering to the treatment plan for psychological and medication treatments, and anything that can be implemented to support this

    Psychological therapy

    First line treatment for anxiety in most situations should be psychological therapy for the following reasons 

    • Demonstrated efficacy and effectiveness in alleviating anxiety symptoms
    • Minimises potential side effects and risks of medication
    • Addresses underlying causes
    • Builds skills to manage anxiety-related challenges and prevents relapse in the future including coping skills, emotional regulation techniques and problem-solving abilities
    • Empowers young individuals to take an active role in their wellbeing

    When recommending psychological therapy consider

    • The developmental age and stage of the child
    • Feasibility of child and family’s capacity to participate in full course of sessions
    • Alternatives if barriers to access eg cost of therapy or lengthy waitlists 

    Cognitive behavioural therapy (CBT) should be used for remission of anxiety diagnosis, reduction of anxiety symptoms and improvement in daily functioning of children aged 8-18, who have mild-moderate symptoms, as a first line treatment before considering medication

    Evidence informed Internet CBT (CBT using online/app-based programs) can be used for children ≥8 yo with anxiety, individually or with assistance, depending on age/developmental stage

    Play therapy could be considered for children <8 yo, those with procedural anxiety or medical trauma, or those <12 yo who have may have difficulty engaging in CBT Acceptance and commitment therapy (ACT) could be used for children and young people 12-18 yo, particularly for those with concurrent chronic health conditions

    Further information on other therapies can be found in resources below


    • Should not be considered a first-line treatment except in exceptional circumstances
    • Best initiated by a clinician with knowledge, training, and experience in prescribing psychotropic medications in children
    • Could be used in conjunction with psychological therapies if the child’s anxiety is:
      • Too severe to allow meaningful engagement in psychological therapy and medication may assist
      • associated with significantly reduced access to education due to limited school attendance
      • associated with a moderate or greater risk of deliberate self-harm*
      • associated with a significant risk to the wellbeing of the family member
    • Psychological therapy should be continued in conjunction with medication

    *NB commencing medications may not reduce this risk and may increase agitation initially. See side effects/activation syndrome below

    Initiating medication
    Selective serotonin reuptake inhibitors (SSRIs) are first-line medication for anxiety

    • As no SSRIs are currently licensed by TGA for use in anxiety or depression in children and adolescents in Australia, medications will be prescribed off label
    • Clinicians should familiarise themselves with 2 or 3 SSRIs with respect to initial and target doses and adverse effect profiles
    • As fluoxetine and escitalopram are approved by FDA for depressive episodes, it is sensible to consider using these
    • When commencing medication, start with a low dose, noting that doses vary depending on age, developmental stage and symptoms
    • An example of common prescribing patterns below



    Starting dose

    +/- by

    Typical dose


    Tab, liquid

    5-10 mg

    5-10 mg

    20-40 mg



    12.5-25 mg

    12.5-25 mg

    50-100 mg



    5 mg

    5 mg

    10-20 mg

    Those unfamiliar with prescribing SSRIs should discuss with senior clinician

    • titrate up slowly whilst monitoring for adverse effects to reach a minimum effective dose
    • SSRIs take several weeks to become effective for anxiety and the benefits, when seen, often continue to increase over time (months)
    • SSRIs remain the first-line medication if the anxiety disorder is comorbid with depression, ADHD or OCD

    Ensure the child and family have clear understanding of indications to cease medications (adverse side effects), formulation options and methods for safe medication storage and disposal

    Adverse effects

    • Most common - nausea, vomiting, loss of appetite, dry mouth, agitation, insomnia (or sometimes sedation), headaches, dizziness, sweating and sexual dysfunction
    • SSRIs should be gradually reduced to minimise discontinuation symptoms
    • Consider SSRIs with longer half-lives eg fluoxetine, or those deemed to be at lower risk of discontinuation syndrome if concern about medication adherence
    • Activation syndrome is a well-known adverse effect of SSRIs and presents with increased activity, impulsivity, disinhibition, restlessness, irritability, and insomnia
    • Caution when prescribing SSRIs is recommended for the following children:
      • highly aroused/ADHD with comorbid anxiety
      • family history of bipolar disorder
      • younger age
    • Dosing needs to be low, and up-titration should be done slowly

    Dose adjustment
    Monitor treatment response using validated rating scales eg Revised child anxiety and depression scale (RCADS). Monitor adverse effects and adherence, and adjustment of dose accordingly

    Medication effect

    Dose adjustment

    Some, but limited effectiveness of medication

    Consider a dose increase

    Side effects that are not tolerated

    Consider dose decrease or medication cessation

    Tolerated therapeutic doses ineffective after reasonable trial (eg 8 weeks)

    Consider medication cessation and change

    Other medical conditions and drug interactions, especially on commencement of new treatment

    Consider dose adjustment

    • When considering medication changes for a child who has been taking SSRIs, the first change to consider is to another SSRI
    • When an SSRI is not tolerated, other medications can be considered
    • Clinicians could cautiously consider the use of short acting benzodiazepines to assist in the management of an acute crisis in high-risk settings (eg emergency department) Acute behavioural disturbance - Acute management
    • Anti-psychotic medications, alpha-2 agonists (clonidine and guanfacine), atomoxetine, reboxetine and tricyclic antidepressants are not recommended for the treatment of anxiety disorders in isolation

    Follow up

    • Symptom and adverse effect rating scales (eg RCADS) should be used throughout the course of both psychological and medication treatment
    • Encourage child to undertake this with parent support
    • On medication initiation, and while establishing stability, clinical response and adverse effects should be reviewed every 2 weeks
    • Trial period of ceasing treatment (psychological or medical) can be considered when the overall balance of benefits and harms indicates this may be appropriate
    • Medications such as SSRIs with discontinuation symptoms should be gradually reduced then discontinued (see switching and stopping antidepressants)

    Consider consultation with local paediatric team when

    Developmental or physical health concerns

    Consider consultation with local Child and Adolescent Mental Health specialist when

    Anxiety presentation with any of the following

    • complicated by coexisting mental health problems
    • significant risk identified for patient or others
    • beyond the comfort of the clinician

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • Risk assessment regarding risk of harm to self or others completed and deemed safe for discharge
    • Appropriate follow up arranged. Children with anxiety will likely require ongoing follow up with a paediatrician or other appropriate clinician

    Parent information


    • RCH Kids Health Info: Anxiety. Fact sheet on anxiety for primary school aged children
    • Healthdirect: Anxiety in children
    • Mental Health Central: Anxiety. Evidence-based Clinical Practice Guideline for anxiety in children that integrates the available evidence, as well as clinical expertise and lived experience perspectives

    Beyond Blue

    Raising Children’s Network


    • Kids Help Line: A free, confidential 24/7 online and phone counselling service for young people
    • Parentline: A free phone counselling service to discuss parenting challenges 

    Online/App based programs and toolkits

    • The Brave Program: An interactive online program aimed at 8-12 yo to help them overcome worries and learn coping strategies
    • Triple P Online Course: A toolkit to help children manage anxiety and become more emotionally resilient
    • Cool Kids Program: An interactive online program aimed at 7-12 yo to help them overcome anxiety and build confidence
    • Mental health and wellbeing toolkit: Advice to support student mental health and wellbeing, aimed at students, parents and caregivers, and school
    • Smiling Mind Kids Care Packages: A series of calming activities and audio recordings for children based on mindfulness meditation

    Additional notes

    Types of Anxiety Disorder

    Generalised anxiety disorder

    • Excessive and persistent worry occurring more days than not about multiple areas of everyday life
    • Child finds this worry is difficult to control
    • May include physical symptoms eg restlessness, fatigue, difficulty concentrating, irritability, muscle tension and sleep disturbance
    • Symptoms significantly impact daily functioning and must be present for at least 6 months, causing significant distress

    Panic disorder

    • Recurrent panic attacks - sudden episodes of overwhelming physical and psychological distress, including intense fear or discomfort
    • May include physical symptoms eg palpitations, sweating, shaking, shortness of breath, chest pain, dizziness, light-headedness, feeling of choking, numbness, tingling, chills or hot flushes, nausea, abdominal pain, feeling detached, fear of losing control, fear of dying

    Phobias (including specific phobias)

    • Excessive and irrational fear of a specific object or situation, out of proportion to actual danger posed by stimulus, eg fear of heights, animals or flying
    • Needle phobia (or procedure related distress)


    • Specific phobia that involves an intense fear or anxiety about being in situations or places where escape might be difficult, or help may not be available, eg crowded places, open spaces, public transport
    • Fear is excessive or significantly interrupts everyday functioning

    Social anxiety disorder (previously Social phobia)

    • Intense fear or anxiety about social situations where individuals may be scrutinised or evaluated by others. People with social anxiety disorder often have a persistent fear of embarrassment or humiliation
    • Significant impact on life and persistent for more than 6 months

    Separation anxiety disorder

    • Excessive and developmentally inappropriate distress when separated from attachment figures eg parents or caregivers
    • May experience persistent worry about potential harm or loss to the person they are attached to, nightmares about separation, may exhibit behaviours such as school refusal, excessive clinginess to caregiver


    Last updated April 2024

  • Reference List

    1. Australian Medicines Handbook, Adverse effects of antidepressants. 2023. (viewed 20 November 2023)
    2. Lawrence D et al., The Mental Health of Children and Adolescents:  Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. 2015. Department of Health, Canberra.
    3. Melbourne Children’s Campus Mental Health Strategy Anxiety Guideline Development Group, Evidence-based Clinical Practice Guideline for Anxiety in Children and Young People. (viewed 20 November 2023).
    4. Viswanathan M et al., Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022. 328(14): 1445-1455.