What are the symptoms of GAD?

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

Core symptoms of GAD

Associated symptoms of GAD

  • Restlessness or feeling “on edge” being unable to relax
  • Easy fatigue
  • Trouble with concentrating or experiencing the mind "going blank"
  • Irritability (e.g., becoming easily annoyed or upset)
  • Muscle aches or tension
  • Sleep issues (e.g., difficulties falling asleep, staying asleep, unrestful sleep)
  • Behavior troubles
  • Physical symptoms, including stomach aches or headaches
  • Mood swings, feeling down, 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 determining that their concerns are not associated with a specific event; they have concerns about several different things, they have difficulty controlling their anxiety or worries; their symptoms have been persistent, occurring more often than not for a period of at least six months; and their symptoms result in significant distress, as well as impairment in several aspects of everyday functioning (e.g., social, familial, academic, etc.).

The child-adolescent psychiatrist may interview and/or assess both the child or teen and a caregiver in order to determine the specific nature of the child’s or teen’s anxiety, although many practitioners also use questionnaires or behavior/emotion rating form results to support the diagnosis and quantify the severity of the problem. The practitioner will also seek to determine that the child’s or teen’s anxiety is not related to something unforeseen.

GAD can be chronic, and the symptoms tend to wax and wane across the lifespan. Rates of full remission are very low.

GAD Facts

Worldwide frequency of the condition

GAD is estimated to be present in 1.3% of the world's population. Anxiety Disorders, in general, are estimated to be present in 6.5% of the world's population. While there is no recent, specific epidemiological data for Greece, a recent review of European countries reported a 7.9% frequency. Estimates created based on data collected during the COVID-19 pandemic are elevated.

Burden of the condition in Greece

Anxiety accounts for 9.8% for all disability adjusted life years (DALYs) lost to health conditions in Greece for 5- to 14-year-old children and adolescents. It is the most prominent mental health condition adding to the health burden of the Greek child and adolescent population.

Gender ratio

Gender comparative data for GAD varies widely based on the severity and the broad range of co-occurring disorders. Generally, females are more likely to be diagnosed than males.

Peak age of onset

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

Proportion of the condition that emerges before age 18

According to recent data, 20.4% of individuals with GAD will have been diagnosed by the time they are 18 years old.

What are the associated factors for GAD?

Some common factors associated with GAD are:

  • Genetic and familial factors. Predisposition toward an anxiety disorder most likely results from a combination of multiple genes that interact in a complex way with multiple environmental factors.
  • Environmental factors. These include adverse experiences (e.g., trauma), parenting practices (e.g., overprotection, overcontrol, or reinforcement of avoidance behaviors), parental loss, and parental separation.

What other disorders co-occur with GAD?

Even though each child and adolescent 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 frequently co-occurs with Disruptive Mood Dysregulation Disorder.

How is GAD treated?

GAD is usually treated with psychotherapy or a combination of psychotherapy 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 multiple therapies that have been shown to effectively treat symptoms of GAD, but the one with the most evidence is a type of therapy called cognitive-behavioral therapy (CBT). CBT is an umbrella term that refers to a wide range of different cognitive and behavioral techniques. One technique called exposure. Using this technique, a therapist exposes the child to something that triggers anxiety, beginning 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 or restructure their thinking about their anxiety by identifying unhelpful thoughts or beliefs, raising the child’s awareness of them, and helping to reframe them. They repeat this process with bigger and bigger stressors. Group-based CBT has been shown to be particularly effective for children and adolescents.

Children and adolescents 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 adolescents. 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 period of time (e.g., 4 weeks) when introducing SSRIs for specific cases in late adolescents, given SSRIs take some time to start reducing symptoms. 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 adolescent who is 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, given some studies show evidence that the combination is the best choice compared to either treatment in isolation in children and adolescents.

Where to find more information

If you need more information on worries and reasons for concerns, you can also go to "Excessive worries" on our website.

To learn more about the technical work conducted to develop this guide, please consult our reference list here (link to content below).

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 SM, Kauffman BY, et al. Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy. 2020;49(1):1-21. doi: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 IA, Karyotaki E, Reijnders M, Huibers MJH. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry. 2016;15(3):245-258. doi:10.1002/wps.20346
  • Gosmann NP, Costa M de A, Jaeger M de B, et al. 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. 2021;18(6):e1003664. doi: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 MW, Sommer K, Meyer AH, Schneider S. The role of exposure in the treatment of anxiety in children and adolescents: protocol of a systematic review and meta-analysis. Syst Rev. 2020;9(1):96. doi: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 SPH, Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatr. 2017;171(11):1049. doi: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

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