Anxiety disorders in children and adolescents — branching viva

Opening

Examiner: What distinguishes an anxiety disorder from normal developmental fear in a child? [2]

Candidate: Normal developmental fear — stranger anxiety at 7 to 9 months, separation distress peaking at 12 to 18 months, fear of the dark and of animals in the preschool years — is age-appropriate, transient and resolves with reassurance. An anxiety disorder is excessive, out of proportion to the actual threat, persists beyond the developmental window (with DSM-5 duration thresholds), and causes functional impairment. The two things that flip it into a disorder are persistence and impairment. [2]

Branch A — Classification

Examiner: Name the seven DSM-5 anxiety disorders you commonly see in children. [2]

Candidate: Separation anxiety, specific phobia, social anxiety, generalised anxiety, panic disorder, agoraphobia, and selective mutism. They share excessive, persistent, impairing fear but differ in the trigger and the duration threshold — for example, separation anxiety needs at least 4 weeks, while specific phobia, social anxiety, generalised anxiety and agoraphobia need at least 6 months. [2]

Probe: Is separation anxiety still an early-childhood-only diagnosis? [2]

Candidate: No — DSM-5 removed the age-of-onset cap, so it is a legitimate diagnosis in adolescents, which is a common viva trap. [2]

Branch B — Assessment and risk

Examiner: How do you assess a child you suspect has an anxiety disorder? [2]

Candidate: Multi-informant by design — interview the young person alone and with caregivers, plus school collateral, because children under-report internalising symptoms. I cover onset and course, the fear map, somatic pattern by day of week, impairment, sleep, bullying, trauma, family psychiatric history and developmental history. I use a validated scale — SCARED is the most widely used, with child and parent versions — and the Spence Children's Anxiety Scale or RCADS as alternatives. [2] [5]

Examiner: What must you not forget at every visit? [4]

Candidate: A structured suicide and self-harm risk assessment — anxiety does not protect against suicide, and comorbid depression is common. I also exclude medical mimics when red flags are present, such as thyroid disease or arrhythmia. [2] [4]

Branch C — Management

Examiner: First-line treatment? [3]

Candidate: Exposure-based CBT is first-line. The active ingredient is graded in vivo exposure, which blocks the avoidance that prevents extinction learning and lets the brain build a new safety memory. Programs like Coping Cat and FRIENDS add cognitive restructuring and parent sessions. The Cochrane 2020 review supports CBT over waitlist for childhood anxiety. [2] [3]

Probe: When would you add an SSRI, and which one? [1]

Candidate: For moderate-severe anxiety, comorbid depression, CBT inaccessible or failed, or combination when impairment is high. Sertraline is the most evidence-based first choice — start 25 mg oral daily, titrate slowly. CAMS is the landmark trial: combination CBT plus sertraline gave the highest response at about 80%, with each monotherapy beating placebo. [1] [2]

Probe: What do you counsel when starting it? [4]

Candidate: The black-box suicidality warning — the Bridge 2007 meta-analysis showed a small absolute increase in suicidal ideation and behaviour signals versus placebo. I discuss the risk-benefit with carer and young person, and review within 1 to 2 weeks of starting and after each dose increase, monitoring for activation, gastrointestinal effects and sleep change. I avoid chronic benzodiazepines. [4]

Branch D — Stumpers

Examiner: A teenager presents with episodic palpitations and a fear of dying, onset at rest — panic disorder or SVT? [2]

Candidate: Panic disorder is recurrent unexpected attacks peaking within minutes followed by a month of worry about further attacks. But SVT can mimic it, so I exclude it when there are cardiovascular features — exertional onset, syncope, a family history of sudden death — with an ECG, ideally during an episode. Thyrotoxicosis and substance causes also enter the differential. [2]

Examiner: An autistic child with school distress — same exposure plan? [2]

Candidate: Same graded-exposure principles, but adapted: sensory plan, visual schedules, predictable transitions, and respect for the social-communication load. Exposure is still needed for phobic avoidance, but I do not force "just try harder" without adapting the load. [2]

Close

Examiner: One-line take-home. [1]

Candidate: Disorder differs from normal fear by persistence and impairment; assess multi-informant with a validated scale; treat exposure-based CBT first, add sertraline when moderate-severe, monitor suicidality — and never forget that anxiety does not protect against suicide. [1] [2] [3]