Prevalence, outcomes, and effective interventions for anxiety disorders in children and adolescents

Abstract

Background

Anxiety disorders are common in children and adolescents worldwide and can seriously affect their functioning and well-being. They often continue into adulthood and are linked to other psychiatric problems. Although treatments have improved, significant challenges remain, especially in non-Western regions due to cultural and access barriers.

Objective

This systematic narrative review aimed to synthesize international and Persian literature (2005–2024) regarding the prevalence, outcomes, and effectiveness of interventions for anxiety disorders in children and adolescents, with specific attention to the Iranian context.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, comprehensive searches were conducted across international (PubMed, PsycINFO, Scopus, Cochrane) and Persian (SID, MagIran) databases. Sixty-four studies were included based on predefined eligibility criteria. Data extraction and quality assessment were performed independently by two reviewers, and a narrative synthesis approach was employed due to heterogeneity across studies.

Results

Findings confirm high prevalence and chronicity of anxiety disorders in youth globally and in Iran. Untreated anxiety is consistently linked to academic impairment, social withdrawal, and increased risk for future psychopathology. Cognitive-behavioral therapy (CBT) emerged as the most effective intervention, with response rates of 55–65%, especially when combined with selective serotonin reuptake inhibitors (SSRIs), which further increased success rates to approximately 75–80%. Family-based and school-based interventions also demonstrated efficacy, though cultural adaptation remains limited. Systemic barriers, including provider shortages and stigma, impede care in resource-limited settings such as Iran.

Conclusion

Anxiety disorders in youth constitute a major public health concern requiring culturally sensitive, evidence-based interventions. While CBT and combined treatments are effective, future research should focus on cultural adaptation, innovative delivery models, and system-level solutions to bridge the treatment gap in low- and middle-income countries.

Introduction

Anxiety disorders represent some of the most prevalent and impactful psychiatric conditions affecting children and adolescents worldwide. Their significance extends beyond the immediate distress and impairment they cause, shaping the trajectory of mental health throughout the lifespan and often serving as precursors to a range of adult psychiatric disorders, including depression and substance use disorders [1, 2]. Recent global epidemiological studies and comprehensive meta-analyses have consistently highlighted that anxiety disorders rank among the most common psychiatric diagnoses in youth, with prevalence rates estimated to range between 10 and 20% [3, 4]. Such high rates underscore the urgent need to view anxiety disorders not only as individual clinical challenges but as pressing public health concerns requiring systematic attention and effective intervention strategies.

The consequences of untreated anxiety disorders in children and adolescents are profound and multifaceted. Empirical evidence demonstrates associations with impaired academic achievement, difficulties in peer and family relationships, reduced quality of life, and increased risk for the development of comorbid psychiatric conditions into adulthood. The chronicity often observed in untreated cases further complicates their long-term management, while the functional impairment and stigma associated with these disorders can have lasting social and economic repercussions for families and communities [1, 2, 4]. In addition to the clinical and psychosocial sequelae, academic functioning is notably impacted by anxiety disorders. Recent behavioral modeling research supports a direct association between psychological difficulties and academic and cognitive outcomes. For instance, Özbay et al. [5] demonstrated, through robust modeling in a university population, how factors such as anxiety and behavioral patterns—particularly academic procrastination—interact and contribute to academic impairment. While this study was conducted in older students, its modeling framework is conceptually relevant for understanding anxiety-related academic impairment in younger populations, highlighting the importance of integrating educational and behavioral perspectives into the assessment and intervention of anxiety disorders in school-aged children and adolescents.

Treatment research over the past two decades has led to significant advances in the management of anxiety in youth. Cognitive-behavioral therapy (CBT) has emerged as a first-line, evidence-based intervention, with numerous randomized controlled trials (RCTs) and systematic reviews confirming its efficacy in reducing anxiety symptoms and improving functional outcomes [6, 7]. Notably, landmark studies such as the child/adolescent anxiety multimodal extended long-term study (CAMELS) trial [8] and research by Walkup et al. [9] have demonstrated that combined approaches—integrating CBT with pharmacotherapy, particularly selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and sertraline—can yield superior outcomes for moderate-to-severe cases or those unresponsive to monotherapy. Despite these advances, questions remain regarding the relative effectiveness of pharmacological versus psychological interventions, the durability of treatment gains, and the optimal modalities for preventing relapse.

Cultural and contextual factors add further complexity to the identification and management of anxiety disorders in children and adolescents. In non-Western countries, including Iran, the prevalence of anxiety disorders in youth mirrors global rates, with local studies documenting significant levels of distress and impairment among students and adolescent populations [10, 11]. However, the translation of evidence-based interventions into culturally congruent clinical practice remains a major challenge. Barriers such as limited access to qualified mental health professionals, insufficient service infrastructure, and cultural beliefs about mental illness contribute to a substantial gap between the need for and receipt of effective treatment [12, 13]. This “treatment gap” is of particular concern in resource-limited settings, where the burden of untreated anxiety may be exacerbated by social stigma and systemic constraints [14].

Moreover, there is a pressing need to adapt and localize interventions to be compatible with the unique familial and cultural structures present in diverse societies. Many existing treatment protocols, developed and validated in Western contexts, may not fully address the nuances of family dynamics, caregiving practices, and community attitudes in other regions [15, 16]. This necessitates a dual approach: systematically reviewing the international evidence base while simultaneously evaluating and integrating findings from local research to inform culturally sensitive and contextually relevant intervention strategies.

Given these complexities, the present narrative review aims to synthesize the most recent international and Persian literature (2005–2024) on the prevalence, outcomes, and effectiveness of interventions for anxiety disorders in children and adolescents. The review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework [17] and seeks to answer three critical research questions: (i) What is the current prevalence and pattern of anxiety disorders among children and adolescents globally and in Iran? (ii) Which therapeutic strategies—including psychological, pharmacological, combination, and family-based interventions—are most supported by current evidence? (iii) What are the limitations and operational gaps in the Iranian context, and what priorities should guide future research and service development? By addressing these questions, this review aims to provide a comprehensive and actionable analysis that bridges global evidence with local realities, ultimately informing policy-makers, clinicians, and researchers in their efforts to reduce the burden of anxiety disorders among children and adolescents.

Methods

Study design and protocol

This systematic narrative review was conducted according to the PRISMA 2020 guidelines [17], with modifications tailored for narrative synthesis given the heterogeneity of study designs and outcomes. The review protocol included structured database searching, independent dual screening, rigorous quality assessment, and comprehensive data extraction, but prioritized thematic integration of results over quantitative meta-analysis.

Data sources and search strategy

A comprehensive and reproducible literature search was performed across the following international databases: PubMed/MEDLINE, PsycINFO, Scopus, and Cochrane Library, as well as Persian-language databases SID and MagIran to ensure linguistic and cultural inclusivity. The search strategy combined controlled vocabulary and free-text terms, including “anxiety disorders,” “children,” “adolescents,” “CBT,” “pharmacotherapy,” alongside their Persian equivalents. Boolean operators (“AND,” “OR,” “NOT”) were systematically applied to maximize sensitivity and specificity. Searches were limited to studies published from January 2005 to March 2024. Additionally, reference lists of identified systematic reviews and clinical guidelines were manually screened (snowballing) to identify further eligible studies.

Eligibility criteria

Studies were included if they met the following criteria: (i) published between 2005 and 2024; (ii) included participants aged 18 years or younger; (iii) provided empirical data on the prevalence, outcomes, or interventions (psychological or pharmacological) for anxiety disorders in children or adolescents; (iv) published in English or Persian; and (v) employed one of the following study designs: RCTs, quasi-experimental studies, systematic reviews, meta-analyses, clinical guidelines, or epidemiological reports.

Studies were excluded if they were: (i) animal studies; (ii) single-case reports or case series without quantitative data; (iii) purely theoretical articles lacking empirical analysis; or (iv) lacking accessible full text.

Study selection

Two reviewers independently screened all titles and abstracts for eligibility using pre-defined criteria. Discrepancies were resolved via discussion or arbitration by a third reviewer. Duplicates and irrelevant records were removed prior to full-text assessment. Eligible full texts were reviewed in detail, resulting in the final inclusion of 36 articles, encompassing RCTs, systematic reviews, meta-analyses, and epidemiological studies (see PRISMA flowchart, Fig. 1).

Fig. 1.

PRISMA flow diagram

Data extraction

Data extraction was independently conducted by two reviewers using a standardized, pre-tested form. Extracted variables included study details (author and year), study design, sample or data source, intervention or topic, and main findings (see Table 1). Any disagreements were resolved by consensus or, if necessary, by consulting a third reviewer.

Table 1.

Summary of international and Persian literature reviews and key studies

Study details (author and year)	Study design	Sample or data source	Intervention or topic	Main findings
Polanczyk et al., 2015 [15]	Global meta-analysis	Epidemiological studies	Prevalence of mental disorders in children	High prevalence of mental disorders; variation across countries
James et al., 2020 [6]	Systematic review	RCTs	CBT	Effectiveness of CBT for child/adolescent anxiety disorders
Walkup et al., 2008 [9]	RCT	n = 488	CBT vs. Sertraline vs. combination	Each effective; Combination was better
Walter et al., 2020 [7]	Clinical guideline (JAACAP)	Guidelines	Diagnosis and treatment	First-line CBT, SSRIs for specific cases
Pegg, 2022 [16]	Synopsis	Reviews/meta-analyses	CBT	Review of moderators and predictors
Rapee, 2023 [3]	Review	Review	Epidemiology and treatment	Summary of recent advances
Dickson et al., 2024 [4]	New meta-analysis	Prevalence studies	Prevalence and disability	New prevalence estimates (6.5% reported in some analyses)
Ganzevoort et al., 2024 [18]	Systematic review	Intensive treatments	Intensive CBT	Intensive treatments show promise for resistant cases
Ginsburg et al., (2018) [8]	RCT/CAMELS	RCTs and follow-ups	Family-based + CBT	Increased effectiveness with parent intervention
Wang et al., 2023 [12]	Epidemiological	Demographic data	Treatment rates	High treatment gap in children and adolescents
Swain et al. 2015 [19]	Systematic review	Third-wave approaches	Acceptance and commitment therapy	ACT improves symptoms, quality of life, and flexibility

Quality assessment

For the quality assessment of included studies, appropriate standardized tools were applied according to study design. RCTs were evaluated using the Cochrane Risk of Bias Tool, which examines domains such as random sequence generation, allocation concealment, blinding, incomplete outcome data, and selective reporting. For quasi-experimental studies, the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Quasi-Experimental Studies was used, assessing aspects like comparability of groups, clarity of cause and effect, and management of confounders. Systematic reviews and meta-analyses were appraised using the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews), which considers protocol registration, comprehensive search, risk of bias, and synthesis methods. Epidemiological studies were assessed with the Newcastle-Ottawa Scale (NOS), focusing on selection, comparability, and outcome/exposure assessment. Each study was independently assessed by two reviewers, and disagreements were resolved through discussion or by consulting a third reviewer.

Statistical considerations

While quantitative synthesis (meta-analysis) was considered, significant heterogeneity in populations, interventions, comparators, and outcome measures precluded meaningful statistical pooling. Heterogeneity was assessed based on differences in study design, intervention protocols, and outcome definitions. Where meta-analyses of sufficient quality existed within the included studies, their pooled estimates and confidence intervals were reported descriptively.

Data synthesis and analysis

A narrative synthesis approach was employed. Studies were grouped thematically by intervention type, target population, and outcome. Main findings were integrated and compared across studies, with particular attention to effect sizes, statistical significance, and reported adverse events. The strength and consistency of evidence were evaluated, and summary tables and visual figures were constructed to illustrate the evidence base for each intervention. This rigorous and transparent methodological approach provides a robust foundation for synthesizing empirical evidence on anxiety disorders and their interventions in children and adolescents, ensuring both statistical and narrative integrity.

Results

Prevalence and patterns of anxiety disorders

The synthesis of 36 eligible studies reveals that anxiety disorders remain among the most prevalent psychiatric conditions in children and adolescents worldwide, with recent large-scale epidemiological research indicating pooled prevalence rates ranging from 6.5% to 20% depending on diagnostic criteria and sampling methods [3, 4, 15]. International meta-analyses and systematic reviews report separation anxiety disorder, generalized anxiety disorder, and specific phobias as the most common subtypes, with typical onset ages varying from early childhood (separation anxiety disorder: 6–9 years, 4–7% prevalence) to adolescence (social anxiety disorder: 12–16 years, 2–5% prevalence; panic disorder: late adolescence, 1–2%) (see Table 2). Notably, comorbidities with depression, conduct disorders, and substance use become increasingly frequent with age progression [4, 15].

Table 2.

Prevalence and key features of anxiety disorders in children and adolescents

Type of anxiety disorder	Average prevalence (%)	Typical age of onset	Key features	Common comorbidities
Separation anxiety disorder	4–7	6–9 years	Excessive worry about parental separation	Depression, conduct disorder
Generalized anxiety disorder	3–6	10–13 years	Persistent and pervasive worry about everyday events	Depression, sleep disorder
Social anxiety disorder	2–5	12–16 years	Persistent and pervasive worry about everyday events	Depression, substance use in adolescents
Specific phobia	5–10	Variable	Intense and irrational fear of objects/situations	Other anxiety disorders
Panic disorder	1–2	Late adolescence	Sudden and recurrent anxiety attacks	Depression, agoraphobia

Persian-language epidemiological studies mirror these global trends, documenting prevalence rates of anxiety disorders in Iranian youth populations that fall within the international range, with some local studies reporting rates as high as 15% in school-aged children and adolescents [10, 11]. These data emphasize the substantial and consistent burden of anxiety disorders across diverse cultural contexts.

Functional outcomes

Across studies, untreated pediatric anxiety is consistently linked to impaired academic achievement, social withdrawal, decreased quality of life, and increased risk for developing further psychiatric conditions, including mood and substance use disorders [1, 2, 4]. Longitudinal evidence suggests that early-onset anxiety, particularly when unaddressed, predicts chronicity and greater functional impairment into adulthood. Stigma and limited access to care further compound these negative outcomes, especially in resource-limited settings [12, 14].

Effectiveness of psychological interventions

CBT, whether delivered individually or in group settings, demonstrates the strongest evidence base for the treatment of anxiety disorders in youth. High-quality systematic reviews and randomized controlled trials consistently report that both individual and group CBT produce significant and sustained reductions in anxiety symptoms compared to waitlist or usual care, with response rates typically ranging from 55 to 65% [6, 9]. Meta-analyses confirm that the effect sizes are moderate to large across most anxiety subtypes, and that CBT is superior to placebo and non-specific supportive therapy [6, 16]. Brief, school-based CBT protocols also show moderate effectiveness and hold promise for wide-scale early intervention, although successful implementation is contingent on sufficient resources and staff training.

Family-based interventions, including parent-led CBT and programs aimed at improving family functioning, provide additional benefit, particularly for younger children or those whose families demonstrate high levels of accommodation of anxiety symptoms. Notably, evidence from the CAMELS trial and its follow-up studies indicates that incorporating parental components with CBT increases both treatment response rates and the durability of therapeutic gains [8, 9]. However, the effectiveness of such interventions may be reduced in families with poor engagement or elevated conflict [8].

When comparing intervention types, review analyses reveal that CBT is the most extensively studied and supported, with nine high-quality reviews or studies. SSRIs are the next most frequently studied, with five studies, followed by combination treatments of CBT and SSRIs (three studies), family-based interventions (four studies), and acceptance and commitment therapy (ACT)/third-wave approaches (three studies). Intensive treatments are least represented, with only two high-quality studies (see Fig. 2) [6–8, 11, 14, 15, 17–19].

Fig. 2.

Trends in high-quality reviews and key studies by intervention type (2005–2024)

Success rates differ across interventions. Combination CBT and SSRI therapy yield the highest success rate, approximately 75%. CBT alone and family-based interventions also demonstrate relatively high success rates, around 65% and 60% respectively. SSRIs and ACT/third-wave therapies have success rates of approximately 55–60%, while intensive treatments have the lowest estimated minimum success rate at roughly 45%. Overall, these findings indicate that combined and behavioral interventions are more effective than medication or intensive treatments alone (see Fig. 3) [6–8, 11, 14, 15, 17–19].

Fig. 3.

Effectiveness of treatment interventions for pediatric anxiety disorders: systematic review-based success rates

Pharmacological and combined interventions

SSRIs, particularly fluoxetine and sertraline, are consistently effective for moderate-to-severe pediatric anxiety, with response rates comparable to or slightly below those of CBT (typically 50–60%) [7, 9]. SSRIs generally produce more rapid symptom reduction than psychological interventions alone but are associated with potential adverse effects such as sleep disturbance, gastrointestinal complaints, and, rarely, activation or behavioral disinhibition (see Table 3). Careful monitoring and individualized risk-benefit discussions are essential.

Table 3.

Summary of evidence-based treatments for childhood and adolescent anxiety disorders

Type of treatment	Evidence of effectiveness	Advantages	Limitations
Individual or group CBT	High	Sustained symptom improvement, can be used without medication	Requires specialist therapist, time-consuming
Family-based therapy	Moderate to high	Increased parental cooperation, improved social support	Limitations in uncooperative families
SSRIs (e.g., fluoxetine and sertraline)	Moderate to high	Rapider symptom reduction	Possible side effects (restlessness, sleep problems)
Combination of CBT and medication	High	More effective than single treatment	Limited availability, potential for drug dependence
School-based interventions	Moderate	Early identification and treatment, broad coverage	Requires resources and staff training
ACT

The strongest evidence for enhanced outcomes is found in combined treatment approaches. The landmark CAMELS RCT demonstrated that the combination of CBT and sertraline yields the highest response rates (approximately 80%), greater functional improvement, and lower dropout compared to either modality alone, particularly in severe or treatment-resistant cases [8, 9]. Intensive CBT protocols also show promise for refractory cases, though their scalability in routine practice remains to be established [18].

Discussion

Anxiety disorders in children and adolescents represent a significant mental health concern globally, characterized by high prevalence rates and substantial negative consequences on social, emotional, and academic functioning. Among the spectrum of anxiety disorders in youth, generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder are the most frequently diagnosed. Each presents distinct clinical profiles, yet all share the potential for chronicity and comorbidity with other psychiatric conditions if not appropriately addressed [20, 21].

Generalized anxiety disorder in young populations is marked by persistent, uncontrollable worry and anxiety experienced most days over a period of at least six months. This condition manifests through symptoms such as restlessness, irritability, muscle tension, fatigue, sleep disturbances, and difficulty concentrating [22–24]. Theoretical models, such as Barlow’s, posit that both psychological and biological vulnerabilities contribute to the etiology of generalized anxiety disorder, with a particular emphasis on the perception of uncontrollability and inconsistent parental behaviors, which may foster a sense of helplessness and behavioral inhibition in the child [25–28]. These vulnerabilities underscore the importance of early detection and intervention to mitigate the long-term trajectory of anxiety.

Social anxiety disorder, often considered a prototypical childhood anxiety disorder, has a reported prevalence ranging from 15 to 56%. While many children naturally outgrow separation anxiety by age 4–5, certain risk factors—including maternal anxiety or depression during pregnancy and parental unemployment—can contribute to its persistence into adolescence and adulthood if left untreated [21, 27]. The disorder is associated not only with anxiety but also with depressive and externalizing behaviors, and its early onset can foreshadow a cascade of further mental health challenges later in life.

Social anxiety disorder typically emerges around age 8, with clinical symptoms and functional impairments often intensifying throughout adolescence. The 12-month prevalence in youth is approximately 7%, paralleling adult rates. Notably, social anxiety disorder displays high rates of comorbidity—up to 81% of affected individuals present with at least one additional psychiatric disorder, most commonly depression, other anxiety disorders, disruptive behavior disorders, or eating disorders. The early identification and intervention of social anxiety disorder are crucial to preventing the development of these associated conditions and promoting adaptive functioning [29, 30].

The consequences of untreated anxiety disorders in youth are profound, encompassing impaired social relationships, academic difficulties, and an increased risk for psychopathology in adulthood. Therefore, prompt and effective interventions are essential for alleviating symptoms and improving long-term outcomes.

CBT has emerged as the gold-standard psychological intervention for youth anxiety disorders, supported by a robust body of empirical evidence [29, 31, 32]. CBT is predicated on the assumption that maladaptive cognitions underlie emotional and behavioral disturbances [33]. Core components of CBT for anxiety in youth include cognitive strategies (e.g., identifying and restructuring cognitive distortions, fostering positive self-talk) and behavioral techniques (e.g., exposure exercises, role-playing, relaxation training, coping skills enhancement, self-control, and self-efficacy development) [31–34]. Therapy is typically delivered in individual or group formats and often incorporates parental involvement to maximize ecological validity and promote generalization of coping skills [29].

CBT protocols have demonstrated efficacy in reducing anxiety symptoms, depressive symptoms, and maladaptive externalizing behaviors, thereby enhancing adaptive functioning. The intervention’s structure often includes psychoeducation for children and parents, progressive muscle relaxation, deep breathing exercises, cognitive restructuring, exposure to anxiety-provoking stimuli, relapse prevention sessions, and collaboration with school personnel. Several standardized CBT-based protocols have been implemented, such as the cat coping protocol, cognitive-behavioral group therapy, reassurance package therapy, single-process approaches, and the McIntyre cognitive therapy method [29].

Empirical studies included in the reviewed literature consistently support the effectiveness of CBT and its variants. For example, group CBT has been shown to reduce social anxiety and improve quality of life and academic performance in students with generalized anxiety disorder. However, some findings suggest a differential effect on fatigue, indicating that anxiety reduction may not always translate to improvements across all domains of functioning. Narrative therapy, a related psychological intervention, has also shown promise in reducing general and social anxiety in school-aged girls.

While psychological interventions are foundational, combining CBT with family-based therapies and pharmacotherapy can yield additional benefits, particularly for youth with severe or treatment-resistant anxiety. However, the decision to incorporate pharmacological treatments must be guided by careful consideration of the risk-benefit profile, especially within specific cultural and healthcare contexts.

Despite the emphasis on intervention outcomes and psychosocial functioning, an equally critical component in youth anxiety research concerns the measurement dimension—specifically, the development, validation, and cultural adaptation of assessment tools designed to capture psychological distress in children and adolescents. Recent work in this area reflects innovative approaches to scale development and validation, ensuring that assessment instruments are psychometrically robust and culturally sensitive. For instance, Semerci Şahin et al. [35] developed the Generative Artificial Intelligence Awareness Scale for secondary school students in Türkiye, demonstrating contemporary methodologies for scale construction, validation, and adaptation to unique educational and sociocultural contexts. Incorporating such measurement tools is especially pertinent in early identification and school-based mental health initiatives, as accurate and culturally appropriate assessment is foundational for effective intervention planning and evaluation [36].

Limitations and operational gaps

This review faces several limitations that should be considered. First, much of the existing evidence for CBT and related interventions is derived from Western contexts, which raises concerns regarding the generalizability of findings to non-Western societies such as Iran. There is a critical need for the cultural adaptation and systematic evaluation of these interventions to ensure their relevance and acceptability in diverse settings. Furthermore, the current literature is limited by the underrepresentation of innovative approaches, including ACT, brief intensive interventions, and internet-delivered CBT (iCBT). Access to trained mental health professionals remains insufficient, and there is a lack of long-term follow-up data, especially in real-world and resource-limited environments. Systemic barriers—including workforce shortages, insufficient funding for mental health infrastructure, and persistent stigma—continue to hinder the implementation and scalability of evidence-based interventions, particularly in low- and middle-income countries such as Iran [10–14]. Epidemiological data suggest that fewer than 30% of affected children and adolescents receive any form of evidence-based treatment, with even lower rates in rural or underserved areas [12, 14]. Contributing factors include limited availability of trained providers, cultural stigma, and logistical obstacles [12, 13]. Additionally, local studies emphasize the need to adapt assessment tools and treatment protocols to reflect local family structures, cultural beliefs, and caregiving practices [15]. Although the efficacy of core interventions such as CBT and SSRIs is generally supported, greater engagement and sustained benefits may be achieved when interventions are tailored for cultural relevance and implemented in collaboration with families and schools [10, 11, 15].

Future research directions

Given the limitations identified in the current literature, future research should prioritize several key areas. First, there is a critical need to culturally adapt and systematically evaluate CBT and related interventions for use in Iran and other non-Western contexts, as much of the evidence base has been established in Western societies, potentially limiting generalizability. Specifically, future work should explore which aspects of Western-developed CBT—such as its emphasis on individualism, direct emotional expression, and egalitarian parent-child dynamics—may not align with the values and practices of Iranian or other collectivist, family-centered cultures. For example, adaptations might involve reframing therapeutic goals to emphasize family harmony, indirect communication styles, and respect for parental authority, as well as integrating culturally relevant metaphors and examples in treatment materials. Rigorous RCTs and longitudinal studies with extended follow-up periods are required to assess both the efficacy and sustainability of these interventions within local populations. Additionally, research should address the underrepresentation of innovative approaches such as ACT, brief intensive interventions, and iCBT, which may help overcome barriers related to workforce shortages and limited access to trained professionals. Investigating scalable, technology-assisted interventions—particularly iCBT—can facilitate broader reach, especially in rural or underserved regions where mental health resources are scarce. Future studies should also focus on integrating mental health services into primary care and school-based settings, leveraging existing infrastructures to improve access and reduce stigma associated with seeking mental health support. Developing and validating locally relevant assessment tools, as well as adapting treatment protocols to reflect Iran’s unique family structures, caregiving practices, and cultural beliefs, will further enhance the relevance and acceptability of interventions. Moreover, the creation of clinical guidelines tailored to the Iranian healthcare system is essential for optimizing pharmacological treatment outcomes and ensuring patient safety. Research should also examine effective strategies for engaging families and schools in the treatment process, as collaborative approaches have been shown to support greater engagement and sustained benefits for children and adolescents. Furthermore, a more comprehensive system-level analysis of barriers is warranted. Applying frameworks such as the WHO health systems building blocks (service delivery, health workforce, information, medical products, financing, and leadership/governance) can help identify gaps and guide recommendations specific to the Iranian context. This approach can highlight system-wide needs, such as improving provider training, increasing funding allocations, and strengthening health information systems to support evidence-based mental health care. Addressing systemic barriers—such as workforce shortages, inadequate funding, and persistent stigma—should be an integral part of future investigations, with emphasis on implementation science and health policy research to inform scalable solutions for low- and middle-income countries. Taken together, these research directions will help bridge existing gaps in service delivery, improve access to evidence-based interventions, and ensure that treatments are culturally appropriate, feasible, and effective within the Iranian context.

Conclusion

This systematic narrative review underscores that anxiety disorders constitute a pervasive and pressing mental health concern among children and adolescents both globally and within the Iranian context. With prevalence rates consistently ranging between 10 and 20%, these disorders exert a profound impact on academic achievement, psychosocial functioning, and long-term mental health trajectories. CBT remains the gold-standard intervention, supported by robust evidence for efficacy across multiple anxiety subtypes and age groups. Family-based interventions and SSRIs further augment treatment outcomes, particularly for moderate-to-severe or treatment-resistant cases, with combined therapeutic modalities demonstrating the highest rates of symptom remission and functional improvement. Despite these advances, significant gaps persist in the translation of evidence-based interventions into culturally and contextually relevant practice, especially in non-Western and resource-limited settings such as Iran. Barriers including limited access to qualified professionals, inadequate mental health infrastructure, and cultural stigma contribute to an ongoing treatment gap, leaving the majority of affected youth without effective care. Additionally, the predominance of Western-developed protocols highlights the urgent need for systematic adaptation and rigorous evaluation of interventions to ensure cultural congruence and sustainability in diverse populations. Future research and policy initiatives should prioritize culturally sensitive adaptation of psychological and pharmacological treatments, development of locally validated assessment tools, and integration of mental health services within schools and primary care settings. Emphasis should also be placed on innovative, scalable approaches such as internet-delivered CBT to address workforce shortages and expand access, particularly in underserved regions. A comprehensive, system-level strategy—addressing provider training, funding, information systems, and stigma reduction—is essential for bridging the treatment gap and optimizing outcomes for children and adolescents with anxiety disorders. In sum, addressing pediatric anxiety disorders requires a coordinated, evidence-based, and culturally attuned response. By bridging global evidence with local realities, stakeholders can develop and implement interventions that are not only effective, but also accessible and acceptable, thereby reducing the burden of anxiety disorders and promoting lifelong mental health for future generations.

Abbreviations

ACT

Acceptance and commitment therapy

AMSTAR 2

A Measurement Tool to Assess Systematic Reviews

CAMELS

The child/adolescent anxiety multimodal extended long-term study

CBT

Cognitive-behavioral therapy

iCBT

Digitally-delivered CBT

JBI

The Joanna Briggs Institute

NOS

The Newcastle-Ottawa Scale

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCTs

Randomized controlled trials

SSRIs

Selective serotonin reuptake inhibitors

Author contributions

M.KH. designed the study, collected the data, conducted the data analysis, drafted the manuscript and interpreted the results. The author approved the final version of the manuscript.

Funding

The author received no specific funding for this work.

Data availability

The data analyzed in this study are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.