Classroom-based accommodations can assist the child when anxiety disorders impair school functioning. A key worker can be identified in the school setting to assist the child with problem-solving or anxiety-management strategies. The school is encouraged to help the child reduce anxiety and remain at school whenever possible to reduce the risk of the child refusing to go to school. If performance or test anxiety is present, then testing in a private environment with extended testing time may be helpful. Accommodations for the anxiety disorder can be written into the student’s 504 Plan or Individualized Educational Plan (IEP).
Placebo-controlled trials have demonstrated short-term effectiveness of SSRIs for the treatment of childhood anxiety disorders (Table 3). SSRIs are the first-line pharmacological treatment for anxiety disorders in this population.16 Although the FDA has issued a black-box warning for use of antidepressants in the pediatric population, including SSRIs, the benefit to risk ratio for anxiety disorders may be more favorable than that for depression.16 Clinicians should monitor for worsening depression, agitation, or suicidality, particularly at the beginning of medication treatment or when there is a change in dosage.
SSRIs have been well tolerated by children with anxiety disorders. Common adverse effects include GI symptoms, headache, increased motor activity, and insomnia. These adverse effects are often mild or temporary. Less common adverse effects include disinhibition and more severe forms of behavioral activation, such as agitation or aggression. These adverse effects may improve by reducing the dose of the SSRI. Disinhibition can present with acute symptoms of defiance or increased emotional reactivity and needs to be distinguished from positive treatment effects such as increased initiative and assertiveness in anxious children. The clinician should screen for symptoms of bipolar disorder or family history of bipolar disorder before initiating treatment with an SSRI or other antidepressant.
Clinicians can consider increasing the SSRI dose by the fourth week of medication treatment if significant improvement in anxiety severity or impairment is not achieved.4,17 Studies of long-term risks and benefits of SSRIs are limited. Clinicians can consider a medication-free trial after 1 year of SSRI treatment for those children who achieve marked improvement in anxiety or depressive symptoms and impairment. This decrease or discontinuation of medication can occur during a low-stress period, with close monitoring for relapse so that medication can be restarted promptly if necessary.
A study of paroxetine in youths with social phobia showed some significant adverse effects, such as vomiting, decreased appetite, and insomnia, in the active-treatment group.18 Relative suicide risk in this trial was elevated, although not statistically significant.
There are no controlled medication studies in youths with panic disorder. Clinically, SSRIs are considered first-line pharmacotherapy and may be combined with benzodiazepines (clonazepam or lorazepam) when severe panic symptoms are present.19
SSRIs have not been compared with one another for the treatment of childhood anxiety disorders, but clinicians can consider adverse-effect profile, duration of action, patient adherence or preference, and positive response in a first-degree relative. Some differences in dosing effects by age are emerging in SSRIs, with children showing more adverse effects and higher peak plasma concentration than adolescents at similar doses. Clinicians are advised to start at low doses, monitor adverse effects closely, and titrate slowly on the basis of treatment response and tolerability. In young children who have selective mutism or other anxiety disorders, using the liquid form of an SSRI medication and starting at a very low dose may reduce the likelihood of adverse effects.
1. Costello EJ, Egger HL, Angold A. Developmental epidemiology of anxiety disorders. In: Ollendick TH, March JS, eds. Phobic and Anxiety Disorders in Children and Adolescents. New York: Oxford University Press; 2004:334-380. Suggested Reading for Clinicians Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283. Suggested Reading for Parents McHolm AE, Cunningham CE, Vanier MK. Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications; 2005.
2. Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46:267-283.
3. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.
4. Birmaher B, Axelson DA, Monk K, et al. Fluoxetine for the treatment of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2003;42:415-423.
5. March JS, Ollendick TH. Integrated psychosocial and pharmacological treatment. In: Ollendick TH, March JS, eds. Phobic and Anxiety Disorders: A Clinician’s Guide to Effective Psychosocial and Pharmacological Interventions. New York: Oxford University Press; 2004:141-174.
6. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359:2753-2766.
7. Connolly SD, Suarez LM. Generalized anxiety disorder, specific phobia, panic disorder, social phobia and selective mutism. In: Dulcan MK, ed. Dulcan’s Textbook of Child and Adolescent Psychiatry. In press.
8. Compton SN, March JS, Brent D, et al. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.
9. Velting ON, Setzer NJ, Albano AM. Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents. Prof Psychol Res Pract. 2004;35:42-54.
10. Albano AM, Kendall PC. Cognitive-behavioural therapy for children and adolescents with anxiety disorders: clinical research advances. Int Rev Psychiatry. 2002;14:129-134.
11. Grover RL, Hughes AA, Bergman RL, Kingery JN. Treatment modifications based on childhood anxiety diagnosis: demonstrating the flexibility in manualized treatment. J Cognitive Psychother. 2006;20:275-286.
12. King NJ, Muris P, Ollendick TH. Childhood fears and phobias: assessment and treatment. Child Adolesc Mental Health. 2005;10:50-56.
13. Barlow DH, Craske MG. Mastery of Your Anxiety and Panic: Therapist Guide for Anxiety, Panic, and Agoraphobia. 4th ed. New York: Oxford University Press; 2007:209.
14. Beidel DC, Turner SM, Young B, Paulson A. Social effectiveness therapy for children: three-year follow-up. J Consult Clin Psychol. 2005;73:721-725.
15. Cohan SL, Chavira DA, Stein MB. Practitioner review: psychosocial interventions for children with selective mutism: a critical evaluation of the literature from 1990-2005. J Child Psychol Psychiatry. 2006;47:1085-1097.
16. Seidel L, Walkup JT. Selective serotonin reup-take inhibitor use in the treatment of pediatric non–obsessive-compulsive disorder anxiety disorders. J Child Adolesc Psychopharmacol. 2006;16:171-179.
17. The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med. 2001;344:1279-1285.
18. Wagner KD, Berard R, Stein MB, et al. A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry. 2004;61:1153-1162.
19. Reinblatt SP, Riddle MA. The pharmacological management of childhood anxiety disorders: a review. Psychopharmacology (Berl). 2007;191:67-86.
20. Rynn MA, Riddle MA, Yeung PP, Kunz NR. Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. AmJ Psychiatry. 2007;164:290-300.
21. Black B, Uhde TW. Treatment of elective mutism with fluoxetine: a double-blind, placebo-controlled study. J Am Acad Child Adolesc Psychiatry. 1994;33: 1000-1006.
22. Rynn MA, Siqueland L, Rickels K. Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. Am J Psychiatry. 2001;158:2008-2014.
Connolly SD, Suarez LM. Generalized anxiety dis-order, specific phobia, panic disorder, social phobia and selective mutism. In: Dulcan MK, ed. Essentials of Child & Adolescent Psychiatry. Washington, DC: American Psychiatric Press. In press.
Ollendick TH, March JS, eds. Phobic and Anxiety Disorders in Children and Adolescents. New York: Oxford University Press; 2004.
Rapee RM, Wignall A, Hudson J, Schniering C. Treating Anxious Children and Adolescents: An Evidence-Based Approach. Oakland, CA: New Harbinger Publications; 2000.
Rapee RM, Wignall A, Spence SH, Cobham V. Helping Your Anxious Child: A Step-by-Step Guide for Parents.Oakland, CA: New Harbinger Publications; 2008.
Suggested Reading for Clinicians
Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007;46:267-283.
Suggested Reading for Parents
McHolm AE, Cunningham CE, Vanier MK. Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications; 2005.