Anxiety Disorders in Children and Adolescents: Page 4 of 4
Anxiety Disorders in Children and Adolescents: Page 4 of 4
The safety and efficacy of medications other than SSRIs for the treatment of childhood anxiety disorders have not been established. Venlafaxine, tricyclic antidepressants (TCAs), buspirone, and benzodiazepines have been used as clinical alternatives, either alone or in combination with SSRIs. Switching to another SSRI to treat resistant anxiety has been shown to be helpful, and adding a second type of medication may be useful when there is a partial response. Comorbid diagnoses must be considered in the selection of medication.2,19
Although the combined results were positive, only 1 of 2 trials with extended-release venlafaxine showed significant improvements relative to placebo in children with GAD.20 On the basis of significant changes in blood pressure, pulse, and cholesterol levels with treatment, venlafaxine is considered only after several failed trials of SSRIs. Also, relative risk of suicidality with venlafaxine may be higher than with SSRIs.
TCAs are not often used in children because of the need for close cardiac monitoring and greater medical risks with overdose. Controlled trials of TCAs for youths with anxiety disorders have demonstrated conflicting results.
Buspirone is used clinically as an alternative to SSRIs for GAD in children and adolescents or as an adjuvant medication, but there are no published controlled studies for its use in children with anxiety disorders. Buspirone may be tolerated at higher doses in adolescents than in children with anxiety. The most common adverse effects are light-headedness, headache, and dyspepsia.
Benzodiazepines have not shown efficacy in controlled trials in children with anxiety disorders. Clinically, they can be used short term to achieve acute reduction in severe anxiety symptoms while an SSRI is started or to permit initiation of the exposure phase of CBT for children who refuse to go to school or who have panic disorder or specific phobia. However, benzodiazepines should be used cautiously in youths because of the risk of developing dependence, and they are contraindicated in youths with a history of substance abuse.2,19 Possible adverse effects include sedation, disinhibition, behavioral dyscontrol, and cognitive impairments. If benzodiazepine treatment is stopped abruptly, there is risk of severe withdrawal symptoms, including insomnia, anxiety, GI upset, and seizures.
References1. 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.
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.
Suggested Reading for CliniciansConnolly 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.
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.
Suggested Reading for ParentsMcHolm AE, Cunningham CE, Vanier MK. Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland, CA: New Harbinger Publications; 2005.
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.