Anxiety Disorders in Children and Adolescents

School interventions

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).

Pharmacotherapy

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(Drug information on 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(Drug information on 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.