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Anxiety Medication and Kids

— Anxiety and Depression Association of America
Updated on Apr 30, 2014

The use of medication is just one of the many treatment options available to manage the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medications without knowing which ones are appropriate, how they will affect their child, and if and when they are safe to use.

Frequently asked questions* about treating anxiety disorders in children with medication:

  1. Which medications are typically used to treat anxiety disorders in children?
  2. Are SSRIs safe for my child?
  3. How is the clinical need for medication determined?
  4. What are the most common side effects of SSRIs?
  5. What do I do if my child develops side effects?
  6. How can I tell if the medication is working?
  7. How long will it take for the medication to work?
  8. How long will my child need to take medicine?
  9. Will my child become addicted to these medications? Will the medications change my child's personality?
  10. What if my child refuses to take the medication?
  11. Can SSRIs be used with other medications, including over-the-counter medicines for common illnesses such as a cold or the flu?
  12. Are there other treatments available if I don't want to put my child on medication?

1. Which medications are typically used to treat anxiety disorders in children?

The selective serotonin reuptake inhibitors (SSRIs) are currently the medications of choice for the treatment of both childhood and adult anxiety disorders. This group of medications includes fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). Tricyclic antidepressants (e.g. imipramine) and benzodiazepines (e.g. lorazepam) are less commonly used in the treatment of childhood anxiety disorders. Other medications have been used to treat anxiety disorders in adults but require further study in children and adolescents.

The Food and Drug Administration (FDA) has approved the use of fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and clomipramine (Anafranil) for the treatment of pediatric Obsessive-Compulsive Disorder. SSRIs are commonly used in clinical practice to treat youth with other anxiety disorders as well based upon controlled studies that report improvement in symptoms and medication safety in children and adults with anxiety and depressive disorders. Controlled clinical studies provide the necessary information for the FDA to determine whether medications will be approved. Unfortunately, studies of the use of medications in children lag behind studies of adults; more research is definitely needed in this area. Discuss the risks and benefits of all medications prescribed for your child, whether FDA approved or not, with your physician.

2. Are SSRIs safe for my child?

The Food and Drug Administration issued a warning in October 2004 that antidepressant medications, including SSRIs, may increase suicidal ideation and suicidal behaviors in a small number of children and adolescents. The FDA report was based upon review of 24 different short-term (4 to 16 weeks) studies of 9 antidepressant medications (SSRIs and others) involving over 4,400 children and adolescents with major depressive disorder, obsessive-compulsive disorder, or other psychiatric disorders. Analyses of the studies showed that the average risk of suicidal ideation and suicidal behaviors occurred in 4% of patients treated with an antidepressant, compared to 2% of patients who were treated with a placebo (sugar pill). No suicides occurred in any of the studies.

Caregivers should be open to asking their child or adolescent if he/she is having suicidal thoughts, and to monitor for changes in behavior such as agitation, restlessness, irritability or other changes in your child's behavior or personality. Parents should contact their child's doctor if any of these or other concerns arise. The medication dose may need to be lowered, or the medication may need to be discontinued. Patients should not stop taking their medication abruptly without their doctor's supervision since this may worsen symptoms. In the recent review of studies by the FDA, there was some limited evidence that suicidal ideation and behaviors occurred most often at the beginning of treatment or at the time of a dosage change. However, because this evidence was far from definitive, monitoring should occur throughout treatment.

The FDA warning does not prohibit the use of these medications in children and adolescents. The FDA warning alerts patients and families to the risk of suicidal thoughts and behavior, but also notes that this risk must be balanced with clinical need.

3. How is the clinical need for medication determined?

Medications are used to treat anxiety disorders when symptoms are causing significant subjective distress for the child and/or are contributing to persistent functional impairment e.g. difficulties at school, with peers, and/or at home. Severity of symptoms will determine whether medications are started at the beginning of treatment at the same time as psychotherapy, or added later if symptoms do not improve with psychotherapy alone.

Some clinicians have argued that medications should only be used after children with an anxiety disorder fail to respond to psychotherapy. While this is a reasonable position, opinions remain mixed on this view. For example, many children with severe anxiety will not even begin to initiate the tasks that must be completed for psychotherapy to be successful. Others will simply refuse to talk with a therapist at all. For these children, it would be reasonable to initiate treatment with a medication before a course of psychotherapy has been attempted.

Caregivers should be open to asking their child or adolescent if he/she is having suicidal thoughts, and to monitor for changes in behavior such as agitation, restlessness, irritability or other changes in your child's behavior or personality. Parents should contact their child's doctor if any of these or other concerns arise. The medication dose may need to be lowered, or the medication may need to be discontinued. Patients should not stop taking their medication abruptly without their doctor's supervision since this may worsen symptoms. In the recent review of studies by the FDA, there was some limited evidence that suicidal ideation and behaviors occurred most often at the beginning of treatment or at the time of a dosage change. However, because this evidence was far from definitive, monitoring should occur throughout treatment.

4. What are the most common side effects of SSRIs?

The SSRIs are generally tolerated very well, with minimal or no side effects. The most commonly reported physical side effects include headache, stomachache or nausea, and sleep difficulties. It is important for your doctor to determine if any of these physical symptoms are present before starting the medication. Physical symptoms could be related to an underlying medical problem, or reflect symptoms of anxiety (e.g. headache or stomachache) that may actually improve with treatment of the anxiety disorder. Your child's physician should review symptoms of possible side effects with you and your child prior to starting an SSRI, and at subsequent follow-up visits.

5. What do I do if my child develops side effects?

Call your doctor with any questions or concerns regarding possible side effects during the course of treatment. Some children have side effects to one SSRI, but not to others, so a trial of a different SSRI may be needed if side effects develop to the initial medication.

6. How can I tell if the medication is working?

Treatment monitoring begins with a thorough assessment and understanding of your child's anxiety symptoms. There are different types of childhood anxiety disorders, and hence, different types of symptoms. For example, separation anxiety disorder symptoms include avoidance of separation from caregivers or home, e.g. school refusal, "shadowing" parents around the house, or avoiding social get-togethers such as peer birthday parties or overnight camps. Generalized anxiety disorder, characterized by multiple areas of worry, is often accompanied by symptoms of tenseness, sleep difficulties and irritability. The child's treatment plan should include specific "target symptoms" that the child is experiencing; these target symptoms can then be followed for assessment of treatment response. Symptom rating scales may be used by your child's health care professional as an additional measure of treatment response. Finally, other adults, such as family members or teachers, are also important sources of information about your child's symptoms.

7. How long will it take for the medication to work?

Initiation of treatment with an SSRI will not produce an immediate decrease in your child's symptoms of anxiety. Improvement in your child's symptoms may begin to occur after a week or more of treatment, although an initial treatment trial of four to six weeks is needed to assess clinical response. It is also very important that your child take the SSRI on a daily basis, at approximately the same time each day (i.e. not on an "as needed" basis), in order to achieve stable and effective medication levels.

8. How long will my child need to take medicine?

Current recommendations suggest that initial treatment of childhood anxiety disorders with an SSRI should be continued for approximately one year. Medication treatment may be recommended beyond this period if symptoms persist or reoccur. Symptoms and treatment response should be reassessed at regular intervals with your child's doctor. Starting a child on an SSRI does not mean that he/she will be on the medication for life. Many children may not need more than one course of medication treatment.

9. Will my child become addicted to these medications?

Will the medications change my child's personality?

There is no evidence that the SSRIs are addictive. If medications are discontinued abruptly, symptoms such as dizziness, nausea, headache, and behavioral changes may occur. Medication dosages should not be changed, and medications should not be discontinued unless directed by the child's physician.

Treatment with SSRIs should not change your child's personality. Conversely, anxiety disorders may cloud features of your child's personality due to the impact of the anxiety symptoms and associated distress. If prominent changes in your child's behavior and demeanor do occur, parents should check with their physician about possible medication-related side effects.

10. What if my child refuses to take the medication?

Children should not be forced to take medications, nor should the medications be disguised or inaccurately described. It is important to try to find out why the child does not want to take the medicine. Questions to consider:

Does the child have difficulty swallowing pills?

Does the child fear that something may happen to him/her if he/she takes the medicine?

Is the child concerned of possible embarrassment if others learn that he/she is taking a medication for anxiety?

Educating and involving your child in the discussion of his/her anxiety disorder is very important. Discussion should include review of symptoms that cause difficulties. Treatments should also be discussed, at a developmentally appropriate level, emphasizing the goal of symptom improvement. If the child refuses to take a medication, an initial treatment course of psychosocial interventions such as cognitive behavioral therapy should be considered, with subsequent review of medication use if symptoms do not improve.

11. Can SSRIs be used with other medications, including over-the-counter medicines for common illnesses such as a cold or the flu?

Check with your physician before adding or changing any of your child's medications to avoid potential medication interactions.

12. Are there other treatments available if I don't want to put my child on medication?

Cognitive behavioral therapy (CBT) is the most widely studied and commonly used form of psychotherapy to treat childhood anxiety disorders. CBT targets the symptoms of anxiety, and incorporates a variety of approaches designed to change maladaptive thoughts/beliefs and behaviors associated with anxiety disorders. Other psychosocial interventions should also be considered for children with anxiety disorders including the possibility of school support, family therapy, and assessment of potential environmental (e.g. home or school) stressors contributing to the child's difficulties.

The use of psychosocial interventions, including CBT, is recommended for all children with anxiety disorders, whether they are being treated with medications or not. Parents should actively discuss treatment options with their child's health care provider.

Additional Resources:

About Our Kids American Academy of Child & Adolescent Psychiatry Caring for Every Child's Mental Health Campaign The Center for Health and Healthcare in Schools

*This information was taken from an interview with Marcia J. Slattery, M.D., M.H.S., Director of Child and Adolescent Psychiatry at the University of Wisconsin Medical School, November 2004. Dr. Slattery specializes in the clinical care and research of children and adolescents with anxiety disorders.

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