What is the recommended treatment for anxiety in an 11-year-old?

Treatment of Anxiety in an 11-Year-Old Child

For an 11-year-old child with anxiety, cognitive behavioral therapy (CBT) should be offered as the first-line treatment, with selective serotonin reuptake inhibitors (SSRIs) considered when CBT alone is insufficient or unavailable. 1

First-Line Treatment: Cognitive Behavioral Therapy (CBT)

CBT is the cornerstone of anxiety treatment in children and should be implemented before considering medication. The American Academy of Child and Adolescent Psychiatry (AACAP) strongly endorses this approach 1. Key components include:

• Education about anxiety
• Behavioral goal setting with rewards
• Self-monitoring techniques
• Relaxation techniques (deep breathing, progressive muscle relaxation)
• Cognitive restructuring to challenge distorted thinking
• Graduated exposure to feared stimuli (the most critical element)
• Problem-solving and social skills training

Implementation Considerations:

• CBT should be delivered by professionals with specialized training
• Treatment should be tailored to the specific anxiety disorder (separation anxiety, social anxiety, generalized anxiety)
• Family involvement is crucial for reinforcing skills and managing anxiety triggers
• School-based interventions may be necessary (can be included in 504 plans or IEPs)

Second-Line Treatment: Medication (SSRIs)

If CBT alone is insufficient or unavailable, SSRIs may be considered for children 6-18 years old with anxiety disorders 1, 2.

SSRI Selection and Dosing:

• Sertraline is recommended as a first-line medication option for children with anxiety disorders 2
  • Starting dose: 25 mg once daily for one week 3
  • Increase to 50 mg once daily after one week 3
  • Maximum dose: up to 200 mg/day, with dose changes at intervals of not less than 1 week 3

Monitoring and Duration:

• Initial follow-up within 1-2 weeks of starting medication 2
• Monitor for treatment-emergent adverse events including headaches, stomach aches, behavioral activation, and suicidal thoughts 2
• Continue effective treatment for approximately 1 year following symptom remission 2

Important Considerations and Cautions

Efficacy Evidence:

• SSRIs have demonstrated moderate efficacy for anxiety disorders in children 1, 4
• Medication and placebo response rates in pediatric anxiety disorders are approximately 58.1% and 31.5%, respectively (NNT = 4) 4

Safety Concerns:

• SSRIs are generally well-tolerated, but monitor for side effects including:
  • Gastrointestinal symptoms (nausea, stomach aches)
  • Headaches
  • Sleep disturbances
  • Behavioral activation
  • Suicidal ideation (rare but serious concern)
• Only 4.9% of children typically withdraw from treatment due to medication side effects 4

Treatment Algorithm:

1. Begin with CBT as first-line treatment
2. If inadequate response after 8-12 weeks of CBT:
   • Add SSRI (sertraline preferred) starting at low dose
   • OR switch to SSRI if CBT is unavailable/inaccessible
3. If partial response to SSRI after 4-6 weeks:
   • Gradually increase dose within recommended range
4. If good response:
   • Continue treatment for approximately 1 year after symptom remission

Common Pitfalls to Avoid

• Premature medication use: Don't skip CBT as first-line treatment
• Inadequate dose or duration: Allow sufficient time (4-6 weeks) at therapeutic doses before determining efficacy
• Abrupt discontinuation: Always taper SSRIs gradually to avoid discontinuation symptoms
• Neglecting family involvement: Parents play a crucial role in reinforcing CBT skills and managing anxiety triggers
• Benzodiazepine use: Benzodiazepines are not recommended for routine use in children due to dependency concerns 5, 4

Remember that anxiety disorders in children are highly treatable with appropriate intervention, and early effective treatment can prevent significant impairment in academic, social, and family functioning 6.