Treatment of Anxiety in Pediatrics
Cognitive-behavioral therapy (CBT) should be offered as first-line treatment for children and adolescents ages 6-18 with anxiety disorders, particularly for mild to moderate presentations, with SSRIs reserved for more severe cases or when quality CBT is unavailable. 1, 2
Treatment Algorithm by Severity
Mild to Moderate Anxiety
- Initiate CBT as monotherapy for children 6-18 years with social anxiety, generalized anxiety, separation anxiety, specific phobia, or panic disorder 1, 2
- CBT typically requires 12-20 sessions to achieve meaningful symptomatic and functional improvement 1, 2
- Use systematic assessment with standardized symptom rating scales throughout treatment to optimize response monitoring 1, 2
Severe Anxiety
- Combination treatment with CBT plus SSRI (particularly sertraline) is more effective than either treatment alone for severe presentations 1, 2, 3
- SSRIs may be initiated as first-line monotherapy when quality CBT is unavailable or access is limited 1, 2
- Consider combination therapy from the outset for patients with significant functional impairment 2
CBT Implementation Details
Core Components
CBT targets three primary anxiety dimensions and includes: 1
- Psychoeducation about anxiety and the cognitive-behavioral model
- Behavioral goal setting and self-monitoring techniques
- Relaxation training for physiologic symptoms
- Cognitive restructuring to address maladaptive beliefs
- Graduated exposure to feared situations (essential component)
- Problem-solving and social skills training 1, 2
Delivery Considerations
- Individual-based CBT is superior to waitlist and attention control 3, 4
- Group-based CBT is superior to waitlist control and treatment as usual 3
- Family-based CBT shows superiority over treatment as usual, waitlist, and attention control 3
- Treatment involves collaboration among patient, family, therapist, and when appropriate, school personnel 1
- Homework assignments are essential for skill reinforcement and generalization 1
Pharmacological Treatment
First-Line Medication: SSRIs
- Sertraline has the strongest evidence as first-line SSRI for pediatric anxiety 2, 5
- SSRIs have considerable empirical support as safe and effective short-term treatments 1, 6
- Start low and titrate gradually at 1-2 week intervals 7
- Monitor for common adverse effects: diarrhea, dizziness, dry mouth, fatigue, headache, nausea, sexual dysfunction, sweating, tremor, weight gain 2
- Close monitoring for suicidal ideation is essential, particularly in children, adolescents, and young adults 7
Second-Line Medication: SNRIs
- SNRIs (e.g., venlafaxine) have some empirical support as an additional treatment option 1, 2
- Consider when SSRIs are ineffective or not tolerated 2
Medications to Avoid
- Benzodiazepines are not recommended for pediatric anxiety disorders 1, 8
- Avoid in patients with substance use history or respiratory disorders 8
Evidence Quality and Comparative Effectiveness
CBT vs. Controls
- Moderate-quality evidence shows CBT improves primary anxiety symptoms (child, parent, clinician report), global function, and treatment response compared to waitlist/no treatment 1
- Low-quality evidence suggests CBT may increase remission compared to attention control 4
- CBT did not separate from pill placebo for child-reported primary anxiety symptoms (low strength of evidence) 1
Combination Treatment Superiority
- Combination CBT plus SSRI is more effective than either treatment alone, particularly for moderate to severe anxiety 1, 2, 5, 6
- The Child-Adolescent Anxiety Multimodal Study (CAMS) demonstrated superiority of combination treatment 7
Critical Pitfalls to Avoid
Assessment Errors
- Failing to confirm full diagnostic criteria including duration, frequency/severity, and clinically significant distress/functional impairment before initiating treatment 1
- Not obtaining multi-informant assessment from child, parents, and when appropriate, teachers 2
- Neglecting to rule out medical conditions mimicking anxiety (e.g., hyperthyroidism, cardiac arrhythmias) 2
Treatment Implementation Errors
- Inadequate CBT training: Specialized education and experience are necessary for effective CBT delivery 1
- Omitting exposure therapy: Graduated exposure is an essential CBT component that cannot be skipped 1
- Premature medication discontinuation: Continue treatment for at least 4-12 months after symptom remission 7
- Abrupt SSRI discontinuation: Always taper slowly to prevent discontinuation syndrome 7
Monitoring Failures
- Not using standardized rating scales to track treatment response systematically 1, 2
- Failing to monitor for behavioral activation/agitation when initiating SSRIs 7
- Inadequate suicide risk monitoring, especially during the first weeks of SSRI treatment 7
Special Populations
Children with Autism Spectrum Disorder
- CBT remains first-line for anxiety in children with ASD 7
- Start with subtherapeutic "test" doses of SSRIs as these children may be more sensitive to side effects 7
- Monitor closely for behavioral activation and agitation 7
Very Young Children (Ages 6-7)
- Treatment statements apply down to age 6 based on available study data 1
- Family involvement in CBT is particularly important for younger children 3
Access and Implementation Barriers
Current Treatment Gap
- Less than half of youth needing mental health treatment receive appropriate care 2
- Shortage of trained CBT providers limits access to first-line treatment 1
- Pharmacotherapeutic task-sharing with pediatric practitioners can expand access for moderate presentations while conserving child psychiatrists for severe/complex cases 1