What can be added to Abilify (aripiprazole) for an 11-year-old child with anxiety?

Treatment Recommendation for Anxiety in an 11-Year-Old on Abilify

Add an SSRI (specifically sertraline) combined with cognitive-behavioral therapy (CBT) to the current Abilify regimen for this 11-year-old child with anxiety. 1, 2

Primary Treatment Approach

The American Academy of Child and Adolescent Psychiatry strongly recommends combination treatment with an SSRI plus CBT as the gold standard for pediatric anxiety disorders in children aged 6-18 years. 1, 2 This combination demonstrates superior efficacy compared to either treatment alone, with a number needed to treat of 3 for response versus a number needed to harm of 143 for suicidal ideation—making the benefit-to-risk ratio highly favorable. 2

Why Sertraline Specifically

• Sertraline has the most robust evidence base for anxiety disorders in children and adolescents, particularly when combined with CBT, showing moderate to high strength of evidence for improving anxiety symptoms, global function, treatment response, and disorder remission. 1, 2
• Start with a subtherapeutic "test" dose to minimize initial anxiety or agitation that can occur with SSRI initiation. 2
• Sertraline may require twice-daily dosing at low doses due to its shorter half-life in adolescents. 2
• Begin with slow up-titration to avoid exceeding the optimal dose, as the dose-response relationship is logarithmic rather than linear. 2

Expected Timeline

• Statistically significant improvement within 2 weeks 2
• Clinically significant improvement by week 6 2
• Maximal improvement by week 12 or later 2

Cognitive-Behavioral Therapy Components

CBT should include these specific evidence-based elements tailored to the child's anxiety presentation: 1

• Graduated exposure (the cornerstone): Create a fear hierarchy that is mastered stepwise using real-life desensitization, emotive imagery, live modeling, and contingency management with positive reinforcement 1
• Education about anxiety and behavioral goal setting with contingent rewards 1
• Self-monitoring for connections between worries/fears, thoughts, and behaviors 1
• Relaxation techniques including deep breathing, progressive muscle relaxation, and guided imagery 1
• Cognitive restructuring that challenges catastrophizing, over-generalization, negative prediction, and all-or-nothing thinking 1
• Family-directed interventions to improve parent-child relationships, strengthen problem-solving skills, reduce parental anxiety, and foster anxiety-reducing parenting skills 1

Critical Safety Monitoring

Monitor closely for suicidal ideation and behavior, especially in the first weeks after starting or increasing the SSRI dose, as all SSRIs carry a boxed warning for suicidal ideation through age 24 years. 2, 3 The pooled absolute rate for suicidal ideation is 1% with antidepressants versus 0.2% with placebo (risk difference 0.7%). 2

Additional monitoring should include: 2

• Behavioral activation/agitation (can occur early in SSRI treatment)
• Common transient adverse effects: nausea, diarrhea, abdominal pain, drowsiness, headache, insomnia, vivid dreams
• Parental oversight of medication regimens is paramount, including monitoring adherence, observing for adverse effects, and ensuring proper dosing schedules 2

Why Not Other Options

Do not use benzodiazepines as first-line treatment despite their rapid anxiolytic effect, due to risks of dependence, cognitive impairment, and lack of evidence for long-term efficacy in adolescents. 3

Hydroxyzine is considered only an alternative option when SSRIs are not suitable or as adjunctive treatment, but it is not first-line and causes significant sedation that may affect school performance and activities. 4

Aripiprazole alone (which the child is already taking) has limited evidence for primary anxiety disorders in children. While some adult studies suggest aripiprazole may augment SSRIs for residual anxiety symptoms 5, 6, there is no established evidence base for using aripiprazole as monotherapy for pediatric anxiety disorders, and the AACAP guidelines do not recommend it for this indication. 1

School Accommodations

Coordinate with the school to implement a 504 plan or IEP modifications that address functional impairments, including graduated practice opportunities for anxiety management and specific anxiety management strategies in the school setting. 1, 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for "the perfect intervention"—early effective treatment strongly predicts better long-term outcomes, even though the superiority of combination treatment may not persist indefinitely. 2, 3
• Do not ignore parental anxiety, which can inadvertently reinforce avoidance behaviors; consider parental treatment if indicated. 3
• Do not treat in isolation—coordinate care between mental health provider, primary care, and school. 3
• Do not use aripiprazole as the primary anxiety treatment when evidence-based options (SSRIs + CBT) are available. 1, 2

Alternative SSRI Options

If sertraline is not tolerated, alternative SSRIs with evidence for pediatric anxiety disorders include fluoxetine, escitalopram, fluvoxamine, and paroxetine. 1, 3 SNRIs (venlafaxine, duloxetine) can be considered as second-line options if SSRIs are ineffective or not tolerated, though they have less robust evidence and are associated with increased fatigue/somnolence. 2