What are the first-line treatments for anxiety disorders in children?

First-Line Treatments for Anxiety Disorders in Children

Cognitive-behavioral therapy (CBT) is the first-line treatment for mild to moderate anxiety in children and adolescents, while selective serotonin reuptake inhibitors (SSRIs)—particularly sertraline—are recommended as first-line pharmacological treatment for severe presentations or when quality CBT is unavailable. 1

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Begin with CBT as monotherapy, delivered over 12-20 sessions targeting cognitive distortions, behavioral avoidance, and physiologic symptoms 1
• CBT components should include psychoeducation about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving/social skills training 1
• Systematic assessment using standardized symptom rating scales should guide treatment effectiveness 1

Severe Anxiety Presentations

• Initiate combination treatment with both CBT and an SSRI for optimal outcomes, as combination therapy is more effective than either treatment alone 1, 2
• The Child-Adolescent Anxiety Multimodal Study (CAMS) demonstrated superior efficacy with combined CBT and sertraline versus monotherapy 2

First-Line Pharmacological Treatment: SSRIs

Sertraline (Preferred Agent)

• Start sertraline at 25 mg once daily for panic disorder, PTSD, and social anxiety disorder; 50 mg once daily for OCD and depression 3
• After one week at 25 mg, increase to 50 mg once daily 3
• Titrate by 25-50 mg increments every 1-2 weeks as tolerated, with target therapeutic range of 50-200 mg/day 1, 3
• Sertraline has the most favorable drug interaction profile among SSRIs and lower risk of discontinuation syndrome compared to paroxetine 2

Alternative SSRIs

• Escitalopram: Start 5-10 mg daily, titrate by 5-10 mg increments every 1-2 weeks, target dose 10-20 mg/day 4
• Fluoxetine: Start 5-10 mg daily, increase by 5-10 mg every 1-2 weeks, target 20-40 mg daily; longer half-life beneficial for patients who occasionally miss doses 4
• Fluvoxamine: Effective but may require twice-daily dosing at low doses and has higher risk of discontinuation symptoms 5, 4

Dosing for Pediatric Patients (Ages 6-17)

• Children ages 6-12: Start sertraline 25 mg once daily for OCD 3
• Adolescents ages 13-17: Start sertraline 50 mg once daily for OCD 3
• Maximum dose 200 mg/day; consider lower body weights in children when advancing doses to avoid excess dosing 3
• Dose changes should not occur at intervals less than 1 week given sertraline's 24-hour elimination half-life 3

Expected Response Timeline and Monitoring

Therapeutic Response Pattern

• Statistically significant improvement may begin by week 2, clinically significant improvement expected by week 6, and maximal benefit by week 12 or later 5, 4
• This logarithmic response model supports slow up-titration to avoid exceeding optimal dose 5
• Do not abandon treatment prematurely; full response requires 12+ weeks 4

Critical Monitoring Requirements

• Monitor closely for suicidal thinking and behavior, especially in the first months and after dose adjustments 5
• Pooled absolute risk of suicidal ideation: 1% with antidepressants vs 0.2% with placebo (risk difference 0.7%, NNH=143) 5
• Number needed to treat for response is 3, far exceeding the NNH of 143 5

Common Adverse Effects (First Few Weeks)

• Gastrointestinal: nausea, diarrhea, heartburn 5
• Neurological: headache, dizziness, tremor 5
• Sleep-related: insomnia, somnolence, vivid dreams 5
• Other: dry mouth, changes in appetite, weight changes, fatigue, nervousness, diaphoresis 5

Behavioral Activation/Agitation

• More common in younger children than adolescents and in anxiety disorders versus depression 5
• Manifests as motor/mental restlessness, insomnia, impulsiveness, talkativeness, disinhibited behavior, aggression 5
• Occurs early in treatment, with dose increases, or with concomitant drugs inhibiting SSRI metabolism 5
• Educate parents/guardians in advance; use slow up-titration and close monitoring, particularly in younger children 5
• Usually improves quickly after dose decrease or discontinuation 5

Second-Line Pharmacological Options

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Consider when SSRIs are ineffective or not tolerated 1
• Venlafaxine extended-release 75-225 mg/day has demonstrated efficacy but requires blood pressure monitoring 4
• Duloxetine 60-120 mg/day effective, particularly with comorbid pain conditions 4

Hydroxyzine

• Appropriate for short-term or situational anxiety management as adjunct to SSRIs or monotherapy for milder cases 1
• Use lowest effective dose to minimize sedation 1

Medications to Avoid

Contraindicated or Not Recommended

• Paroxetine should be avoided due to higher risk of discontinuation syndrome, greater anticholinergic effects, and increased risk of suicidal thinking 2, 4
• Benzodiazepines lack efficacy data in randomized controlled trials for pediatric anxiety disorders 6
• Buspirone (5HT1A agonist) does not show efficacy in pediatric anxiety disorder cases 6
• Tricyclic antidepressants are ineffective for anxiety in youth and have unfavorable risk-benefit profile 4, 7

Treatment Duration and Discontinuation

Maintenance Treatment

• Continue treatment for at least 4-12 months after symptom remission 2
• Anxiety disorders in children and adolescents are often chronic with waxing and waning symptoms requiring ongoing monitoring 1
• Periodically reassess to determine need for continued treatment 3

Discontinuation Strategy

• Avoid abrupt discontinuation; taper medication slowly to prevent discontinuation syndrome 2, 4
• Shorter-acting SSRIs like sertraline require particularly careful tapering 2
• Paroxetine has highest risk of discontinuation symptoms 2, 4

Critical Pitfalls to Avoid

• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability and avoid overshooting therapeutic window 4
• Do not underestimate sensitivity in younger children: Start with subtherapeutic "test" doses and monitor closely for behavioral activation 2
• Do not use paroxetine as first-line: Higher discontinuation syndrome risk and potentially increased suicidal thinking 2, 4
• Do not prescribe benzodiazepines: Lack of efficacy data in pediatric anxiety despite common historical use 6