What is the recommended treatment for pediatric anxiety?

Recommended Treatment for Pediatric Anxiety

Cognitive-behavioral therapy (CBT) is the first-line treatment for children and adolescents aged 6-18 years with anxiety disorders, with SSRIs (particularly sertraline) recommended as an alternative for severe presentations or when quality CBT is unavailable. 1, 2

Treatment Algorithm Based on Severity

Mild to Moderate Anxiety

• Start with CBT alone as the initial intervention, consisting of 12-20 sessions targeting cognitive distortions, avoidance behaviors, and physiologic symptoms 1, 2
• CBT components should include psychoeducation about anxiety, behavioral goal setting with rewards, self-monitoring, relaxation techniques (deep breathing, progressive muscle relaxation), cognitive restructuring, graduated exposure to feared stimuli, and problem-solving skills training 1, 2
• Systematic assessment using standardized symptom rating scales should supplement clinical interviews to optimize treatment response monitoring 1

Severe Anxiety or Significant Functional Impairment

• Initiate combination treatment with CBT plus an SSRI (preferably sertraline), which demonstrates superior efficacy compared to either treatment alone 2, 3
• Start sertraline at 25-50 mg daily (lower doses for younger children) with gradual titration at 1-2 week intervals 2, 4, 3
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later—this logarithmic response pattern supports slow up-titration to avoid exceeding optimal dose 2

When CBT is Unavailable or Inaccessible

• SSRIs become the recommended first-line treatment, with sertraline or escitalopram as preferred agents 2, 4
• Alternative SSRIs include fluoxetine (starting 10 mg/day) or fluvoxamine (starting 25 mg/day, though requires twice-daily dosing at low doses) 2, 3

Critical Monitoring Requirements

SSRI Safety Monitoring

• Monitor closely for suicidal ideation and behavior, particularly in the first months of treatment and after dose adjustments, with special attention to younger children 2
• The pooled absolute risk of suicidal ideation with antidepressants is 1% versus 0.2% with placebo (risk difference 0.7%, number needed to harm = 143), while the number needed to treat for response is only 3 2
• Track common adverse effects including gastrointestinal symptoms (nausea, diarrhea, heartburn), headaches, behavioral activation/agitation (more common in younger children and anxiety disorders versus depression), insomnia, and restlessness 2, 3

Treatment Duration

• Continue medication for approximately 1 year following symptom remission 3
• When discontinuing, choose a stress-free time of year and taper gradually to minimize discontinuation symptoms 3
• If symptoms return after discontinuation, seriously consider medication re-initiation 3

Treatments NOT Recommended

Beta-Blockers (Propranolol)

• Do not use propranolol for pediatric anxiety disorders—the Canadian Clinical Practice Guideline specifically deprecates beta-blockers for social anxiety disorder based on negative evidence, and no international guidelines (NICE, S3, Canadian CPG) recommend propranolol for anxiety in any age group 4
• Using propranolol delays effective intervention and risks long-term impairments in social, educational, and health outcomes 4

Hydroxyzine Considerations

• Hydroxyzine may be appropriate only for short-term or situational anxiety as an adjunct to SSRIs or as monotherapy for milder cases, using the lowest effective dose to minimize sedation 2, 4
• This should not replace evidence-based first-line treatments (CBT or SSRIs) 4

Special Populations

Autism Spectrum Disorder

• Modified CBT remains first-line treatment with accommodations for autism-specific communication and cognitive differences 5
• If pharmacotherapy is needed, start sertraline at lower doses (25-50 mg daily for adults, lower for children) with gradual titration, as individuals with ASD may be more sensitive to medication side effects, particularly activation/agitation 5
• Begin with subtherapeutic "test" doses to assess tolerability 5

Common Pitfalls to Avoid

• Do not abandon treatment prematurely—maximal SSRI benefit requires 12+ weeks, and premature discontinuation prevents optimal outcomes 2, 4
• Do not ignore parental anxiety—parents who themselves struggle with anxiety benefit from additional psychoeducation and support; consider referral for parental treatment to optimize the child's treatment success 1
• Do not overlook comorbidities—anxiety disorders frequently co-occur with depression (56% prevalence) and other conditions that require assessment and may influence treatment selection 2
• Do not use attention control or treatment-as-usual as substitutes for evidence-based CBT—these approaches show inferior outcomes compared to structured, protocol-driven CBT 1