What are the recommended medications and treatments for anxiety in children?

Recommended Medications for Childhood Anxiety

For children ages 6-18 with anxiety disorders (social anxiety, generalized anxiety, separation anxiety, or panic disorder), start with cognitive-behavioral therapy (CBT) as first-line treatment for mild-to-moderate cases, and use selective serotonin reuptake inhibitors (SSRIs)—specifically fluoxetine or sertraline—as first-line pharmacotherapy for severe presentations or when quality CBT is unavailable. 1, 2

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Begin with CBT monotherapy delivered over 12-20 structured sessions targeting cognitive distortions, behavioral avoidance, and physiologic arousal 1, 2
• CBT should include psychoeducation, behavioral goal-setting with rewards, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure to feared stimuli (the cornerstone for situation-specific anxiety) 1
• CBT demonstrates moderate strength of evidence for improving anxiety symptoms, global function, and treatment response compared to inactive controls 2

Severe Anxiety or CBT Failure

• Initiate SSRI pharmacotherapy when anxiety causes significant functional impairment, CBT alone is insufficient, or quality CBT is unavailable 1, 2
• Fluoxetine is the preferred first-line SSRI due to robust evidence and FDA approval for pediatric anxiety 1
  • Start at 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks
  • Target dose: 20-40 mg daily by weeks 4-6
  • Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 1
• Sertraline is an equally effective alternative 3, 4
  • Children ages 6-12: Start 25 mg once daily
  • Adolescents ages 13-17: Start 50 mg once daily
  • May increase up to maximum 200 mg/day based on response, with dose changes no more frequently than weekly 4

Combination Treatment for Optimal Outcomes

• For severe anxiety, offer combination CBT plus SSRI preferentially over monotherapy 3
• Combination CBT plus sertraline demonstrates superior efficacy to either treatment alone for improving anxiety symptoms, global function, treatment response, and remission rates (moderate strength of evidence) 3
• Initial response to combination treatment strongly predicts long-term outcomes 3
• The number needed to treat for response with SSRIs is 3, compared to a number needed to harm of 143 for suicidal ideation, making the benefit-to-risk ratio highly favorable 2

Second-Line Medication Options

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

• Consider venlafaxine or duloxetine if SSRIs are ineffective or not tolerated 3
• SNRIs demonstrate high strength of evidence for improving clinician-reported anxiety symptoms but have less robust pediatric data than SSRIs 3
• Associated with increased fatigue/somnolence compared to placebo (moderate strength of evidence) 3

Hydroxyzine

• May be appropriate for short-term or situational anxiety management as an adjunct to SSRIs or as monotherapy for milder cases 2, 5
• Use at the lowest effective dose to minimize sedation 5

Critical Safety Monitoring

Suicidal Ideation Surveillance

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dose adjustments 1, 2
• All SSRIs carry a boxed warning for suicidal ideation through age 24 years 2
• Pooled absolute risk: 1% with antidepressants versus 0.2% with placebo (risk difference 0.7%) 1, 2

Common Adverse Effects

• Expect nausea, headache, insomnia, diarrhea, heartburn, somnolence, dizziness, sexual dysfunction, sweating, and tremor within the first few weeks 1
• Most adverse effects resolve with continued treatment 1
• Behavioral activation or agitation is more common in younger children than adolescents and in anxiety versus depression, manifesting as restlessness, insomnia, impulsiveness, and aggression 5

Medications to Avoid

Do not use the following in pediatric anxiety:

• Benzodiazepines (not recommended for routine use) 1
• Paroxetine (higher risk of discontinuation syndrome and potentially increased suicidal thinking) 1
• Tricyclic antidepressants (not recommended) 1

Common Pitfalls to Avoid

• Do not start with medication alone for mild-to-moderate anxiety when CBT is accessible, as CBT has fewer adverse effects and lower relapse rates after treatment completion 2
• Do not titrate SSRIs too rapidly—the dose-response relationship is logarithmic, not linear; exceeding optimal dosing does not improve outcomes and increases adverse effects 3, 2
• Do not discontinue SSRIs abruptly—gradual tapering is essential to minimize discontinuation symptoms, particularly problematic with fluvoxamine 2, 5
• Do not overlook parental oversight—in children and adolescents, parental supervision of medication regimens is paramount 3
• Start with a subtherapeutic "test" dose when initiating SSRIs, as initial adverse effects can include anxiety or agitation 3