What is the recommended approach for managing anxiety in pediatric patients?

Management of Anxiety in Pediatric Patients

For pediatric anxiety disorders, cognitive-behavioral therapy (CBT) should be the first-line treatment for mild to moderate presentations, while combination therapy with CBT plus an SSRI (specifically sertraline) is recommended immediately for functionally impairing anxiety. 1, 2

Treatment Algorithm by Severity

Mild to Moderate Anxiety

• Start with CBT alone as first-line treatment, delivered as 12-20 structured individual sessions over 3-4 months by a trained therapist 1, 3
• CBT must include specific core components: cognitive restructuring to challenge catastrophizing and negative predictions, graduated exposure using a fear hierarchy, relaxation techniques (deep breathing, progressive muscle relaxation), and behavioral activation with homework assignments 3
• Individual face-to-face therapy is superior to group therapy for both clinical effectiveness and cost-effectiveness 3

Functionally Impairing or Severe Anxiety

• Initiate combination therapy with CBT plus sertraline immediately, as this demonstrates superior efficacy compared to either treatment alone with moderate to high strength evidence 2
• Start sertraline at 25 mg daily for 3-7 days, then increase to 50 mg daily by week 1-2, with a target therapeutic dose of 50-175 mg daily 2
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 2

Pharmacotherapy Details

First-Line SSRI Options

• Sertraline (preferred): Start 25 mg daily, increase to 50 mg by week 1-2, target 50-175 mg daily 2, 4
• Escitalopram (alternative): Start 5-10 mg daily if sertraline not tolerated 2
• Fluoxetine (alternative): Start 5-10 mg daily, increase by 5-10 mg increments every 1-2 weeks 2, 4

Critical Safety Monitoring

• Monitor weekly for suicidal ideation and behavior, especially in the first weeks after starting or increasing SSRI dose—adolescents have a 0.7% increased risk versus placebo (number needed to harm = 143) 2
• Track treatment-emergent adverse events systematically: headaches, stomach aches, behavioral activation, worsening symptoms 4

Treatment Duration

• Continue medication for a minimum of 12-24 months after symptom remission 2
• Taper gradually over 2-4 weeks when discontinuing to avoid withdrawal symptoms 2
• Choose a stress-free time of year for discontinuation 4

Cognitive-Behavioral Therapy Specifics

Essential CBT Components

• Education about anxiety physiology explaining cognitive, behavioral, and physiologic dimensions 3
• Cognitive restructuring to identify and modify automatic thoughts, catastrophizing, overgeneralization, and all-or-nothing thinking 3
• Graduated exposure using a fear hierarchy from least to most distressing situations, with prolonged exposure while abstaining from safety behaviors 3
• Relaxation training including deep breathing to counteract hyperventilation, progressive muscle relaxation for physical tension, and guided imagery 3
• Homework assignments between sessions for real-world skill generalization—this is the most robust predictor of both short-term and long-term treatment success 3

Session Structure

• Deliver 60-90 minute sessions with collaborative agenda involving patient, therapist, and when appropriate, family members 3
• Use standardized anxiety rating scales (GAD-7, HAM-A) at regular intervals to objectively track response 2, 3
• Set specific behavioral goals with contingent rewards to reinforce progress 3

Non-Pharmacological Adjuncts

For Procedural Anxiety

• Attention diversion/distraction is a powerful intervention for young children and when advance preparation is not possible 1
• Play therapy using directed activities with age-appropriate toys and medical props is highly effective for processing stressful experiences 1
• Coping skills training (progressive muscle relaxation, guided imagery, conscious breathing, positive self-talk) is effective for anxious patients with previous negative medical experiences, though requires 4-6 weeks of practice with professional coaching 1
• Peer modeling through videotape or audiovisual methods demonstrating positive coping is effective for adolescents and treatment-naive children 1

For Acute Procedural Anxiety Requiring Medication

• Hydroxyzine is FDA-approved for pediatric anxiolysis with few contraindications, available in tablet and syrup formulations 5
• Nitrous oxide provides effective analgesia and anxiolysis with minimal side effects, though has a 20-30% failure rate and should be avoided in pneumothorax, bowel obstruction, or cardiovascular compromise 1, 5
• Incorporate child life specialists trained in nonpharmacologic stress reduction to alleviate anxiety related to procedures 1

Family and School Interventions

Family-Directed Components

• Include interventions that improve parent-child relationships, strengthen communication skills, reduce parental anxiety, and foster anxiety-reducing parenting approaches 3
• Allow family presence during procedures when appropriate, as this can be viable and useful in acute care settings 1

School Accommodations

• Coordinate immediately with school to implement accommodations including a safe space and ability to leave class briefly during panic episodes 2
• Educate teachers about anxiety management strategies and incorporate plans into 504 or IEP documents when appropriate 3

Critical Pitfalls to Avoid

Medication Errors

• Do not use benzodiazepines as first-line treatment due to risks of dependence, cognitive impairment, and lack of evidence for long-term efficacy in adolescents 2
• Do not use beta-blockers (propranolol, atenolol) for anxiety disorder treatment, as they do not treat the underlying condition and provide only symptom relief 2
• Do not combine benzodiazepines with opioids due to increased risk of respiratory compromise 5

CBT Implementation Errors

• Do not rely solely on exposure without addressing underlying cognitive distortions—integration of cognitive reappraisal with exposure makes treatment less aversive and enhances effectiveness 3
• Ensure homework completion between sessions, as this is the most robust predictor of treatment success 3
• Address avoidance of exposure exercises early by starting with lower-intensity exposures to build confidence 3

Assessment Errors

• Do not withhold pain medication in children with abdominal pain—administration preserves the ability to assess patients and should not be withheld 1
• Do not assume pain insensitivity in children with developmental disabilities—use validated tools like the Non-communicating Children's Pain Checklist-Revised for ages 3-18 years 1

When CBT Alone Is Insufficient

• Add an SSRI if CBT produces insufficient improvement, if the patient expresses preference for medication, or if access to trained CBT therapists is limited 3
• Higher doses of SSRIs are typically required for anxiety disorders compared to depression, though this increases dropout risk due to side effects 3
• Consider SNRI medication (venlafaxine extended-release) as an additional treatment option with some empirical support 1

Special Populations

Children with Developmental Disabilities

• Use the Non-communicating Children's Pain Checklist-Revised or Individual Numeric Rating Scale for assessment 1
• Learn about the child's anticipated response and previous experiences from parents and specialists 1
• Utilize child life specialists knowledgeable in distinct coping strategies for children with developmental disabilities 1

Neonates and Young Infants

• Provide adequate pain prophylaxis for procedures and pain relief as appropriate—do not assume reduced pain perception 1