What is the best approach to manage anxiety in children?

Managing Anxiety in Children

Cognitive-behavioral therapy (CBT) is the first-line treatment for mild to moderate anxiety in children, while severe anxiety requires combination treatment with both CBT and an SSRI (specifically sertraline) from the outset. 1

Initial Assessment

Before initiating treatment, conduct a comprehensive diagnostic evaluation to confirm the specific anxiety disorder and rule out medical mimics:

• Screen for medical conditions that can present as anxiety, including hyperthyroidism, hypoglycemia, and excessive caffeine intake 2
• Order thyroid function tests and glucose levels if the clinical presentation suggests these conditions 2
• Assess for psychiatric comorbidities, particularly depression (which co-occurs in 56% of cases), ADHD, bipolar disorder, and behavioral disorders 3, 4
• Use validated screening instruments such as the Pediatric Symptom Checklist or the AACAP Level 1 Cross-Cutting Symptom Measures to systematically identify anxiety symptoms 4
• Gather information from multiple sources including the child, parents, and teachers, as children often struggle to accurately report symptom presence and severity 5, 6

Common pitfall: Younger children cannot verbalize anxiety well and instead show regression in physical abilities (toileting problems, needing to be carried), increased clinginess, or physical complaints like stomach aches 7. Don't miss the diagnosis by relying solely on verbal reports.

Treatment Algorithm by Severity

Mild to Moderate Anxiety

Begin with CBT as monotherapy, delivered over 12-20 structured sessions 1, 4:

• Core CBT components include psychoeducation about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure therapy, and problem-solving/social skills training 1
• CBT targets all three dimensions of anxiety: cognitive (worried thoughts), behavioral (avoidance), and physiologic (physical symptoms like headaches and palpitations) 1, 8
• Use standardized symptom rating scales at each visit to systematically track treatment response, not just subjective impressions 4

Severe Anxiety

Initiate combination treatment with both CBT and an SSRI immediately rather than sequential monotherapies 1, 2:

• Sertraline is the preferred SSRI with strong evidence as first-line pharmacological treatment 1, 2
• Starting dose for sertraline is 25 mg daily (though lower doses are possible), with dose adjustments as often as weekly to achieve optimal response while minimizing side effects 8
• Combination therapy is superior to either treatment alone for severe presentations, providing both immediate symptom relief and durable skills to prevent relapse 2

When Quality CBT is Unavailable

Offer SSRIs as monotherapy when access to trained CBT providers is limited 1, 4:

• SSRIs have considerable empirical support as safe and effective treatments for pediatric anxiety 1
• The number needed to treat for response with SSRIs is 3, demonstrating robust efficacy 2

SSRI Management Details

Efficacy Timeline and Monitoring

• Statistically significant improvement may begin by week 2, clinically significant improvement is expected by week 6, and maximal benefit by week 12 or later 2
• Schedule follow-up at 2 weeks, then monthly for the first 3 months to monitor for worsening anxiety, suicidal ideation, and medication adherence 2
• Common early adverse effects include gastrointestinal symptoms (nausea, diarrhea, heartburn), headaches, and stomach aches 2, 8

Critical Safety Monitoring

Monitor closely for suicidal ideation, especially in the first months and after dose adjustments 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) 2
• This risk must be balanced against the number needed to treat of 3 for clinical response 2

Watch for behavioral activation or agitation, which is more common in younger children than adolescents and manifests as motor restlessness, insomnia, impulsiveness, and aggression 2

Duration of Treatment

• Continue medication for approximately 1 year following symptom remission 8
• Choose a stress-free time of year when discontinuing medication 8
• If symptoms return after discontinuation, seriously consider medication re-initiation 8

Alternative Pharmacological Options

When SSRIs Fail or Are Not Tolerated

• SNRIs (serotonin-norepinephrine reuptake inhibitors) may be considered as second-line agents 1
• Fluvoxamine is effective but requires twice-daily dosing at low doses and has higher risk of discontinuation symptoms 2

Short-Term or Situational Anxiety

• Hydroxyzine may be appropriate for short-term or situational anxiety management, either as adjunct to SSRIs or as monotherapy for milder cases 1
• Use hydroxyzine at the lowest effective dose to minimize sedation 1

What NOT to Use

Do not prescribe benzodiazepines for pediatric anxiety due to lack of efficacy data and risk of dependence 4

Developmental Considerations

Anxiety disorders typically onset during specific developmental phases 3:

• Separation anxiety: preschool/early school-age years
• Specific phobias: school-age years
• Social anxiety: later school-age and early adolescent years
• Generalized anxiety, panic, agoraphobia: later adolescent/young adult years

The median age of onset across all anxiety disorders is 11 years 3

Consequences of Untreated Anxiety

Early intervention is critical because untreated childhood anxiety leads to 3, 4:

• Impairments in social, educational, occupational, and health outcomes extending into adulthood
• Children with anxiety disorders are 3.5 times more likely to experience depression or anxiety in adulthood 7
• Among adolescents with anxiety, 24% have suicidal ideation and 6% make suicide attempts, with generalized anxiety plus comorbid depression conveying the greatest risk 3

Despite availability of effective treatments, less than half of youth needing mental health treatment receive appropriate care, highlighting the urgent need for improved identification and treatment 3, 4