Can I prescribe hydroxyzine (an antihistamine) for my child with Autism Spectrum Disorder (ASD) who is experiencing anxiety or panic attacks?

Hydroxyzine for Anxiety in Children with Autism Spectrum Disorder

You should not prescribe hydroxyzine for your child with ASD who is experiencing anxiety or panic attacks, as it lacks evidence for treating anxiety in this population and may cause paradoxical agitation. 1, 2

Why Hydroxyzine Is Not Recommended for ASD-Related Anxiety

Lack of Evidence for Anxiety Treatment in ASD

• The American Academy of Child and Adolescent Psychiatry explicitly states that hydroxyzine lacks evidence for treating anger, irritability, or mood instability in adolescents and should not be used as a substitute for adequate treatment when psychiatric conditions are present. 1
• Hydroxyzine is identified as a less commonly used agent for acute agitation with limited controlled trial data and primarily sedative effects—not anxiolytic effects in this population. 2
• Guidelines only support hydroxyzine use for acute agitation in emergency settings, not for ongoing anxiety management in children with ASD. 2

Risk of Paradoxical Reactions

• Hydroxyzine and other antihistamines carry an unpredictable risk of paradoxical increase in rage and agitation in children and adolescents, which is particularly concerning in ASD populations who may already struggle with behavioral regulation. 2
• This paradoxical reaction cannot be predicted unless previously documented in your specific child. 2

Sedation Without Therapeutic Benefit

• The primary effect of hydroxyzine is sedation rather than true anxiolysis, which may mask symptoms temporarily but will not address the underlying anxiety driving the symptoms. 2
• The FDA label confirms hydroxyzine's effectiveness as an antianxiety agent for long-term use (more than 4 months) has not been assessed by systematic clinical studies. 3

Evidence-Based Treatment Recommendations for Anxiety in ASD

First-Line Treatment: Modified Cognitive-Behavioral Therapy

• Modified cognitive-behavioral therapy (CBT) is the recommended first-line treatment for anxiety in children and adolescents with high-functioning ASD. 4
• Behavioral interventions should be the foundation for managing anxiety and irritability, including functional behavioral assessment, positive reinforcement strategies, and de-escalation techniques. 2
• Evidence is growing in support of using CBT to treat anxiety in youth with ASD, with specialized protocols like Behavioral Interventions for Anxiety in Children with Autism showing promise. 5, 6

Pharmacological Options When Needed

• SSRIs (Selective Serotonin Reuptake Inhibitors) are the primary pharmacological option if medication is necessary, though they should be prescribed cautiously with close monitoring. 4
• The American Academy of Child and Adolescent Psychiatry recommends SSRIs (such as sertraline, fluoxetine, or citalopram/escitalopram) for anxiety disorders in children and adolescents, with citalopram/escitalopram having the least effect on drug interactions. 7
• However, recent evidence shows mixed results: citalopram did not significantly improve anxiety in children with ASD in a well-designed RCT, suggesting clinicians should be cautious in their use of SSRIs for this specific indication. 8

Important Prescribing Considerations for SSRIs in ASD

• Start with subtherapeutic "test" doses due to potential for behavioral activation/agitation early in treatment, with slow up-titration and close monitoring (particularly in younger children). 7
• Parental oversight of medication regimens is paramount in children and adolescents. 7
• Monitor for treatment-emergent activation, as SSRIs can occasionally cause behavioral activation or disinhibition in adolescents, which should be distinguished from inadequate treatment response. 2
• Systematic assessment of treatment response using standardized symptom rating scales should be considered. 7

Critical Pitfalls to Avoid

Do Not Combine Hydroxyzine with SSRIs

• If your child is already on or being considered for an SSRI like sertraline, adding hydroxyzine creates potential for additive sedation and may complicate the clinical picture, making it harder to assess the true therapeutic response. 2
• The combination increases sedation risk without established benefit for anxiety management in adolescents. 2

Avoid Anticholinergic Burden

• The American Academy of Child and Adolescent Psychiatry recommends avoiding combining hydroxyzine with other medications that have anticholinergic properties to prevent cumulative effects. 9
• Anticholinergic burden can affect memory and cognitive function, though this is more concerning with long-term use and in elderly populations. 9

Emergency Settings Only

• For acute agitation in emergency settings only, guidelines support short-acting benzodiazepines or atypical antipsychotics over hydroxyzine. 2
• Risperidone is FDA-approved for irritability associated with autism and has evidence for managing severe tantrum behavior and physical aggression in ASD. 7

Practical Next Steps

• Consult with a developmental-behavioral pediatrician or child psychiatrist experienced in treating anxiety in ASD populations. 4
• Consider referral for modified CBT specifically designed for children with ASD and anxiety. 4
• If pharmacological intervention is deemed necessary after behavioral approaches, discuss SSRIs with careful monitoring rather than hydroxyzine. 4
• Ensure comprehensive assessment of anxiety symptoms and potential contributing factors across your child's developmental level before initiating any treatment. 4