What is the recommended first‑line and subsequent treatment for anxiety in children and adolescents, including psychotherapy, medication choices, dosing, and monitoring?

Treatment of Anxiety in Children and Adolescents

Cognitive-behavioral therapy (CBT) should be offered as first-line treatment to children and adolescents aged 6-18 years with anxiety disorders, with SSRIs (sertraline or escitalopram) reserved for moderate-to-severe presentations, inadequate CBT response, or when combined treatment is needed. 1

First-Line Treatment: Cognitive-Behavioral Therapy

CBT is the recommended initial intervention for pediatric anxiety disorders including social anxiety, generalized anxiety, separation anxiety, panic disorder, and specific phobia. 1

CBT Structure and Components

• Deliver 12-20 structured sessions targeting cognitive distortions, behavioral avoidance, and physiologic arousal symptoms. 1
• Include psychoeducation about anxiety, cognitive restructuring to challenge distorted thinking, relaxation techniques, and gradual exposure to feared situations. 1
• Individual CBT is superior to group-based CBT for clinical effectiveness and cost-efficiency. 2
• Involve parents through separate parent sessions, joint parent-adolescent sessions, or provision of workbooks to help them understand CBT components and manage their child's anxiety. 3

Evidence Base for CBT

• Compared to waitlist/no treatment, CBT improves primary anxiety symptoms (child, parent, and clinician report), global function, and treatment response with moderate strength of evidence. 1
• CBT reduces treatment dropouts compared to pill placebo and reduces dropouts due to adverse events compared to waitlist controls. 1

When to Initiate Pharmacotherapy

Start medication when anxiety is moderate-to-severe, causes significant functional impairment, or when CBT alone is insufficient after 8-12 weeks. 1

Clinical Decision Algorithm

• For mild, recent-onset anxiety with minimal functional impairment: Begin with CBT monotherapy. 1
• For moderate-to-severe anxiety or significant functional impairment: Consider combination CBT plus SSRI from the outset. 1, 4
• When expert CBT providers are unavailable: SSRI monotherapy is an acceptable evidence-based alternative. 1
• When anxiety severity precludes active participation in psychotherapy: Begin with SSRI and supportive treatment, then add CBT once symptoms improve. 1

First-Line Pharmacotherapy: SSRIs

Sertraline (starting 25-50 mg daily) or escitalopram (starting 5-10 mg daily) are the preferred first-line SSRIs for pediatric anxiety disorders. 2

Dosing and Titration

• Start sertraline at 25-50 mg daily and increase by 25-50 mg increments every 1-2 weeks as tolerated, targeting 50-200 mg/day. 2
• Start escitalopram at 5-10 mg daily and increase by 5-10 mg increments every 1-2 weeks, targeting 10-20 mg/day. 2
• For fluoxetine, start at 5-10 mg daily and increase by 5-10 mg increments every 1-2 weeks, targeting 20-40 mg daily by weeks 4-6. 2
• Begin with low "test" doses to minimize initial anxiety, agitation, or activation symptoms that can occur with SSRIs. 2

Expected Response Timeline

• Statistically significant improvement may begin by week 2, clinically significant improvement is expected by week 6, and maximal therapeutic benefit is achieved by week 12 or later. 2
• Do not abandon treatment prematurely; full response may require 12+ weeks at therapeutic doses. 2

Monitoring for Adverse Effects

• Most adverse effects (nausea, headache, insomnia, nervousness, sexual dysfunction, diarrhea, dry mouth) emerge within the first few weeks and typically resolve with continued treatment. 2
• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a pooled absolute risk of 1% versus 0.2% for placebo (number needed to harm = 143). 2, 5
• Assess treatment response using standardized anxiety rating scales (e.g., child/parent/clinician report measures) to supplement clinical interview. 1

SSRI Selection Considerations

• Fluoxetine has a longer half-life, which may benefit patients who occasionally miss doses and reduces risk of discontinuation syndrome. 2
• Paroxetine and fluvoxamine are effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail. 2
• All SSRIs as a class demonstrate similar efficacy with moderate to high strength of evidence for improving anxiety symptoms, treatment response, and remission rates. 2

Second-Line Pharmacotherapy: SNRIs

If inadequate response after 8-12 weeks at therapeutic SSRI doses, switch to a different SSRI or consider an SNRI (venlafaxine extended-release 75-225 mg/day or duloxetine 60-120 mg/day). 2

• Venlafaxine extended-release requires blood pressure monitoring due to risk of sustained hypertension. 2
• SNRIs may be particularly useful for patients with comorbid pain conditions. 2

Combination Treatment

For moderate-to-severe anxiety, combination treatment with CBT plus SSRI provides superior outcomes compared to either treatment alone. 1, 4, 6

• The Child-Adolescent Anxiety Multimodal Study (CAMS) demonstrated that combination therapy was more effective than monotherapy for pediatric anxiety disorders. 4
• Combination treatment should be considered when monotherapy produces only partial response or when severity warrants aggressive initial intervention. 1

Maintenance and Discontinuation

Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse. 2

• Taper medication gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline and paroxetine. 2
• Reassess monthly until symptoms stabilize, then every 3 months during maintenance phase. 2
• Monitor for late-onset side effects and maintain adherence during the maintenance phase. 1

Medications to Avoid

Benzodiazepines are not recommended for routine treatment of pediatric anxiety due to lack of efficacy data, risks of dependence, tolerance, and withdrawal. 2, 5

• Reserve benzodiazepines only for short-term use in crisis situations, not as ongoing treatment. 2
• Tricyclic antidepressants should be avoided due to unfavorable risk-benefit profile, particularly cardiac toxicity. 2

Adjunctive Non-Pharmacological Strategies

Incorporate psychoeducation for patients and families about anxiety symptoms, treatment expectations, and common side effects. 1

• Teach breathing techniques, progressive muscle relaxation, grounding strategies, visualization, and mindfulness as adjunctive anxiety management tools. 2
• Encourage regular cardiovascular exercise and activities of enjoyment, which provide moderate to large reduction in anxiety symptoms. 2
• Address parental anxiety through referral for treatment, as parental anxiety can impede the child's treatment progress. 2
• Ensure adequate supervision of medication adherence and parental understanding of target symptoms and side effects. 1

Common Pitfalls to Avoid

Do not initiate pharmacotherapy before trialing evidence-based psychotherapy (CBT) for mild anxiety, as CBT provides more durable long-term benefits. 2

• Do not escalate SSRI doses too quickly; allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 2
• Do not overlook functional impairment assessment; significant impairment may justify earlier or more intensive treatment despite low symptom scores. 2
• Do not abandon treatment prematurely if no improvement is seen before 8-12 weeks at therapeutic doses with good adherence. 2
• Patients with anxiety commonly avoid follow-through on referrals; proactively assess and address barriers to treatment adherence. 2