The use of medication is just one of the many treatment options available to manage the symptoms of anxiety disorders. Parents are understandably hesitant about putting their children on medication without knowing which ones are appropriate, how they will affect their child, and if and when they are safe to use. To help address these concerns, ADAA has gotten some answers to these and other frequently asked questions about treating anxiety disorders in children with medication.

1. Which medications are typically used to treat anxiety disorders in children?
The selective serotonin reuptake inhibitors (SSRIs) are currently the medications of choice for the treatment of both childhood and adult anxiety disorders. This group of medications includes fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). Tricyclic antidepressants (e.g. imipramine) and benzodiazepines (e.g. lorazepam) are less commonly used in the treatment of childhood anxiety disorders. Other medications have been used to treat anxiety disorders in adults but require further study in children and adolescents.

Approval by the Food and Drug Administration (FDA) of the use of SSRIs in youth with anxiety disorders is currently limited to the use of Prozac, Zoloft and Luvox for the treatment of pediatric Obsessive-Compulsive Disorder. However, SSRIs are commonly used in clinical practice to treat youth with anxiety disorders, based upon several studies that report improvement in symptoms and medication safety in children with anxiety and depressive disorders. Clinical studies, in turn, provide the necessary information for the FDA to determine whether medications will be approved. Unfortunately, studies of the use of medications in children often lag behind studies of adults; more research is definitely needed in this area. Discuss with your physician the benefits and risks of the use of all medications, whether FDA approved or not.

2. Are SSRIs safe for my child?
There are now several studies reporting the safety of SSRIs in the acute treatment of children with anxiety and depressive disorders. Additional studies are needed to assess the efficacy and safety of SSRIs when these medications are used to treat youth for longer periods of time. Parents should discuss duration of medication treatment with their child's physician, including length of the initial treatment period.

Concerns of medication safety are understandable. Risks associated with medication use, however, must also be weighed with risks of not treating anxiety disorders. For example, children with anxiety disorders frequently experience (often silently and secretively) significant discomfort and distress associated with their anxiety. Symptoms may negatively impact important developmental experiences such as learning and socialization, with risk of both short-term and longer-term functional difficulties.

3. How long will my child need to take medicine?
Current recommendations suggest that initial treatment of childhood anxiety disorders with an SSRI should be continued for approximately one year. Medication treatment may be recommended beyond this period if symptoms persist or reoccur. Symptoms and treatment response should be reassessed at regular intervals. Starting a child on an SSRI does not mean that he/she will be on the medication for life.

4. What are the most common side-effects of SSRIs?
The SSRIs are generally tolerated very well, with minimal or no side-effects. The most commonly reported side-effects include headache, stomachache or nausea, sleep changes, and jitteriness or agitation. It is important for your doctor to determine if any of these physical symptoms are present before starting the medication. Physical symptoms could be related to an underlying medical problem, or reflect symptoms of anxiety (e.g. headache or stomachache) that may actually improve with treatment of the anxiety disorder. Your child's physician should review symptoms of possible side-effects with you and your child prior to starting an SSRI, and at subsequent follow-up visits.

5. What do I do if my child develops side-effects?
Medication side-effects are often mild and transient, and frequently do not require medication discontinuation. Call your doctor with any questions or concerns regarding possible side-effects during the course of treatment. If side-effects are more distressing or enduring, the dose of the medication may need to be adjusted and/or the medication may need to be stopped. Some children have side-effects to one SSRI, but not to others, so that a trial of a different SSRI may be needed if side-effects develop to the initial medication.

6. How can I tell if the medication is working?
Treatment monitoring begins with a thorough assessment and understanding of your child's anxiety symptoms. There are different types of childhood anxiety disorders, and hence, different types of symptoms. For example, separation anxiety disorder symptoms include avoidance of separation from caregivers or home, e.g. school refusal, "shadowing" parents around the house, or avoiding social get-togethers such as peer birthday parties or overnight camps. Generalized anxiety disorder, characterized by multiple areas of worry, is often accompanied by symptoms of tenseness, sleep difficulties and irritability. The child's treatment plan should include specific "target symptoms" that the child is experiencing; these target symptoms can then be followed for assessment of treatment response. Symptom rating scales may be used by your child's health care professional as an additional measure of treatment response. Finally, other adults, such as parents or teachers, are also important sources of information about your child's symptoms.

7. How long will it take for the medication to work?
Initiation of treatment with an SSRI will not produce an immediate decrease in your child's symptoms of anxiety. Improvement in your child's symptoms may begin to occur after a week or more of treatment, although an initial treatment trial of four to six weeks is needed to assess clinical response. It is also very important that your child take the SSRI on a daily basis, at approximately the same time each day (i.e. not on an "as needed" basis), in order to achieve stable and effective medication levels.

8. Will my child become addicted to these medications? Will the medications change my child's personality?
There is no evidence that the SSRIs are addictive. If medications are discontinued abruptly, symptoms such as dizziness, nausea, headache, and behavioral changes may occur. Medication dosages should not be changed, and medications should not be discontinued unless directed by the child's physician.

Treatment with SSRIs should not change your child's personality. Conversely, anxiety disorders may cloud features of your child's personality due to the impact of the anxiety symptoms and associated distress. If prominent changes in your child's behavior and demeanor do occur, parents should check with their physician about possible medication-related side-effects.

9. What if my child refuses to take the medication?
Children should not be forced to take medications, nor should the medications be disguised or inaccurately described. It is important to try to find out why the child does not want to take the medicine. For example, does the child have difficulty swallowing pills? Does the child fear that something may happen to him/her if he/she takes the medicine? Is the child concerned of possible embarrassment if others learn that he/she is taking a medication for anxiety?

Educating and involving your child in the discussion of his/her anxiety disorder is very important. Discussion should include review of symptoms that cause difficulties. Treatments should also be discussed, at a developmentally appropriate level, emphasizing the goal of symptom improvement. If the child refuses to take a medication, an initial treatment course of psychosocial interventions such as cognitive behavioral therapy should be considered, with subsequent review of medication use if symptoms do not improve.

10. Can SSRIs be used with other medications, including over-the-counter medicines for common illnesses such as a cold or the flu?
Check with your physician before adding or changing any of your child's medications to avoid potential medication interactions.

11. Are there other treatments available if I don't want to put my child on medication?
Cognitive behavioral therapy (CBT) is the most widely studied and commonly used form of psychotherapy to treat childhood anxiety disorders. CBT incorporates a variety of approaches designed to change maladaptive thoughts/beliefs and behaviors associated with anxiety disorders. Other psychosocial interventions should also be considered for children with anxiety disorders including the possibility of school support, family therapy, and assessment of potential environmental stressors contributing to the child's difficulties.

The use of psychosocial interventions, including CBT, should be considered for all children with anxiety disorders, whether they are being treated with medications or not. Parents should actively discuss treatment options with their child's health care provider.

This information was taken from an interview with Marcia J. Slattery, M.D., M.H.S., a child and adolescent psychiatrist at the Mayo Clinic who specializes in the clinical care and research of children with anxiety disorders. The interview appears in the September/October 2003 issue of ADAA's newsletter, Reporter.

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