Anxious children, especially severely anxious children or those who are struggling with therapy or having major difficulties, often benefit from the addition of a medication. Early treatment is important because children diagnosed with anxiety are also more likely to develop anxiety as adults. Medication may be beneficial to children and adolescents who are unable to go to school due to panic attacks, separation anxiety or social anxiety. Any anxiety medication used in childhood should always be accompanied by a good therapist who engages the child, parent and school if necessary. In fact, in 2019 researchers at Yale did a study showing that stand alone parent therapy was just as effective as therapy directed at the child. Most medications used to treat childhood anxiety are not highly toxic and typically have mild side effects.
The most commonly used medications are selective serotonin re-uptake inhibitors or SSRI’s as they typically have few side effects and benefit can been seen in about 2 weeks. Fluoxetine, sertraline, citalopram and escitalopram. Despite being equally as effective as SSRIs, serotonin and norepinephrine re-uptake inhibitors or SNRI’s such as venlafaxine are less commonly used as they are associated with slightly higher rates of side effects.
Side effects typically are mild and include
- Gastrointestinal distress : diarrhea, nausea, vomiting
More rare but concerning side effects include:
- increased anxiety
- panic attacks
- hostility and aggression
- akathisia (restlessness)
- Depression and suicidal thinking
Activation syndrome is considered to be a cluster of side effects including severe emotional reactions and/or behavioral activation. In some clinical trials, activation symptoms are responsible for about 12%of children leaving clinical trials.
Medications for Insomnia
Settling down for bed is a typical time that anxious thoughts plague a child’s brain. After ruling out a medical cause, pharmacotherapy may be helpful in instances where cognitive behavioral therapy for insomnia (CBT-I) and healthy sleep practices have not been effective.
First line medications include melatonin (1 to 9 mg), which can be purchased at a drug store. Next in line is typically a product containing diphenhydramine. Diphenhydramine in a dose of 25-50 mg , an antihistamine and allergy medication, may cause dry mouth, dry eyes and constipation and typically is not very effective when used for multiple days in a row. Other medications commonly used include trazodone and mirtazapine, both atypical antidepressants (see above). Other good options are clonidine and guanfacine, both which are used in children with ADHD and have proven safety and efficacy. Click here for a good review on pediatric sleep medications.
Benzodiazepines are used when a SSRI’s (typically first line treatment for pediatric anxiety) work incompletely, or in the first two weeks of treatment when the SSRI has not began to work. Click here for more information.
Typical side effects of benzodiazepines include:
- drowsiness, confusion, grogginess,
- disinhibition (acting out or inappropriate behaviors)
- oppositional behaviors
Rare but concerning side effects:
- abuse or addiction
- diversion or sale of the medication
- suicidal thinking
Antipsychotics are typically used for schizophrenia and bipolar disorder, but when other agents don’t work are sometimes used in severe and treatment refractory cases of anxiety such as obsessive compulsive disorder. Risperidone, quetiapine and aripiprazole have some efficacy in reducing anxiety symptoms in children and teenagers.
Typical side effects include:
- Weight gain
- Extrapyramadial symptoms: akathisia, acute muscle spasm, tremor
- decreased emotional expression
Rare but concerning side effects include
- Tardive dyskinesia (a possibly permanent motor tic)
- A cardiovascular event
- Neuroleptic malignant syndrome (symptom cluster including: mental status changes, muscle rigidity, high blood pressure and laboratory abnormalities)
***Please consult a child psychiatrist to go over the particular use and side effects of any medication and to develop a plan that best fits your child’s needs.