Editorial: When You Worry About Anxiety in Children

For a child with moderate to severe anxiety, medication is appropriate if the child is resistant to treatment or so anxious that the condition impedes treatment. The SSRI fluoxetine (Prozac) holds the best evidence in children.

SSRI treatment is associated with a 79% resolution of symptoms versus a 30% placebo effect. That is really a big difference. There is also some evidence for fluvoxamine being effective, which has a somewhat different mechanism of action and, therefore, is a good alternative if fluoxetine fails to help.

Start low and go slow in treating anxiety with SSRIs. The child and the parent are both going to be anxious (of course!) about using medicine, and either may refuse to continue if the child experiences a lot of side effects in the beginning. Increase the dose after 4 weeks if the symptoms do not adequately resolve. Use checklists such as SCARED to monitor progress. You can increase fluoxetine to 20 mg/day or even 60 mg/day in children.

Fluoxetine comes in liquid form, 20 mg per 5 cc, which means you can give as little as 1 cc. Primary care doctors should use fluoxetine only for the indicated age range of 7 years and above, and refer the younger child to a specialist.

In general, treat the child for 1 year and then wean the child during a time of low stress, such as summer vacation, monitoring anxiety symptoms closely.

Medication should really be prescribed in conjunction with CBT or other supportive therapy.

These days, parents may shy away from SSRIs after hearing about suicidal ideation in the press. You need to develop confidence in explaining the black box warning to the child and parent, and how there can be an increase in "dark thoughts" during the first few weeks of treatment. I specify that any dark thoughts that may arise are "coming from the medicine, not from you, so you shouldn’t act on them." I ask them to tell their parent or call me. Such suicidal thoughts have been reported in youth being treated for depression rather than anxiety, though. Even for depression, the careful use of SSRIs has saved many lives and very rarely, if ever, cost them.

The Web site animalagentz.com features cartoon characters to teach children skills to cope with their anxiety. The American Academy of Child and Adolescent Psychiatry also provides reliable information at their Facts for Families site.

Dr. Howard is one of the writers for the column, "Behavioral Consult," which regularly appears in Pediatric News, an Elsevier publication. She is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant financial disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.