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While talk therapy is the first line of treatment for anxiety disorders in children, moderate to severe anxiety that does not respond well to CBT or is so bad that the child can't attend therapy at all calls for antidepressant medication.

Is your child suffering from an anxiety disorder, and has your healthcare provider suggested treatment with antidepressant medication? 

You'll have heard that anxiety disorders are among the most common psychiatric conditions in children and adolescents, and that unfortunately, most kids with anxiety do not receive the treatment they need. A lack of treatment places them at risk of anxiety later in life, as well as negatively impacting school performance, family life, and leisure activities right now — not to mention increasing the risk of depression and behavioral disorders. [1, 2]

At the same time, you may have serious concerns about medication, either due to a gut feeling or because you have heard that the Food and Drug Administration (FDA) has warned that antidepressants can lead to suicidal thoughts and behavior in young people. [3]

Before agreeing to place your child on antidepressants for their anxiety disorder, you will simply want to know more — when are antidepressants necessary, what risk does their use carry, and which antidepressants are safest for anxiety in children?

When Should Antidepressants Be Prescribed To Children And Adolescents With Anxiety Disorders?

Antidepressants are rarely the first line of treatment in children and adolescents suffering from an anxiety disorder; cognitive behavioral therapy (CBT), during which anxiety sufferers learn to replace their negative and unrealistic thought patterns with healthier ones, will always almost be the first thing healthcare providers suggest. This form of talk therapy generally provides symptom relief very quickly, with studies indicating that this improvement is maintained over the long term. [4]

Children with separation anxiety disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, and specific phobias will not be offered antidepressants if talk therapy alone is effective, and due to concerns that such medications may cause harm to young people, their routine prescription is not recommended. [5]

As such, antidepressants may be considered in children who suffer from moderate to severe symptoms, and children with comorbid depression and anxiety [6].

Do SSRIs Increase The Risk Of Suicide In Children With Depression And Anxiety?

The Food and Drug Administration (FDA) warns that "antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, and young adults when the medicine is first started", and advises patients and their families to keep a close eye on sudden behavioral changes, mood alterations, thoughts, and feelings. [7]

There is evidence that the therapeutic benefits of antidepressants are greater for children suffering from anxiety disorders rather than depression, however, while the risk of self-harm is simultaneously reduced.

In cases where the benefits of antidepressant therapy are deemed to outweigh the risks, benzodiazepines and tricyclic antidepressants should be avoided, and selective serotonin re-uptake inhibitors (SSRIs) are the first choice. When SSRIs are prescribed to young people with anxiety disorders, they do require careful monitoring due to the possibility that that they are suffering from depression alongside their anxiety. [8]

What Medications May Be Prescribed To Children And Adolescents With Anxiety Disorders?

Fluoxetine, more commonly known under the trade names Prozac and Sarafem, is an SSRI antidepressant and the medication your child will most likely be prescribed. Fluoxetine is used in children as young as seven, and research shows that it is generally very well tolerated — mild headaches that last only a short time, and gastrointestinal upsets, are generally the only side effects. This medication may be used to treat social anxiety disorder, generalized anxiety disorder, separation anxiety in children, and obsessive compulsive disorder in children, along with major depression and bulimia. [9, 6]

Citalopram, another SSRI, is likewise sometimes used to treat anxiety in children and adolescents, with data suggesting that this drug tends to be fairly well-tolerated and effective, but also that further study is still needed. [10, 6] 

Lexapro (Escitalopram) is also sometimes offered to adolescents with anxiety disorders. It is not approved for use in children younger than 12 years of age, and the FDA suggests that physical side effects such as nausea and back pain occur in adolescents at a greater rate than in adults, and that the safety and efficacy of Lexapro is not established for individuals below the age of 18 suffering from general anxiety disorder. [11]

Sertraline (Zoloft) can likewise be considered to be among the safer SSRIs for use in children and adolescents with anxiety disorders, including obsessive compulsive disorder. It has been found to be unlikely to lead to homocidal and suicidal thoughts. [12, 6]

In Conclusion

Your child's healthcare provider will consider the nature and severity of your child's anxiety disorder before making treatment recommendations. Where possible, treatment will be limited to psychotherapy, with cognitive behavioral therapy being the first choice. As a parent, you may also be advised to attend therapy yourself to learn to help your child cope with their anxiety better.

Where anxiety in children is so severe that talk therapy either proves insufficient or your child finds it difficult to attend therapy at all, however, SSRI antidepressants will be the pharmacological treatment of choice.

Your child's healthcare provider will recommend the medication least likely to cause major side effects, including suicidal thoughts, and most likely to be effective at treating your child's particular anxiety disorder. Your child will continue to be monitored closely for side effects and progress. [13]

Meanwhile, some families will also want to look into St Johns Wort, valerian and other natural remedies for anxiety in children. Some herbal treatments have been shown to be effective and safe in young people. 

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