Welcome to our Summer Blog Series examining the impact of anxiety disorders on church participation and spiritual development in kids. Today and tomorrow, we’ll discuss the use of medication for kids with anxiety.
When should medication be considered for kids with anxiety? Medication is appropriate for children who experience moderate to severe functional impairment from anxiety symptoms, fail to respond or respond incompletely to psychotherapy or experience one or more comorbid conditions that require concurrent treatment. Medication is also appropriate when anxiety symptoms interfere with the child’s ability to participate in or benefit from talk therapy, or situations when the family is unable to access therapy for geographic or financial reasons.
What medications have been shown helpful in children and teens with anxiety? The serotonin-specific reuptake inhibitors (SSRIs) have been recognized as the medication of choice for treating anxiety, according to practice parameters developed by the American Academy of Child and Adolescent Psychiatry. This class of medications, including fluoxetine (Prozac™), sertraline (Zoloft™) and fluvoxamine (Luvox™) has been shown to be effective in treating children and teens with selective mutism, social anxiety disorder, separation anxiety disorder, generalized anxiety disorder and obsessive-compulsive disorder. The SSRIs as a class have been more extensively researched than any other category of medications for pediatric anxiety disorders and don’t typically require blood work or EKG testing upon initiation of medication or during the course of ongoing follow-up. Imipramine (Tofranil™) and clomipramine (Anafranil™) are members of an older class of medications known as tricyclic antidepressants that have been shown to be effective in treating specific types of anxiety in kids. These medications have fallen out of favor with many clinicians because they are associated with a small, but not insignificant risk of cardiac effects, resulting in the need for ongoing monitoring of EKG tests. Tricyclics are also far more likely than the SSRIs to result in death in the event of a purposeful or accidental overdose. Nevertheless, clomipramine was shown in one analysis of the research literature to be the most effective medication for the treatment of pediatric obsessive-compulsive disorder. No other medications have been shown in well-designed research studies to be effective in the treatment of pediatric anxiety disorders. Benzodiazepines (Ativan™, Valium™, Klonopin™ and Xanax™) may be used on a very short term basis to rapidly reduce acute anxiety that interferes with a child’s ability to attend school or participate in talk therapy as an adjunct to a SSRI, since several weeks or more of continuous treatment with an SSRI is often required for clinical response. Benzodiazepines must be used very carefully because sedation, disinhibition and cognitive impairment have been reported as side effects and children can become dependent upon the medication.
What do we hope medication will do for a child with anxiety? The goal when using medication is to reduce the frequency and severity of the child’s anxiety symptoms and allow them to function in an age-appropriate manner in school, at home, with friends and in extracurricular activities. For some types of anxiety, such as panic disorder and school phobia complete remission of anxiety symptoms may be possible. With obsessive-compulsive disorder, a 50% improvement in the frequency and severity of obsessive thoughts and compulsive behavior may represent a very positive response to medication. While some children may respond very quickly to the effects of medication, a rapid response (within a week or less) is generally the exception as opposed to the norm. For most anxiety disorders, two to four weeks or longer may be required to fully assess the clinical response on a given dose of a SSRI. Children with OCD may not fully respond to a given medication for eight weeks or longer. In the CAMS study, kids experienced the greatest improvement from medication in the first four weeks of treatment, but further improvement was seen between week 4 and week 8 in a study that permitted optimization of the child’s medication dose. If a child hasn’t responded to an optimal dose of medication for most types of anxiety within eight weeks or for OCD within twelve weeks, it is unlikely the child will respond to ongoing treatment with that medication.
When I’m discussing the use of medication for anxiety with a child and their parent(s), I usually tell them medication may make it easier for them to make use of the tools and skills they will learn in their therapy to help manage their anxiety symptoms. I don’t want to create unrealistic expectations for medication or subject kids to multiple medication trials because parents or kids are disappointed by a less than expected response.
If medication can result in episodes of anxiety, obsessive thinking or compulsive behavior that are 50% less frequent, last for 50% less time and are 50% less severe, the child will usually feel significantly better. They are then in a better position to effectively manage the remainder of their symptoms through the skills they learn in CBT.
Tomorrow: Are medications used to treat anxiety safe for children and teens?