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Best Medications for Kids With Anxiety

Antidepressants trump all others as the most effective evidence-based choice  

John T. Walkup, MD

We see a lot of the wrong medications being given to anxious kids because people who are treating them don't really understand what these children are experiencing, and they don't know what the evidence-based treatments are.

Anxious kids have a hard time paying attention. It's not because they have attention deficit, it's because their heads are full of worry. But their parents and teachers may only notice that they're having trouble paying attention, and so they get misdiagnosed as having the inattentive subtype of ADHD and put on stimulants. Stimulants will help anybody feel a little bit more attentive, so they will help these kids concentrate better, but they might also have more stomachaches, and often they're not happy, they're not comfortable. The stimulants may actually make the anxiety a little bit worse. Plus anxious kids have trouble sleeping, and sometime the stimulus makes sleeping even harder.

Another type of medicine some practitioners use, because they're comfortable with it, is clonidine or guanfacine. These are alpha-two agonists; they calm, they lower arousal levels, but they don't really treat anxiety.

The third group of medicines that we see people using are, believe it or not, are antipsychotics. With the scare a few years ago about suicidal behavior on antidepressants, people moved away from the antidepressants and now they're treating anxious kids with antipsychotics. Now, in someone's mind that may be safe, but from an evidence-based point of view it's terrible care.

The clear medications of choice for anxiety are the serotonin reuptake inhibitors, the antidepressants. Study after study shows those are the medicines that are effective, and they can be extremely effective. With the right assessment, with the right youngster, the use of antidepressants for anxiety can be transformative. And it can happen relatively quickly; in our studies we often see kids better by the first week or two of treatment. They're not completely well but they're moving in the right direction, and that kind of response early on generates confidence in the treatment, makes moms and dads feel a little bit better and makes the kids feel pretty good.

The other evidence-based treatment for anxiety is cognitive behavioral therapy and it's important to understand that in our big study, where we compared combination treatment of cognitive behavioral therapy and medication with either one of those treatments alone, that the combination beat them all handily. So when you're thinking about the very best treatment you've got to be thinking in terms of medication plus a psychological intervention.

Finally, the benzodiazepines are the other treatment that I commonly see being used in kids with anxiety disorders. They are short-term, they can be extremely effective in reducing intense anxiety in youngsters who are really suffering and in distress. But the data supporting their long-term usefulness is very thin, even in adults.

There are kids who are so anxious and uncomfortable and are on the verge of school failure or disruption of the home or something like that where you just really need an acute way to bring down everybody's anxiety, and in those cases the benzodiazepines can be very helpful. But sometimes they're a little too helpful, because people begin to like how they feel on them and don't really shift focus from those medicines onto the antidepressants, which really offer long-term, durable anxiety reduction without really any side effects or problems.

With benzodiazepines you can actually develop tolerance to them, so they might work the first month or two, but to keep them working in the long haul you often have to increase the dose. They manage anxiety, they offer anxiety relief, but they don't really seem to have that kind of almost curative property that the antidepressants seem to have.

John T. Walkup, MD, is a leader in the treatment of anxiety in children and adolescents and chief of the department of child and adolescent psychiatry at New York-Presbyterian Hospital and the Weill Cornell Medical Center.

Published: January 26, 2012

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