Guide to Medications for Anxiety in Children

Medications used to treat anxiety in children can be confusing because they include several different kinds of drugs that work in different ways. Some of them were not originally developed to treat anxiety, so their names are misleading. For instance, the most effective medications for anxiety are antidepressants — called that because they were first approved for treating depression.

Some anti-anxiety medications — including the antidepressants — are used to reduce the child’s overall symptoms, with the child taking them every day. Others are used only occasionally, when a child is facing a situation that triggers intense anxiety.

Some medications work by reducing the anxiety itself — antidepressants do that by boosting the level of serotonin, the chemical in the brain which most directly regulates mood and anxiety. Other medications work by reducing physical symptoms caused by anxiety. They have an effect on other neurotransmitters and other pathways in the body’s nervous system.

Though there are many different anxiety disorders, anti-anxiety medications tend to work for the symptoms that these diagnoses have in common: worrying, nervousness, obsessing, anxiety.

Studies show the most effective treatment for anxiety is not medication alone but medication in combination with cognitive behavioral therapy, or CBT. In CBT children are taught skills to overcome their anxiety, rather than giving in to it, and their anxiety diminishes gradually, over a period of weeks. Medication can help kids who are extremely anxious get comfortable enough to participate in the therapy.

Most experts recommend that kids with mild-to-moderate anxiety be treated first with CBT. Medication can be added after the child starts CBT if therapy alone does not seem to be working to relieve their symptoms. But for more severe anxiety, it’s recommended that kids start on medication along with therapy — or even before therapy starts, to help them get comfortable enough to participate.

While medication is not as effective alone as it is in combination with CBT, it is often prescribed alone if CBT is not available or not feasible for the child’s family.

Medications are also frequently combined to treat severe anxiety. For instance, since antidepressants aren’t fully effective right away, a second medication may be added to relieve anxiety during the initial weeks of taking an antidepressant. A second medication can also be added to a fully active antidepressant if a child needs more relief.

Some medications widely used to treat anxiety in children are not approved by the Food and Drug Administration (FDA) for that use. But that doesn’t mean they are not safe and effective, or that they haven’t been thoroughly studied.

When drug companies develop a new medicine, they are required to prove to the FDA that it is safe and effective for treating a specific problem in a specific group of patients — say, depression in adults. Once the drug is approved, it can also be prescribed “off label,” for a different use and/or a different age group — say, anxiety in children.

The drug company may choose not to seek FDA approval for the drug’s use with these additional disorders or age groups, since the process is expensive. But other scientists may have studied these different uses for the medications extensively, and published their research in credible, peer-reviewed journals. That is the case, for instance, with the use of antidepressants for childhood anxiety. There is a lot of research backing up their safety and effectiveness for kids with anxiety, even though they are not approved by the FDA for this use.

There are several categories of medication that are commonly prescribed for kids with anxiety:

• Anti-depressants called SSRIs (such as Zoloft, Prozac, Paxil,
• Anti-depressants called SNRIs (such as Effexor XR, Cymbalta)
• Anti-anxiety medications called benzodiazepines (such as Ativan or Klonopin)
• Atypical antipsychotics (such as Abilify or Risperdal)
• Alpha agonists (such as Catapres, Kapvay, Tenex, Intuniv)
• Atypical anxiolytics (such as Buspar)
• Antihistamines (such as Benadryl, Atarax or Vistaril)

There are several types of antidepressants that have an effect on childhood anxiety. Experts note that if the first antidepressant your child tries isn’t successful in reducing anxiety symptoms — or your child isn’t able to tolerate the side effects — another should be tried. Kids respond to different types and individual formulations in different ways.

SSRIs

Antidepressants called SSRIs (selective serotonin reuptake inhibitors) are the recommended first choice of medication for treating anxiety in children. That’s because they have been shown to be the most effective, and they have relatively mild side effects. They are also the most commonly prescribed. They work by increasing the amount of serotonin — the most important chemical in the brain that regulates mood.

SSRIs that are commonly prescribed for anxiety in children and teenagers include:

• Zoloft (sertraline)
• Prozac (fluoxetine)
• Luvox (fluvoxamine)
• Paxil (paroxetine)
• Celexa (citalopram)
• Lexapro (escitalopram)

SNRIs

Another set of antidepressants that work for anxiety are SNRIs (serotonin-norepinephrine reuptake inhibitors). They work by increasing the level of two neurotransmitters in the brain — both serotonin and norepinephrine. 

SNRIs that are commonly prescribed for child and adolescent anxiety include:

• Effexor XR (venlafaxine ER)
• Cymbalta (duloxetine)

The SNRIs may be less frequently prescribed for childhood anxiety because they can have a slightly higher rate of side effects, since they work on two different neurotransmitter systems in the brain. Paul Mitrani, MD, a child and adolescent psychiatrist at the Child Mind Institute, notes that clinicians usually prescribe an SNRI as a second choice for a child who does not respond to SSRIs, or  when there is a parent or sibling who has had a positive response to an SNRI.

Side effects

While side effects vary for individual children, and individual medications, side effects of SSRIs and SNRIs are relatively mild, compared to other medications. They often subside after the first few weeks. Side effects can include:

• Nausea, vomiting or diarrhea
• Stomachaches
• Headache
• Drowsiness
• Dry mouth
• Insomnia
• Nervousness, agitation or restlessness
• Activation — increasing irritability and impulsiveness
• Dizziness
• Reduced sexual desire
• Impact on appetite, leading to weight loss or weight gain

Safety

Since 2004 antidepressants, including SSRIs and SNRIs, have carried what’s called a “black box” warning that they may increase the risk of suicidal thoughts and behavior in young people, especially in the first few weeks of starting on them, or when the dose is changed. But studies have shown that “the warning, contrary to its intention, may have increased young suicides by leaving a number of suicidal young persons without treatment with antidepressants.” 

Dr. Mitrani notes that the risk of suicidality is less of a concern when treating anxiety alone as opposed to a child or teen with depression, who may already be having suicidal thoughts. Either way, he adds, it’s crucial for the clinician to monitor for any mood changes when first starting a medication or when increasing the dose, since this side effect will usually occur in the 1 to 2 weeks after the change.

Timing

It takes 2-4 weeks before an antidepressant begins to be effective in reducing symptoms of anxiety, and it continues to become more effective over the first 8 to 12 weeks. The dose is gradually increased until the best dose is reached — maximum reduction of anxiety symptoms without problematic side effects. This dose varies from child to child, so it’s important to always start with a low dose and work up gradually under a doctor’s guidance.

It’s usually recommended that kids continue to take an antidepressant for a year after their symptoms have disappeared (or diminished to a manageable level). This allows the brain to build up the pathways that help manage anxiety, Dr. Mitrani explains, and for the patient to build skills through therapy. “Think of it as a year of practice,” he adds.

When antidepressant treatment is stopped, it should be done during periods of low stress, not when the child might be expected to be most anxious. For example, kids shouldn’t stop taking antidepressants at the start of a new school year or when they first leave for college. SSRIs are not addictive, but a child who stops taking them abruptly can experience withdrawal-like symptoms. It’s important to work with the doctor to decrease the dose gradually.

Some anti-anxiety medications, called anxiolytics, are best used for short-term treatment, including the class called benzodiazepines. They can be used to reduce anxiety in specific stressful or anxiety-triggering situations (flying on a plane, going to the doctor, etc.). They reduce the physical symptoms of anxiety, such as rapid heartbeat, trembling and sweating. 

Benzodiazepines given to children include:

Ativan (lorazepam)

Klonopin (clonazepam)

Benzodiazepines can also be used as a “bridge” medication, to help a child with acute anxiety get rapid relief during the initial weeks before an antidepressant medication kicks in. And they are sometimes used as an ongoing supplement to an SSRI when the SSRI is not working well enough to reduce symptoms.

But benzodiazepines are not appropriate for long-term use in children, because some patients develop dependence, and experience withdrawal symptoms when they try to stop. Abuse or addiction are a risk in teens and young adults.

Side effects of benzodiazepines include:

• Drowsiness, confusion, grogginess,
• Disinhibition (acting out or inappropriate behaviors)
• Oppositional behaviors
• Respiratory depression (especially in overdose/misuse)

Antipsychotics are a class of drugs originally developed to reduce the symptoms of psychosis — delusions and hallucinations — which can occur in people with schizophrenia and bipolar disorder. But they are sometimes used to help kids with intense, persistent anxiety.

The antipsychotics most commonly prescribed for anxious children and teenagers are:

• Risperdal (risperidone)
• Abilify (aripiprazole)
• Seroquel (quetiapine)

Antipsychotics are sometimes paired with an antidepressant, especially in kids with OCD, as they can be helpful in reducing obsessive thoughts. They can be effective in treating rigidity, Dr. Mitrani notes, and helpful for kids with OCD who are stuck with extreme and unrealistic worries and thoughts. 

But they should be used carefully as they can have serious side effects, including weight gain and metabolic, neurological and hormonal changes that can be harmful. Side effects increase as the dose is increased, and some medications have more side effects than others.

Side effects of antipsychotics include:

• Drowsiness
• Dizziness
• Restlessness
• Weight gain
• Metabolic abnormalities, including a rise in blood sugar, lipids and triglycerides that increase the risk of diabetes and heart disease in later life
• A neurological condition called tardive dyskinesia, which is a potentially permanent motor tic
• An increase in a hormone called prolactin, which can cause breast enlargement in girls and breast growth in boys
• Decreased emotional expression
• A cardiovascular event

Buspirone (Buspar) is another anti-anxiety medication. It works by activating a certain type of receptor in the brain to affect the balance of neurotransmitters. Buspar is not as effective in curbing anxiety as benzodiazepines, but it has significantly fewer side effects and a lower potential for dependence or abuse. That makes it appropriate for longer-term use.

Side effects of atypical anxiolytics like buspirone include:

• Sedation
• Spaciness or confusion
• Disinhibition
• Dizziness
• Headaches
• Nausea
• Nervousness
• Lightheadedness
• Excitement
• Trouble sleeping

Buspar takes 1 to 2 weeks to work, and 4 to 6 weeks to get to its full effectiveness.

The medications called alpha agonists were originally developed to lower high blood pressure in adults. But they were also found to reduce symptoms of anxiety by acting on the sympathetic nervous system, which regulates the body’s fight-or-flight response. As Dr. Mitrani puts it, “They can reduce the sensitivity of the body’s alarm system so it does not go off as frequently or as intensely.”

The alpha-agonists prescribed for anxiety in children and teens include:

• Catapres, Kapvay (clonidine)
• Tenex, Intuniv (guanfacine)

Some families of children with anxiety choose them over antidepressants, which are more effective in combatting anxiety, because of the black box warning for increased risk of suicidality associated with antidepressants.

Side effects of clonidine and guanfacine include:

• Sleepiness
• Headache
• Dizziness
• Dry mouth
• Loss of appetite
• Nausea
• Stomach pain
• Vomiting

Blood pressure should be monitored in kids who take clonidine or guanfacine as they can lower blood pressure.

Antihistamines are medications primarily used to reduce allergic reactions. They do that by blocking the receptors for chemicals called histamines in the central nervous system. But they also block some serotonin receptors, which increases serotonin levels and creates a sedative effect. Some clinicians recommend them to reduce anxiety in children for short periods of time. They work quickly, can help extremely anxious kids calm down, and are non-addictive when taken as directed.

Antihistamines used for anxiety include:

• Benadryl (diphenhydramine)
• Atarax, Vistaril (hydroxyzine) 

Possible side effects of antihistamines include:

• Drowsiness
• Dizziness
• Fatigue
• Dry mouth
• Urinary retention
• Blurred vision
• Confusion
• Irritability
• Headache