What Is the Best Treatment for Anxiety in Children?

Children are affected by many different forms of anxiety, from separation anxiety to OCD, but the treatment options are basically the same for all of them. The most effective treatment for each child depends on factors that include:

• How severe the anxiety is
• How willing and able the child is to participate in therapy
• What options are available (and doable) for the family

For children with mild-to-moderate anxiety, the first-line treatment recommended by most experts is cognitive behavior therapy (CBT), in which the child gradually learns how to tolerate anxiety rather than avoid it, and the anxiety fades over time. CBT is not a quick fix, but kids learn skills that they will be able to use whenever they might need them.

In cases that are more severe, where children are in acute distress and the anxiety is preventing them from everyday functioning — going to school, spending time with friends, participating in activities — the recommendation is usually a combination of CBT plus medication. The medication reduces the child’s anxiety enough to enable them to participate in therapy that provides a longer-term solution.

Medication alone can be the most effective treatment when families don’t have access to therapy or are not able to support kids through the process, which involves a role for parents and can take several months.

While there are many different kinds of anxiety, they all involve intense, sometimes paralyzing, fear as well as physical symptoms such as rapid heartbeat, trembling, and sweating. These treatment approaches are ways to reduce those symptoms.

The most common (and most comprehensively tested) form of therapy for anxiety is a specialized kind of cognitive behavioral therapy called exposure and response prevention (ERP). In ERP, often called exposure therapy, children are “exposed” to the things that trigger their anxiety in small steps and in a safe setting, supported by a therapist. They are taught skills to cope with the discomfort of anxiety without avoiding the thing that triggers it.

To start, the child and the therapist make a list of the child’s triggers and rank them on a scale of 1 to 10. Next, the child is exposed to their fear in its mildest possible form. (For instance, if a child is terrified of dogs, it might be a picture of a dog or simply the written word “dog.”) The therapist supports the child until the anxiety fades. Children learn that if they tolerate the discomfort rather than avoiding it, the anxiety will diminish.   

As the child begins to tolerate the anxiety produced by each trigger, and the anxiety fades, they are ready to take on another trigger that’s higher on their list. (That might include seeing a dog from a distance, then gradually closer up, then actually touching a dog.) At home, parents are enlisted to encourage kids to tolerate the things that make them anxious, rather than avoiding them, and express confidence that they can handle the discomfort until it fades.

Treatment usually takes up to 12 sessions, which may be done weekly or daily, in an intensive program designed to get faster results.

In a more recent form of therapy for kids with anxiety, the therapist works only with the parents, not the children themselves. It’s called Supportive Parenting for Anxious Childhood Emotions (SPACE).

SPACE is based on the understanding that anxious children rely on their parents to accommodate their anxiety by helping them avoid the things they fear. (This could mean crossing the street to avoid a dog, or sitting with a child who is afraid to fall asleep alone). Parents are trained to reduce their accommodations to the child’s fears in small steps,  and to express confidence in their child’s ability to handle uncomfortable feelings. As the parental accommodations are gradually withdrawn, the child learns to tolerate anxiety and the anxiety fades. The more kids practice coping with anxiety, the better they get at it, and their confidence grows that they can handle it without their parents coming to the rescue.

Studies have shown SPACE to be as effective as direct therapy with children and particularly beneficial for younger kids, whose parents tend to do the most accommodating. But if a child is also depressed, engaging in self-harm, or suicidal, it’s not recommended that parents begin reducing accommodations until the depression has been treated.

There are several types of medication that can help with symptoms of anxiety, and they work in different ways. Some are taken every day, while others are taken occasionally to reduce anxiety in specific stressful situations. The medication names can sometimes be confusing because they were originally developed to treat a different condition and later found to be effective for anxiety.

The first choice in medications for kids with anxiety are antidepressants called SSRIs (selective serotonin reuptake inhibitors). SSRIs were developed to treat depression, but they have also been shown to be the most effective medication for reducing symptoms of depression, with relatively few troubling side effects. It takes 2-4 weeks before SSRIs begin to be effective, and they continue to become more effective over the first 8 to 12 weeks. 

But SSRIs don’t work for all children, so there are a number of alternatives. Here are the basics on the different kinds of medications used to treat anxiety:

SSRIs, including such medications as Zoloft, Prozac, and Paxil, are most often prescribed for anxiety. They work by increasing the amount of serotonin, the most important chemical in the brain that regulates mood.

SNRIs, such as Effexor XR and Cymbalta, are another type of antidepressant also used for treating anxiety. They work by increasing the level of two neurotransmitters in the brain —serotonin and norepinephrine. The SNRIs are less frequently prescribed for childhood anxiety because they have a slightly higher rate of side effects. They also take several weeks to begin to work.

These medications, such as Ativan and Klonopin, are used for acute anxiety relief but are generally recommended only for short-term use due to the risk of dependency. Benzodiazepines reduce the physical symptoms of anxiety, such as racing heart and sweating. 

Medications like Abilify, Risperdal, and Seroqual, which were developed to reduce the symptoms of psychosis, can also help with intense, persistent anxiety and the obsessive thoughts that plague kids with OCD. Sometimes they are paired with an antidepressant. But they should be used carefully, because they can have serious side effects like weight gain and hormonal and metabolic changes that can be harmful.

Buspirone, which is often sold as BuSpar, works by activating a certain type of receptor in the brain to affect the balance of neurotransmitters. Buspirone is not as effective in curbing anxiety as benzodiazepines, but it has significantly fewer side effects and a lower potential for dependence or abuse.

The medications called alpha agonists — clonidine and guanfacine — were originally developed to treat 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. Clonidine is sold as Catapres and Kapvay, and guanfacine goes by Tenex and Intuniv.

Drugs like Benadryl are primarily used to reduce allergic reactions 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.