Treatment of Anxiety in Children

Initial Assessment and Diagnosis

The American Academy of Child and Adolescent Psychiatry recommends confirming the specific anxiety disorder diagnosis, such as separation anxiety, generalized anxiety, social anxiety, or specific phobia, which are most common at age 11, and ruling out medical mimics, particularly hyperthyroidism and cardiac conditions, before initiating treatment 1, 3
The American Academy of Child and Adolescent Psychiatry suggests screening for comorbid conditions, especially depression, ADHD, and other anxiety disorders, as 50-60% of anxiety cases present with depression 1, 3, 5
Assessing suicide risk is crucial, as 24% of adolescents with anxiety have suicidal ideation and 6% make suicide attempts, with the highest risk in generalized anxiety disorder plus depression 6, 3
Quantifying severity using the GAD-7 scale is recommended, with scores ranging from 0-4 (mild) to 15-21 (severe) 4

The American Academy of Child and Adolescent Psychiatry recommends starting with cognitive-behavioral therapy (CBT) as the first-line treatment for mild to moderate anxiety, with 12-20 sessions typically required 1, 2
For severe anxiety, the American Academy of Child and Adolescent Psychiatry suggests initiating combination treatment with both CBT and an SSRI, such as sertraline, from the outset, as this approach is superior to either treatment alone 2, 4
The treatment should include core CBT components, such as education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving/social skills training 1, 2

The American Academy of Child and Adolescent Psychiatry recommends starting sertraline at 25 mg once daily, with slow titration and a target dose range of 25-200 mg/day, based on response and tolerability 2
Monitoring for adverse effects, such as gastrointestinal symptoms, behavioral activation/agitation, and suicidal ideation, is crucial, especially in the first few weeks and after dose adjustments 2

The American Academy of Child and Adolescent Psychiatry suggests continuing pharmacotherapy for 12 months after achieving remission before considering tapering to prevent relapse 4
Immediate psychiatric referral is required for suicidal ideation, self-harm behaviors, risk of harm to others, psychosis, and severe agitation requiring one-to-one observation 4, 5

The American Academy of Child and Adolescent Psychiatry recommends avoiding benzodiazepines as first-line or long-term treatment due to dependence risk and cognitive impairment 4
Treating severe anxiety with monotherapy alone should be avoided, as combination CBT plus SSRI is superior 4
Attributing all anxiety symptoms to psychiatric causes without first ruling out hyperthyroidism and cardiac conditions should be avoided 4, 5
Discontinuing SSRIs before 12 months of remission should be avoided, as premature discontinuation significantly increases relapse risk 4