Anxiety Disorders: Parents’ Medication Guide Disorders: Parents' Medication Guide Work Group

CO-CHAIRS: John T. Walkup, MD Jeffrey R. Strawn, MD

MEMBERS: Kareem Ghalib, MD Kimberly A. Gordon, MD Tanya Murphy, MD, MS Daniel S. Pine, MD Adelaide S. Robb, MD Moira A. Rynn, MD Timothy E. Wilens, MD

STAFF: Carmen J. Thornton, MPH, CHES, Director, Research, Development, & Workforce Sarah Hellwege, MEd, Assistant Director, Research, Training, & Education

CONSULTANT: Esha Gupta, Medical Science Writer

The American Academy of Child and Adolescent promotes the healthy development of children, adolescents, and families through advocacy, education, and research. Child and adolescent psychiatrists are the leading physician authority on children’s .

©2020 American Academy of Child and Adolescent Psychiatry, all rights reserved. Table of Contents

Introduction...... 4

The Anxiety Disorders...... 6

Assessment and Treatment...... 8

Medication as a Tool for Treating Anxiety...... 9

Psychosocial Treatments for Anxiety ...... 16

Resources...... 17 Introduction

he purpose of the Anxiety Disorders: experience an , and 5.9% will Parents’ Medication Guide is to provide experience a severe anxiety disorder. Boys and T parents with an easy-to-read and easy- girls are equally affected in childhood, and after to-understand resource on treating anxiety puberty, girls appear to be more commonly disorders in children. In this Guide, we discuss affected than boys. the most common forms of anxiety and related disorders, including the following: Both genetics and the environment play a role in the anxiety disorders. A genetic family • Specific history of anxiety disorder puts a young person • Separation anxiety disorder at for developing an anxiety disorder. In • Generalized anxiety disorder addition, caregivers or relatives can respond to an anxious child in such a way as to make • disorder the child’s anxiety even worse by unknowingly • disorder supporting avoidance instead of engagement and unintentionally reinforce and • Obsessive-compulsive disorder instead of good . What is anxiety? Anxiety is a normal that is critical What is the difference for our survival and functioning. It can help between “normal” anxiety and us avoid potentially dangerous situations an anxiety disorder? and prepare for challenges. Stressful life Anxiety disorders are different from regular or events, such as taking a test, starting a new typical anxiety, just like is different school, or speaking in front of a group can from everyday or the way trigger normal forms of childhood anxiety (elevated and expansive ) is different that are helpful in preparing a child for the from regular and excitement. challenge ahead. That said, sometimes there can be problems in expressing that Despite the different ways anxiety is can negatively day-to-day living. Fear, expressed among children from different anxiety, sadness, and even our capacity to backgrounds and ethnicities, symptoms of enjoy ourselves can be a problem if these anxiety disorders differ from those of normal emotions become extreme and impair one’s anxiety in a number of important ways. capacity to function. 1. Normal anxiety occurs at all time points in How common are the anxiety life. Yet, the anxiety disorders first affect children before puberty and can begin or disorders, and who is affected? get worse unexpectedly “out of the blue." Anxiety disorders are common in children and adolescents, and typically begin during 2. Typical and developmentally appropriate childhood and adolescence. In fact, some activities that most children enjoy are suggest that anxiety disorders may affect 1 in 8 not manageable for children with anxiety children. The National Institute of Mental Health disorders. For a child with an anxiety disorder, (NIMH) estimates that 25.1% of adolescents going to school, participating in sleepovers or between the ages of 13 and 18 years will going to camp, making new friends at a party,

4 Anxiety: Parents’ Medication Guide “showing off,” and participating in new leading to missed school days and even the symptom patterns of an anxiety and potentially rewarding experiences unnecessary medical procedures. disorder, in part because the types ( parks) can be very anxiety of symptoms are very similar among provoking. As a matter of fact, the child’s 4. The persistence and consistency of children with anxiety disorders. intense reaction is often surprising to the anxiety symptom picture over time their caregivers, as the triggering cause is key to diagnosing an anxiety disorder. Parents and caregivers often get into a That said, some anxious children can is often a routine and normal life event a pattern of anticipating a child’s anxious experience a sudden worsening of child of a certain age is expected to be behaviors and, in an effort to relieve their anxiety symptoms. For example, an able to do. child’s distress, will help their child avoid 8-year-old child who has been mildly a potential anxiety trigger. Unfortunately, 3. Children with anxiety disorders often anxious as a younger child but enjoyed although the parents and caregivers experience a number of unexplained school may now suffer from separation have the best intentions, their actions physical symptoms, such as anxiety and refuse to go to school. may actually make the anxiety worse stomachaches, , shortness and prevent the child from coping with 5. Children with anxiety tend to cope by of breath, chest , worrying about and adapting to typical and important avoiding situations that make them choking, and gagging or . They developmental tasks. Avoidance, anxious. If the triggering experiences often worry about their overall health. meltdowns, or other behaviors that are routine and necessary tasks Anxious children may pay too much continually keep a child from doing age- of growing up, the child’s everyday to their body’s sensations appropriate activities result in “functional” functioning and home or school life and mistakenly believe that these can be disrupted. impairment. In addition, the physical sensations are symptoms of an illness. and emotional distress of anxiety is As a result, these children are likely to 6. Children with anxiety disorders can “psychological” impairment. When a child appear as physically ill to their parents, also have normal anxiety. Trained with anxiety is experiencing functional and to visit the school nurse and/or professionals, such as child and and psychological impairment, they are pediatrician more often, potentially adolescent psychiatrists, can recognize from an anxiety disorder.

Anxiety: Parents’ Medication Guide 5 The Anxiety Disorders

nxiety disorders are categorized into • Physical complaints—headaches, fear of different forms depending on the gagging, choking or vomiting, , A symptoms children display. (Table 1) shortness of , poor appetite, stomachache, urgent bathroom trips, Common Symptoms Across increased sweating, muscle tension, All the Anxiety Disorders jitteriness, and difficulty falling asleep. Although there are specific symptoms associated • Avoidance—the most common and easiest with each of the anxiety disorders listed in way for a child to cope with anxiety is to Table 1, there are common symptoms among avoid. Instead of approaching a new situation these disorders. with as most children do, children with anxiety disorders avoid their anxiety- • Hypervigilance—continuous scanning of the triggering situations. Avoidance of important environment for anything new and different. developmental tasks is a signal that the • Reactivity—whereas most children are child’s anxiety needs to be addressed. curious and interested in new things, • Behavioral issues—if the child cannot children with anxiety often feel threatened avoid an anxiety-triggering situation, by new or changing events or expectations he/she may demonstrate significant and react accordingly. behavioral issues, often described as “meltdowns,” such as refusing to participate, becoming oppositional, and having temper tantrums. Intense anxiety or meltdowns are very challenging for most caregivers and often leave them powerless to help their child.

6 Anxiety: Parents’ Medication Guide Table 1.

Anxiety and Related Disorders

Specific • Irrational or extreme fearful reactions to an object or situation (e.g., animals, heights, costume characters, and type of transportation) Phobia • Results in avoiding the objects or situations or in demonstrating distress when exposed to them in normal everyday life • Often the first sign of an anxiety disorder and can be associated with other anxiety disorders

Separation • Specific worry that something bad will happen to them or to their caregivers if they are apart (e.g., in a different room in Anxiety the house from their caregivers, falling asleep alone in their bed, going to school in the morning, attending a sleepover at a close friend’s house, or worry when their caregivers are not home or late coming home) • They may be described as being clingy or easily homesick

Generalized • A variety of and worries about everyday life experiences (i.e., they often anticipate disaster [e.g., catastrophic thinking], worry Anxiety about their health issues and financial status, as well as their families’ health and finances, think about life and death, as well as Disorder family and interpersonal relationship problems, and feel intense academic pressures) • They may be described as being worriers, tense, uptight, inflexible, and perfectionistic • May feel as if “something bad will always happen,” (if of dread are extremely intense, may be misdiagnosed with depression) • May have problems falling asleep at night because of worry • Sometimes have problems focusing and concentrating in school because they are preoccupied with worry (if significant, may be misdiagnosed with attention-deficit/hyperactivity disorder)

Social • Fear or worry about their functioning in social interactions (i.e., they are extremely self-conscious and are afraid of being judged Anxiety or humiliated in a social situation or doing something silly or embarrassing, frightened at the thought of becoming the focus of Disorder others’ attention) • May be limited to specific settings (i.e., speaking in front of a group) or can be a global problem and affect them in 1:1 situations (i.e., ordering food in a restaurant and/or asking a safe stranger like a teacher a question or policeman for directions) • They are often considered to be shy, highly self-conscious, “slow to warm up,” hesitant to talk in social settings, “soft spoken,” and reluctant to ask others’ questions, or may answer questions with short phrases and avoid making socially appropriate eye contact • Often have physical symptoms (i.e., , sweating, trembling or shaking, or feeling nauseated or sick to their stomach) when they are confronting a social situation

Panic • Experience panic attacks that are characterized by the sudden onset (within minutes) of intense fear that something bad is Disorder happening or going to happen or fear of losing control • The usually peaks in 10 minutes and lasts for approximately 15 to 30 minutes, but the effects of having had a panic attack can continue as the person worries about having another attack and what the attack could mean about their health, causing them to avoid situations associated with the feeling of panic • Physical symptoms of a panic attack may include , chest pain, sense of irregular heartbeat, heart beating too hard or too fast, increased breathing () with tingling or numbness around the mouth and in the fingers, sweating, and shaking; although they feel life threatening, they are not dangerous

Obsessive • Characterized by obsessions, which are repeated and unwanted thoughts, urges, or mental images that cause anxiety, distress, and Compulsive are linked to compulsive behaviors Disorder • Compulsive rituals seem to relieve the anxiety from these thoughts in the short run, but the child often spends a substantial amount of time obsessing or engaging in compulsions (more than 1 hour a day), which causes distress and daily dysfunction • Common obsessions include the following: fear of germs or contamination; unwanted, taboo thoughts about sex, religion, and harm to self or others; unwanted aggressive thoughts; and the need for things to be balanced, symmetrical, or in perfect order • Common compulsions include the following: excessive grooming and hand washing; ordering and arranging things in a particular and precise way; repeatedly checking on things such as whether the door is locked or whether the stove is off; and conducting mental rituals such as replacing a “bad thought” with a “good thought”

Anxiety: Parents’ Medication Guide 7 Assessment and Treatment

t is important that the clinician evaluating a scales and interviewing the parent and child about child for an anxiety disorder is familiar with the child’s internal symptoms and functional I the diagnosis, life course, and treatment impairment. The clinician will work to understand of anxiety disorders. Given the potential for the child’s pattern of anxiety symptoms, level of the overlap of normal anxiety and anxiety avoidance, and family readiness to engage in disorders, some pediatricians, primary care treatment. They will also determine whether the doctors, school personnel, and mental health child has other problems that might make the professionals may not understand what the treatment plan more challenging. anxiety disorders look like in children and may not fully recognize anxiety disorders as an The clinician will consider many factors in important mental health problem. deciding what treatment is needed for a child with an anxiety disorder. After the clinician has Child and adolescent psychiatrists, physicians evaluated a child, he/she should communicate who specialize in the diagnosis and the the results of the evaluation, specific treatment treatment of mental health conditions in recommendations and the reason behind children and adolescents, are important treatment recommendations. Treatment members of your child’s mental health care recommendations often include specific team, as they offer families the advantages of recommendations about how the family can a medical education, the medical traditions of best engage and support the child, essentially professional ethics, and medical responsibility becoming “coaches” who work with the child to for providing comprehensive care. “take on” their fears and worries.

It is important to differentiate severe and ongoing While it is a big decision to enter a child into anxious reactions to significant life events treatment for an anxiety disorder, it is important Regardless of the (i.e., “normal” anxious reactions to extreme life to understand that it is also a big decision to not circumstance) from an anxiety disorder. Anxiety situation, when a engage in treatment. Clinical studies suggest disorders require specific treatments and children with an anxiety disorder do not get child is having trouble anxious reactions to extreme life circumstances better with just support and longer-term studies are managed by providing children with safe, handling their day- suggest anxiety, if not treated, is associated with secure, and predictable environments and even a number of poor life outcomes including the to-day life activities treatment including psychological support. In both risk for depression, substance misuse, suicidal circumstances children having trouble handling because of anxiety, thoughts and behaviors, and difficulties with their day-to-day life activities should be seen by a adapting and coping. they should be seen clinician for a complete assessment to see what kind of treatment is needed. by a clinician for a Role of the Family in complete assessment Because many of the symptoms of anxiety Assessment and Treatment are experienced internally by a child (e.g., fear It is very important to have family involvement to see if treatment is or worry), a caregiver may only recognize in the assessment and treatment of anxiety. recommended. the functional impairment that the child is Clinicians know about anxiety disorders in demonstrating; for example, difficulty falling children, but they highly rely on the caregivers’ asleep, not going to school, anxiety around active engagement in assessment and situations, reluctance to engage treatment to be able to do best by the child. The in social activities and make friends, strong child’s caregivers are the clinician's “eyes and emotional reactions, and other avoidance ears.” Treatment is much more effective when behavior. A comprehensive evaluation by a parents and clinicians work together to reduce clinician will likely include completing rating the child's anxiety.

8 Anxiety: Parents’ Medication Guide Medication as a Tool for Treating Anxiety

he Food and adolescents with anxiety disorders will often Administration (FDA) oversees the recommend and prescribe safe and effective T approval process to show that a medications “off label.” This is not a bad thing, medication is safe and effective for a specific as the medications have been proven to be condition (e.g., generalized anxiety disorder). effective and safe, even though they have not After a medication has been approved by the gone through the FDA approval process. FDA, clinicians can use the medication for the specific condition (i.e., on-label prescribing) For childhood anxiety disorders, only one or for any other condition where studies medication, , has received FDA have proven them effective or the physician approval and can be prescribed “on label” believes the medication can be effective and for children 7 years of age and older with safe (i.e., off-label prescribing). generalized anxiety disorder. However, a number of other medications have been It is important to recognize that clinicians proven to be safe and effective for treating who practice high quality “evidence-based” the childhood anxiety disorders but have not medication treatment for children and gone through the FDA approval process.

It is important to recognize that clinicians who practice high quality “evidence- based” medication treatment for children and adolescents with anxiety disorders often will recommend and prescribe safe and effective medications “off label.”

Anxiety: Parents’ Medication Guide 9 What medications reduce treatment or treatment anxiety and its symptoms combined with psychological treatment, the clinician may consider a variety consistently over time? of approaches, including medication Antidepressant medications represent changes or adding other psychological the foundation of medication treatment interventions. It is important to keep for with anxiety disorders and OCD. in mind that it is okay if a medication Many of the medications that benefit change is suggested to reach the goal of anxiety disorders and OCD were initially remission because a child may respond recognized as medications for depression better to the second medication. Changing and thus, called . The most the treatment in youth who do not respond effective antidepressant medications, to initial medication treatment has been selective serotonin reuptake inhibitors shown to be beneficial. (SSRIs), and selective norepinephrine reuptake inhibitors (SNRIs), increase the effects of serotonin and norepinephrine, What have studies on chemical neurotransmitters in the antidepressant medication body that help regulate anxiety, mood, and use in children and social behavior. adolescents with anxiety disorders shown? Antidepressant medications that have Nearly a dozen studies have evaluated proven to be effective for childhood antidepressant medications in children anxiety disorders that can be prescribed and adolescents with generalized, "on label" include duloxetine (Cymbalta™) The goal of treatment social, and separation anxiety disorders. and "off label" include (Zoloft™), (Table 2) In nearly all studies, youth who for a child is always (Prozac™), received antidepressant medication did (Luvox™), (Paxil™), and remission (having few, better than those who received placebo ER (Effexor XR™). if any symptoms) of the (sugar pill). And those children who received a combination of medication and anxiety disorder. What is the goal of psychological treatment of anxiety did treatment in a child or best. Likewise, in children with OCD, the teenager with anxiety? SSRIs have been studied and are effective The goal of treatment for a child is always in reducing OCD symptoms. Studies that remission (having few, if any symptoms) have compared SSRIs and of the anxiety disorder. If remission is in youth with OCD have generally shown not achieved with either antidepressant that the combination of an antidepressant

10 Anxiety: Parents’ Medication Guide medication and psychotherapy is far for remission. In the clinical studies of more effective than either psychotherapy medication, the best treatment dose is often or medication alone. identified in 8 to 12 weeks of treatment, with symptoms continuously improving even after that. Studies suggest the beneficial effects of SSRI treatment—regardless of How are medications chosen? whether it is given with cognitive-behavioral A clinician will consider several therapy (CBT)—reach maximum benefit at factors in choosing whether to 6–9 months of treatment. prescribe a specific medication for a child. What medications are • Diagnosis used occasionally for intense • Age of the child episodes of anxiety? Clinicians often use medications from • Medication effectiveness different classes to address a specific • Side effects experience of anxiety such as flying on a plane, giving a speech, or other • How quickly the medication works performance activity. Some of these • Interactions with other medications come from the class of medications taken by the child , such as lorazepam • Way in which the medication is (Ativan™) and (Klonipin™). taken (capsules, tablets, liquid) Benzodiazepines are generally used for short term treatment. When used for In the clinical studies long periods of time, some patients have of medication, the difficulty stopping the medication and best treatment dose is How long does experience withdrawal symptoms. often identified in 8 to medication take to work? Some clinicians will also use Often, improvement from antidepressant antihistamines such as 12 weeks of treatment, medication begins in 2 to 4 weeks with (Benadryl™) or (Atarax™, with symptoms additional improvement over 8 to 12 weeks. Vistaril™) to reduce anxiety for short Some children show improvement at low periods of time. Also, medications from continuously improving doses of antidepressant medication very the class of beta-blockers such as even after that. early in treatment, however, clinicians (Inderal™) have been used for may increase the dose of the medication performance challenges such as public to ensure the child has the best chance speaking events.

Anxiety: Parents’ Medication Guide 11 Adapted from Wilens, Hammerness. Straight Talk about Psychiatric Medications in Kids (Guilford Press, 2016). Table 2. Antihistamine Atypical SNRI SSRI Class Hydroxyzine (Atarax (Unisom Doxylamine Diphenhist (Benadryl Diphenhydramine (Buspar Lorazepam Intensol Lorazepam (Ativan Clonazepam (Klonopin Intensol Alprazolam (Xanax (Trofanil (Anafranil Atomoxetine (Strattera Duloxetine (Cymbalta Venlafaxine ER (Effexor Paroxetine (Paxil (Prozac Fluoxetine (ZoloftSertraline Luvox CR Fluvoxamine (Luvox (Celexa/Lexapro / (Brand name) Medication TM TM TM TM) TM , Sarafem , Trofranil-PM , WalSom TM

, Banophen

) Medications that may be used to treat anxiety disorders in children and adolescents. TM TM TM , Pexeva , ) TM ) TM TM TM TM TM TM TM TM ) , , ) TM ) ) , ) ) TM TM TM

TM ) TM TM , ) ) ) TM ) ) ) 25–50 25–50 12.5–50 12.5–50 15–60 1–2 0.5–3 0.5–1.5 75–250 10–100 30–120 37.5–225 10–50 10–60 25–200 100–300 10/5–40/20 (mg/day) Common dose range 10, 25, 50 25, 50 25, 50 5, 10, 15, 30 1, 2 0.5, 1, 2 0.25, 0.5, 1, 2 10, 25, 50 25, 50, 75 10, 18, 25, 40, 60, 80, 100 20, 30, 40, 60 37.5, 75, 150, 225 10, 20, 40 10, 20, 40, 60 25, 50, 100 25, 50, 100, 150 10/5, 20/10, 40 (mg) Tablet size

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Common side effects Decreased sweating mouth Dry Sleepiness Tiredness Abdominal pain Dizziness mouth Dry Clumsiness Drowsiness Weight gain mouth Dry Sleepiness Weight loss/gain Muscle pain rateIncreased heart Increased blood pressure Increased / mouth Dry Restlessness Sleepiness Weight loss/gain Muscle pain Sexual dysfunction Increased anger/irritability Vomiting Hyperactivity/restlessness Decreased appetite Insomnia Headache • • • • • • • • • • • • • • • • • • Serious side effects Seizures types of blood cells Harm to certain Difficulty completely emptying the bladder Agitation rhythms Abnormal heart Worsening depression impairment Memory Disinhibition of withdrawal symptoms. is a common strategy to decrease the risk long periods. Decreasing the dose gradually doses, especially when administered over Withdrawal symptoms when used at high Possible dependence Mania blood levels electrocardiogram and rhythm problems; Heart young adults behavior in children, adolescents, and Boxed warning–suicidal thinking and Mania young adults behavior in children, adolescents, and Boxed warning—suicidal thinking and Mania rhythm heart Potential for abnormal young adults behavior in children, adolescents, and Boxed warning—suicidal thinking and

nervous system )nervous combined with other central at high doses and when Respiratory depression (possible Serotonin syndrome • • • • Uncommon, serious side effects Bleeding problems Serotonin syndrome Bleeding problems Serotonin syndrome

12 Anxiety: Parents’ Medication Guide What medications are used child’s physician. Everyone worries about for occasional problems side effects but people and children with What is the FDA warning? anxiety disorders are likely to worry more The FDA added a “boxed in youth with anxiety? than others do. The presence of side warning” to all antidepressant Sleep is often a significant problem in effects is an important part of decision medications to alert youth with anxiety. Treatment of the anxiety making for dose adjustments. Sometimes prescribing physicians and disorder with antidepressants and/or it is difficult to tell if the child is having a patients that special care CBT is often beneficial in reducing anxiety side effect or if it is the anxiety that is still should be taken when using and restoring normal sleep patterns. If impacting the child (e.g. stomachache). antidepressant medications the child’s anxiety is under very good in children, adolescents, and control and falling asleep is still a problem, Common side effects, which occur in young adults. The warning behavioral approaches should be tried next. approximately 10–20% of patients, include states that antidepressant If behavioral approaches are not successful headaches, difficulty sleeping, appetite medications are “associated there are different medications that help changes, abdominal pain, and diarrhea. with an increased risk of children with anxiety sleep better. Clinicians Possible side effects, which may occur in 5% suicidal thinking and/or often pick among medications such as of patients, include weight gain, muscle pain, behavior in a small proportion melatonin, antihistamines, antidepressants and common cold symptoms. Rare side of children and adolescents, that sedate like , and even effects, which occur much less frequently, especially during the early some medications specifically marketed include seizures, deliberate self-harm, phases of treatment.” Such for insomnia in adults such as zolpidem abnormal heart rhythms, and mania. Suicidal “adverse events” (mostly (Ambien™) and zaleplon (Sonata™). While thinking and behavior is discussed in the box suicidal thoughts) were medicines used in adults for insomnia may to the left. It is important to know that this reported by approximately 4% be useful in children, they have not been risk has not been shown in most studies of of all children and adolescents studied extensively in children. SSRIs in youth with anxiety disorders. taking medication compared Perhaps of most concern to parents with 2% of those taking a How is the medication placebo. More recent and is whether the medication will change larger studies suggest that the dose selected and changed? a child’s behavior or personality in an associated risk is even less. It For the antidepressant medications, unwanted way. In general, when SSRIs is important to understand that physicians select an initial dose based on and SNRIs work well they reduce the it is not known why there is a studies that have evaluated the medication child’s anxiety greatly, and allow the child small but somewhat greater in children and adolescents. In general, to function as they would if they were not risk for suicidal thoughts or children with anxiety are started on a low anxious. It is important to know that the behavior on medication than dose of medication, with incremental medications reduce anxiety, but don’t solve on placebo. increases to reach the appropriate dose all the problems a child might have. that offers the best chance for remission with minimal, if any side effects. Over the Lastly, across all the SSRI and SNRI course of treatment, the caregiver and studies there is a common pattern of child will meet with the clinician regarding side effects that we call “activation how the anxiety symptoms have changed syndrome”—an excessive and and whether there are side effects. Some uncomfortable restlessness that occurs clinicians adjust doses more quickly (with early in treatment or soon after a dose more frequent check-in visits), and others change. The activation may cause the may prefer a more gradual approach. child to be more irritable, impulsive, and “Going low and slow” is okay; however, it is overall more difficult to manage. Reducing important to understand that starting too the dose of medication or discontinuing it low and going too slow may unnecessarily is the best management strategy until the activation symptoms go away. Since the prolong a child’s suffering. The common activation symptoms most often occur dose ranges for medications that are used early in treatment and at lower doses, to treat children with anxiety are shown it may be difficult to get a child to a full in Table 2. treatment dose if the medication seems to cause activation. How are side effects managed? Antidepressants such as SSRIs and The usual strategy for managing SNRIs can have various side effects, side effects is to reduce the dose or as shown in Table 2. It is important to discontinue the medication. However, discuss medication side effects with your adjusting the dose to minimize the side

Anxiety: Parents’ Medication Guide 13 effects may result in losing some of improvements in specific target the benefit of the medication. It can be symptoms, such as worrying excessively. a delicate balance that a caregiver and In general, for kids with anxiety disorders, the clinician have to manage together. parents and caregivers will be able If the clinician has to reduce the dose to observe that the child is able to do of the medication to reduce side effects things now that they could not do before and symptoms return, the clinician will such as falling asleep quickly, spending review the treatment options with the the night at a friend’s house, going to caregiver so the child can have his/her a party, attending school and camp, best outcome. Switching medication is being around groups of people, going to something that is commonly done when malls or restaurants, etc. Anxiety-related the first medication does not work or physical symptoms (e.g., headaches, there are side effects. stomachaches, difficulty swallowing, etc.) will decrease or stop altogether. How do I know the medication is working? How long should The question of whether treatment— medication be continued? medication, psychological treatment, or As caregivers and the child consider the combination of the two—is working when to stop antidepressant treatment, is best answered by observing whether it is important to recall that the end a child’s anxiety decreases in frequency goal of treatment is having few if any and severity and the child appears overall symptoms. The child has the best chance more comfortable and able to do things. of discontinuing treatment if they have Parents, caregivers, and clinicians may experienced remission and functional also answer this question by examining recovery. Any discussion regarding if

14 Anxiety: Parents’ Medication Guide and when to discontinue treatment A risk of discontinuing medication is should only happen then. Children with the chance that anxiety symptoms ongoing symptoms of anxiety and will return even in children who have associated impairment may not be recovered. Families should only consider the best candidates for stopping their stopping antidepressant treatment during medication. Increasing their medication periods of low and specifically or psychological treatment to achieve not when the child might be expected to remission before considering stopping be most anxious. For example, stopping treatment may be best. medication before school starts in the fall in a child with separation anxiety who While a specific timeframe is not known, struggled to go to school is probably not some experts recommend discontinuing a good idea. Also, for some children with medication 6–12 months after remission anxiety, seemingly low stress periods has been achieved. A child who has like family vacations or holidays may successfully worked with his/her family seem like a good time to stop medication in psychotherapy along with medication but may actually be stressful and the treatment or a child with a faster resulting anxiety be mistakenly blamed on response to treatment (more likely with the medication discontinuation. antidepressant plus psychotherapy) might be ready to discontinue medication If a child has successfully come treatment more quickly. It is important off medication, it can be useful to to keep in mind that there is no evidence monitor the child off medication to suggesting that long-term antidepressant ensure that subtle anxiety symptoms treatment is unsafe when medication is do not return, and the child maintains overall well-tolerated. their functional recovery.

Anxiety: Parents’ Medication Guide 15 Psychosocial Treatments for Anxiety

he clinician who assesses should engage the child in a process the child may recommend a called “exposure and response T specific psychological treatment prevention.” Exposure and response such as cognitive-behavioral therapy prevention treatment teaches the (CBT), or a combination of CBT and child two important things: 1) the fear medication, which are the evidence- or worry is not necessary for normal based treatments for the childhood- developmental tasks; and 2) with time, onset anxiety disorders—specifically, the fear or worry will go away or be separation, generalized and social better tolerated, and the child will learn anxiety disorders, and OCD. how to cope without avoiding.

The evidence-based psychological Although psychotherapy can be a treatment (CBT) for the anxiety very effective form of treatment for disorders and OCD begins with some children with anxiety disorders, educating the child and family about this guide focuses on medication the nature of the anxiety symptoms treatments. Other resources that and how the symptoms may worsen discuss CBT in more detail are available. over time, if not addressed effectively. Also, psychotherapy may be used in For example, a child who is anxious, combination with medication. Children and copes by avoiding, may feel better who receive the combination in the short term but avoiding actually of psychotherapy plus medication reinforces anxiety in the long term. have fewer anxiety symptoms than After the child and family understand children who receive medication only this important dynamic, the clinician or psychotherapy only. The evidence- based psychological treatment (CBT) for the anxiety disorders and OCD begins with educating the child and family about the nature of the anxiety symptoms and how the symptoms may worsen over time.

16 Anxiety: Parents’ Medication Guide Resources

• American Academy of Child & Adolescent Psychiatry (AACAP) https://www.aacap.org/AACAP/Families_and_ Youth/Resource_Centers/Anxiety_Disorder_ Resource_Center/Home.aspx

• Anxiety and Depression Association of America https://adaa.org

• Centers for Control and Prevention (CDC) https://www.cdc.gov/childrensmentalhealth/ depression.html

• National Alliance on Mental Illness (NAMI) https://www.nami.org/Find-Support/Family- Members-and-Caregivers

• National Institute of Mental Health (NIMH) https://www.nimh.nih.gov/health/topics/ anxiety-disorders/index.shtml

• https://www.nimh.nih.gov/health/publications/ anxiety-disorders-listing.shtml

Anxiety: Parents’ Medication Guide 17 Medication Tracking Form

Use this form to track your child’s medication history. Bring this form to appointments with your provider and update changes in medications, doses, side effects and results.

Date Medication Dose Side Effects Reason for keeping/stopping

18 Anxiety: Parents’ Medication Guide Author Disclosures

KAREEM GHALIB, MD Data and Safety Monitoring Board: Research Funding: Allergan, Inc.; Lundbeck; Assistant Clinical Professor, National Institute of Mental Health for National Institute of Child Health and Department of Psychiatry University of Cincinnati; Neuronetics; Development; National Institute of Columbia University Medical Center Otsuka America Pharmaceutical, Inc. Environmental Health Sciences; National Institute of Mental Health; Neuronetics; No disclosures to report Honoraria for Speaking at a Meeting: Otsuka America Pharmaceutical, Inc.; Yung American Academy of Child and Family Foundation KIMBERLY A. GORDON-ACHEBE, MD Adolescent Psychiatry; American Medical Director Academy of Pediatrics Health Systems, Inc. JOHN T. WALKUP, MD In-Kind Services: Allergan, Inc.; American Leadership Roles: Caucus of Black Professor, Department of Psychiatry, Academy of Child and Adolescent Psychiatrists; Council on Children, Northwestern University Feinberg Psychiatry; American Academy of School of Medicine; Director, Adolescents, and Their Families, Pediatrics; Supernus Pharmaceuticals, Inc. Department of Psychiatry American Psychiatric Association Research Funding: Allergan, Inc.; Ann and Robert H. Lurie Children’s Lundbeck; National Center for Advancing Hospital of Chicago TANYA MURPHY, MD, MS Translational Sciences; National Institute Books, Intellectual Property: Guilford Endowed Chair, College of Medicine of Mental Health; National Institute of Press; Oxford Press Pediatrics; Director and Professor, Neurological Disorders and ; Pfizer Rothman Center for Pediatric Honoraria: American Academy of Child Inc.; Supernus Pharmaceuticals, Inc. and Adolescent Psychiatry, American Neuropsychiatry; Professor, Pediatrics and Psychiatric Association, Tourette Psychiatry, College of Medicine Pediatrics Stock in IRA: Eli Lilly and Company; Association of America University of South Florida GlaxoSmithKline; Johnson & Johnson Research Funding: Centers for Disease Services, Inc.; Pfizer Inc. Research Funding: Abbott Laboratories; Control and Prevention; F. Hoffmann-La Eli Lilly and Company; The Hartwell Roche Ltd.; National Institute of Mental MOIRA A. RYNN, MD Foundation; Pfizer Inc.; Tourette Health; Neurocrine Biosciences, Inc.; Chair, Department of Psychiatry and Association of America PANDAS Network; Pfizer Inc.; Psyadon Behavioral Sciences Pharmaceuticals, Inc.; Shire; Teva Duke University School of Medicine TIMOTHY E. WILENS, MD Pharmaceuticals Industries, Ltd.; Tourette Books, Intellectual Property: Chief, Child and Adolescent Psychiatry Association of America American Psychiatric Association Department; Co-director, Center for Publishing; UptoDate Medicine Scientific Advisory Board: International Consultant: Allergan, Inc. Massachusetts General Hospital OCD Foundation, PANDAS Network, Advisor/Consultant: Bay Cove Human Tourette Association of America Data Safety Monitoring Board: Allergan, Inc. Services; Gavin Foundation; Ironshore Research Funding: National Institute of Pharmaceuticals Inc.; KemPharm, Inc.; DANIEL S. PINE, MD Child Health and Development; National National Institute on Drug ; Otsuka Chief, Emotion and Development Branch; Institute of Mental Health America Pharmaceutical, Inc.; US Minor/ Chief, Section on Development and Major League Baseball; US National JEFFREY R. STRAWN, MD Football League (ERM Associates) National Institute of Mental Health Associate Professor Books, Intellectual Property: Cambridge No disclosures to report University of Cincinnati University Press; Elsevier; Guilford Press Books, Intellectual Property: Springer Co-Owner of a Copyrighted Diagnostic ADELAIDE S. ROBB, MD In-Kind Services: Travel support Questionnaire: Before School Functioning Chief, Psychiatry and Behavioral Sciences from American Academy of Child and Questionnaire (BSFQ) Children’s National Health System Adolescent Psychiatry Advisor/Consultant: Allergan, Inc.; Licensing Agreement: Ironshore Neuronetics; National Institute of Mental Honorarium: CMEology Pharmaceuticals Inc. Health; Supernus Pharmaceuticals, Inc.; Material Support: GeneSight/Assurex Research Funding: Lloyd Foundation; University of Cambridge Health, Inc. National Institute on Drug Abuse 3615 Wisconsin Avenue, NW | Washington, DC 20016-3007 | www.aacap.org

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