Written with Emily Powell, MACC
What is the best course of treatment for children and adolescents suffering from anxiety? The research is clear that, when possible, Cognitive-Behavioral Therapy (CBT) is the most effective course of treatment. Medication combined with CBT may be most effective in many cases but for many reasons parents can be cautious or even opposed to the use of medication for their children. So when should medication be considered, if at all, for children with anxiety? (The writers are not physicians and this is not a medical opinion.)
First, what exactly is CBT?
CBT is a practical and logical approach to working with child anxiety that has been used successfully for adults battling anxiety since the 1960s. With CBT, people with anxiety learn a new way of reacting and responding to anxiety. The automatic response of fear or panic, accompanied by escape or avoidance, is stopped by relearning how to interpret and respond to the instinctive feelings of fear. Using CBT helps the child to think more practically about fears, to confront them and test their validity, and to become less reactive to physical symptoms and feelings of anxiety. CBT is an active, experiential form of learning, similar to riding a bicycle, which is mostly learned by doing, and which must be practiced often in order to improve.
A 1994 study by Dr. Philip Kendall at Temple University found that of the anxious children who received a 16-week CBT treatment, 64% improved significantly. Of the children who were on a waiting list and did not receive treatment, only 5% improved. The anxious children who received CBT treatment remained improved even one year after completion of treatment. CBT can be used effectively with children as young as six-years-old. In just released research, Turnaround, which is based on CBT, was similarly effective.
Despite its benefits, some children do not participate in CBT, it may not be available and others may need both CBT and medication(s) for the most overall benefit. We discuss some of the conditions that might make medication important to consider below. In the Turnaround program we include an interview with a neuropsychiatrist discussing medication in detail. It is also available separately.
What are the kinds of medication to consider?
Although a wide variety of medications are used for anxiety in children,*** the amount of research available regarding their effectiveness is limited relative to adults. Medications used to treat anxiety disorders are the SSRI’s, which stands for selective serotonin reuptake inhibitor, and they have the strongest research support. In addition to SSRI’s, serotonin norepinephrine reuptake inhibitors (SNRI’s) have been researched and found to be a beneficial and effective treatment for anxiety. Other medications like benzodiazepines are used, but less frequently with children. Clinical experience and case reports show that medications can often reduce the symptoms of anxiety effectively for some children. Many times, a combination of CBT and medications is most effective. The ADAA website notes a major study that found the combination worked better for ages 7-17 than either treatment by itself.
How do the medications work?
SSRI’s work by blocking a receptor in the brain that absorbs the chemical serotonin. Nerve cells normally recycle serotonin by reabsorbing it, and the SSRIs work by inhibiting this re-uptake of serotonin. As a result, more serotonin will be present to pass on messages to nerve cells nearby. SSRI’s work selectively on serotonin and have the power to mildly influence mood, outlook, and behavior.
Certain neurotransmitters—including serotonin and norepinephrine—are known to affect mood. Serotonin is sometimes called a “feel good” chemical because it is associated with positive feelings of wellbeing. Norepinephrine is related to alertness and energy. SNRI’s increase the amount of available serotonin and norepinephrine in the brain by blocking the reabsorption of those neurotransmitters.
When should parents consider medication as a possible treatment option?
Generally, medications should be used when the child’s anxiety has not been responsive to properly delivered CBT, the symptoms are seriously debilitating or when CBT is not available. Some children with anxiety do not need medication, and experience significant improvements with CBT alone. Although many parents are reluctant to place their young children on medication, it is important to be open to considering the option that benefits the child most. Medication can help some children be more open to CBT because it “takes the edge off” the severity of their symptoms, possibly making CBT an effective option.
Medication decisions should not be considered until there has been a thorough diagnostic assessment by a licensed physician; ideally, a child psychiatrist. Parents should have thoughtful deliberation of whether the benefits for the child outweigh the drawbacks. A physician should also closely monitor any use of medication.
Reasons to consider medications for child anxiety
- The child lacks maturity to comprehend or participate in CBT
- The child’s symptoms are overwhelmingly severe and he is not able to control them sufficiently to engage in CBT
- The child is unable to function, go to school, or leave the house
- The child suffers from depression, Tourrette Syndrome, ADHD, rages, aggression or other conditions in addition to anxiety
- The child has suicidal thoughts or intentions
- The child is unable to muster the motivation, insight, commitment, willingness, time or energy to engage in CBT
- The child is motivated but needs the extra help to get “unstuck”
- The level of stress, conflict or distress in the child’s family interferes with the family’s ability to support the child in CBT
- The child has already had a course of proper CBT and still has bothersome symptoms. (The CBT must involve exposure by a trained therapist)
- The child’s suffering and the impact of the anxiety are so great that the aftermath of not placing him on medication may be far more severe and permanent than the drawbacks of medications.
One final note
It’s important to remember that although medications can be extremely effective in eliminating or reducing anxiety symptoms, they do not cure anxiety. It’s also important to understand that in most cases, once medications are stopped, anxiety symptoms may return. This is essentially the main factor why it’s important, whenever possible, to pursue CBT. The chances of recurrence of anxiety may be reduced when medications are combined with CBT.