Anxiety disorders are characterized by fear, worry, or dread that greatly impairs the ability to function normally and that is disproportionate to the circumstances at hand. Anxiety may result in physical symptoms. Diagnosis is usually based on history. Treatment is with behavioral therapy and medications, usually selective serotonin reuptake inhibitors (SSRIs).
Some anxiety is an expected aspect of development, as in the following:
Most toddlers become fearful when separated from their parent, especially in unfamiliar surroundings.
Fears of the dark, monsters, bugs, and spiders are common in 3- to 4-year-olds.
Shy children may initially react to new situations with fear or withdrawal.
Fears of injury and death are more common among older children.
Older children and adolescents often become anxious when presenting information in public (eg, giving a book report in front of their classmates).
Such difficulties should not be viewed as evidence of a disorder. However, if manifestations of anxiety become so exaggerated that they greatly impair function or cause severe distress and/or avoidance, an anxiety disorder should be considered.
The peak age of onset of anxiety disorders is at 5.5 years, with 38% of cases starting by age 14, 52% by age 18, and 73% by age 25 with a median age of diagnosis of 17 years (1). Children with an anxiety disorder have an increased risk of depression (2), suicidal ideation and attempts (3), drug and alcohol addiction (especially with panic disorder, 4), and academic difficulties (5) later in life.
Anxiety disorders that can occur in children and adolescents include
General references
1. Solmi M, Radua J, Olivola M, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry. 2022;27(1):281-295. doi:10.1038/s41380-021-01161-7
2. Cummings CM, Caporino NE, Kendall PC. Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull. 140(3):816-845, 2014. doi: 10.1037/a0034733
3. Husky MM, Olfson M, He J, et al. Twelve-month suicidal symptoms and use of services among adolescents: Results from the National Comorbidity Survey. Psychiatr Serv.63(10):989-996, 2012.
4. Zimmermann P, Wittchen HU, Hofler M, et al. Primary anxiety disorders and the development of subsequent alcohol use disorders: A 4-year community study of adolescents and young adults. Psychol Med. 33(7);1211-1222, 2003. doi: 10.1017/s0033291703008158
5. Van Ameringen M, Mancini C, Farvolden P. The impact of anxiety disorders on educational achievement. J Anxiety Disord. 17(5):561-571, 2003. doi: 10.1016/s0887-6185(02)00228-1
Etiology of Anxiety Disorders
The etiology of anxiety disorders in children is multifactorial, arising from interactions between various biological, psychological, social, and environmental factors. Heritability studies indicate a role for both genetic and environmental factors. Several genetic variants are likely involved, including a single-nucleotide polymorphism in the brain-derived neurotrophic factor (BDNF) gene and a microsatellite marker linked to the corticotropin releasing hormonecorticotropin releasing hormone (CRH) gene (1, 2).
Several risk factors that influence the likelihood of developing childhood anxiety disorders have been proposed, including parental anxiety, child maltreatment, infections, and stress. Notably, anxiety symptoms among youth doubled during the COVID-19 pandemic, especially in girls (3), and mental health visits for anxiety increased 43% (4). These study results were controlled for gender, age, and presence of pre-COVID anxiety symptoms and showed that poor connectedness to one's caregiver, poor sleep hygiene, and high amounts of screen time were reported to be significant predictors of the child's COVID-19 anxiety symptoms (5). Higher frequencies of new-onset anxiety disorders were found in children and adolescents who, in addition to the pandemic stressors, also had a COVID-19 infection compared to those without COVID-19 infection (6). Taken together, these findings may indicate a role for viral infections known to affect the central nervous system.
Anxious parents tend to have anxious children; their parenting style may make children’s symptoms worse than they otherwise might be. Even typical children have difficulty remaining calm and composed in the presence of an anxious parent, and children who are genetically predisposed to anxiety have even greater difficulty. Maltreatment at home or school and a lack of ability to control one's circumstances may also contribute; both maltreatment and lack of perceived control are more likely to occur in children and adolescents than in adults.
Etiology references
1. Adhikari A, Topiwala M, Gordon JA. Synchronized activity between the ventral hippocampus and the medial prefrontal cortex during anxiety. Neuron. 65:257-269, 2010. doi: 10.1016/j.neuron.2009.12.002
2. Smoller JW, Yamaki LH, Fagerness JA, et al. The corticotropin-releasing hormone gene and behavioral inhibition in children at risk for panic disorder. . The corticotropin-releasing hormone gene and behavioral inhibition in children at risk for panic disorder.Biol Psychiatry. 2005;57(12):1485-1492. doi:10.1016/j.biopsych.2005.02.018
3. Racine N, McArthur B, Cooke J, et al. Global prevalence of depressive and anxiety symptoms in children and adolescence during COVID-19: A meta-analysis. JAMA Pediatr. 175(11):1142-1150, 2021. doi: 10.1001/jamapediatrics.2021.2482
4. Dvir Y, Ryan C, Straus JH. Comparison of use of the Massachusetts Child Psychiatry Access Program and patient characteristics before vs during the COVID-19 pandemic. JAMA Netw Open.5(2):e2146618, 2022. doi:10.1001/jamanetworkopen.2021.46618
5. McArthur BA, Racine N, McDonald S, et al. Child and family factors associated with child mental health and well-being during COVID-19. Eur Child Adolesc Psychiatry. Jul 24;1-11, 2021. doi: 10.1007/s00787-021-01849-
6. Lu Y, Tong J, Zhang D, et al. Risk of neuropsychiatric and related conditions associated with SARS-CoV-2 infection: a difference-in-differences analysis. Nat Commun. 2025;16(1):6829. Published 2025 Jul 24. doi:10.1038/s41467-025-61961-1
Pathophysiology of Anxiety Disorders
Evidence suggests that anxiety disorders involve dysfunction in the parts of the limbic system and hippocampus that regulate emotions in general and in response to fear specifically. In mice, loss of expression of the serotonin 1A-receptor (5-HT1AR) in the forebrain during early development results in dysregulation of the hippocampus and leads to anxious behaviors (1). Genetic and environmental factors likely influence these biological functions and shape symptom expression (2).
Pathophysiology references
1. Adhikari A, Topiwala M, Gordon JA. Synchronized activity between the ventral hippocampus and the medial prefrontal cortex during anxiety. Neuron. 65:257-269, 2010. doi: 10.1016/j.neuron.2009.12.002
2. Meier SM, Trontti K, Purves KL, et al. Genetic Variants Associated With Anxiety and Stress-Related Disorders: A Genome-Wide Association Study and Mouse-Model Study. JAMA Psychiatry. 2019;76(9):924-932. doi:10.1001/jamapsychiatry.2019.1119
Symptoms and Signs of Anxiety Disorders
Perhaps the most common presentation of an anxiety disorder in children and adolescents is socially avoidant behavior, which includes school refusal. “School refusal” has largely supplanted the term “school phobia.” Most children who refuse to go to school probably have separation anxiety, social anxiety disorder, panic disorder, or a combination of these. Some may have a specific phobia. The possibility that the child is being bullied at school must also be considered.
Children with perfectionism may also describe anxiety that may be attributed to their need to perform well and their fear of making mistakes. Some children report directly about their anxiety, describing it in terms of worries (eg, “I am worried that I will never see you again” [separation anxiety] or “I am worried the kids will laugh at me” [social anxiety disorder]).
Most children may also describe their discomfort in terms of somatic symptoms: “I cannot go to school because I have a stomachache.” These children are often telling the truth because an upset stomach, nausea, headaches, palpitations, and sleep problems (ie, falling and staying asleep) often do develop in children with anxiety. Panic attacks may present in older children with episodes of intense fear or discomfort that may include symptoms such as heart palpitations, shortness of breath, or feelings of impending doom. Data confirm that many children with somatic complaints, especially abdominal pain, have an underlying anxiety disorder (1).
Symptoms and signs reference
1. Korterink JJ, Diederen K, Benninga MA, Tabbers MM. Epidemiology of pediatric functional abdominal pain disorders: a meta-analysis. PLoS One. 2015;10(5):e0126982. Published 2015 May 20. doi:10.1371/journal.pone.0126982
Diagnosis of Anxiety Disorders
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria
The diagnosis of an anxiety disorder is usually based on a clinical assessment (1, 2). A thorough psychosocial history can usually confirm it. Specific subtypes of anxiety disorders (eg, separation anxiety disorder, social anxiety disorder) may be diagnosed based on the DSM-5-TR criteria for that subtype.
Rating scales can be useful for screening.
Several validated scales are freely available:
Screen for Child Anxiety-Related Emotional Disorders (SCARED): ages 8 to 18; 41-item scale completed separately by child and parent/guardian
Spence Children's Anxiety Scale (SCAS): ages 8 to 15; 44-item scale completed by either child or by parent/guardian
Preschool Anxiety Scale (PAS): ages 2.5 to 6.5; 28-item scale completed by parent/guardian
General Anxiety Disorder-7 (GAD-7): ages 14+; 7-item scale administered by a healthcare professional
Physical symptoms that anxiety can cause in children can complicate the evaluation. In many children, a thorough assessment to exclude general medical disorders is conducted before clinicians consider an anxiety disorder.
Diagnosis references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Washington: American Psychiatric Association, 2022.
2. Walter HJ, Bukstein OG, Abright AR, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 59(10):1107-1124, 2020. doi: https://doi.org/10.1016/j.jaac.2020.05.005
Treatment of Anxiety Disorders
Behavioral therapy (exposure-based cognitive-behavioral therapy)
Parent-child and family interventions
Anxiolytic pharmacotherapy, usually selective serotonin reuptake inhibitors (SSRIs) and to a lesser degree, serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants for long-term treatment and sometimes benzodiazepines to relieve acute symptoms
Cognitive behavioral therapy (CBT) is the first-line intervention for the treatment of anxiety disorders in children and adolescents; family-centered interventions may serve to reinforce the impact of CBT. Pharmacotherapy (typically SSRIs or SNRIs) may be considered when symptoms are moderate to severe, functionally impairing, or when CBT alone is insufficient. Anxiolytics (eg, benzodiazepine) may be helpful to abort acute attacks of anxiety.
Behavioral therapy
Anxiety disorders in children are treated primarily with behavioral therapy (using principles of exposure and response prevention) (1), sometimes in conjunction with anxiolytic pharmacotherapy (1–5). In exposure-based cognitive behavioral therapy (CBT), children are systematically exposed to the anxiety-provoking situation in a graded fashion. By helping children remain in the anxiety-provoking situation (response prevention), therapists can enable them to gradually become desensitized and feel less anxiety. Behavioral therapy is most effective when an experienced therapist knowledgeable in child development individualizes these principles.
Family interventions
Family-centered interventions that focus on identifying anxiety triggers, implementing coping skills (eg, breathing and relaxation exercises), and managing avoidance behaviors while fostering a supportive environment may sometimes be offered in a group setting as is culturally or regionally appropriate (6, 7). School-based interventions can also supplement individual treatment, especially for younger children, to address environmental factors and support coping skills.
Pharmacotherapy
Pharmacotherapy may be needed when anxiety disorders are severe or when access to an experienced child behavior therapist is limited. When pharmacotherapy is initiated, clinicians should be aware of the potential for adverse effects. Adverse effects can be idiosyncratic and may occur with any antidepressant and at any time during treatment; therefore, close monitoring is essential.
SSRIs and SNRIs
SSRIs are usually the first-line option for long-term treatment. There is no evidence that any one SSRI is more effective than another (8); however, adverse effects can vary (eg, depending on slow or rapid metabolism, interaction with other medications). Dose titration, tapering, and discontinuation can be more quickly managed with the SSRIs that have shorter half-lives, such as sertraline and escitalopram, 2 of the most commonly used SSRIs to treat children and adolescents (); however, adverse effects can vary (eg, depending on slow or rapid metabolism, interaction with other medications). Dose titration, tapering, and discontinuation can be more quickly managed with the SSRIs that have shorter half-lives, such as sertraline and escitalopram, 2 of the most commonly used SSRIs to treat children and adolescents (9, 10).
SNRIs (eg, duloxetine, venlafaxine) may be considered as second-line options. (eg, duloxetine, venlafaxine) may be considered as second-line options.Tricyclic antidepressants are third-line options. When combined with CBT, SSRIs have the highest likelihood of improving symptoms compared to either medication or therapy alone (11).
Genetic testing panels for enzymes that metabolize various medications are available. Genotyping can identify patients at increased risk of adverse reactions or inadequate responses to an SSRI. Specifically, the CPIC (Clinical Pharmacogenetics Implementation Consortium) guidelines provide support for testing a limited number of genetic variants (eg, CYP2D6, CYP2C19, 2B6) that alter (ie, increase or decrease) the metabolism of an SSRI or of other medications, leading to poor therapeutic outcomes due to impacts on efficacy or adverse effects (12–14). Testing done before starting treatment identifies at-risk patients. Once treatment is initiated, testing may be considered in those with poor medication response or with adverse effects. Testing patients without risk factors and those with good response and tolerability is not recommended. Testing for other variants (CYP1A2, CYP2C9, CYP3A4, SLC6A4, HTR2A) is not recommended given the limited evidence supporting gene-based dosing recommendations. Other factors impacting drug metabolism that are not identified in current testing platforms include novel or rare genetic or epigenetic variants as well as age and diet. (15). Cannabis or cannabidiol (CBD) and tetrahydrocannabinol (THC) are moderate to strong inhibitors of CYP enzymes, increasing SSRI plasma concentrations (). Cannabis or cannabidiol (CBD) and tetrahydrocannabinol (THC) are moderate to strong inhibitors of CYP enzymes, increasing SSRI plasma concentrations (16, 17) and contributing to adverse effects (eg, diarrhea, dizziness, fatigue). Clinicians who order these tests will need to help families interpret the results (12). (See table Medications For Long-Term Treatment of Anxiety, Depression, and Related Disorders.)
SSRIs are generally well tolerated across the indications for which they are prescribed. Some early adverse effects (eg, nausea, abdominal pain, headache, activation [restlessness, insomnia, irritability, disinhibition]) usually resolve quickly. Starting at the lowest dose, slower titration, administering at different times of day (evening if there is tiredness; morning if there is insomnia) may be helpful. Late-emerging adverse effects (eg, hyperhidrosis, anorgasmia, usually persist (9). Weight gain can emerge early or late in treatment and is associated mostly with escitalopram and citalopram, less with fluoxetine, and not at all with sertraline (). Weight gain can emerge early or late in treatment and is associated mostly with escitalopram and citalopram, less with fluoxetine, and not at all with sertraline (18).
SNRIs, which are less well-tolerated than the SSRIs, can also increase the risk of hypertension due to their inhibition of norepinephrine uptake, leading to increased noradrenergic activity (SNRIs, which are less well-tolerated than the SSRIs, can also increase the risk of hypertension due to their inhibition of norepinephrine uptake, leading to increased noradrenergic activity (19, 20).
SSRIs and SNRIs should be tapered gradually because withdrawal symptoms (eg, dizziness, headache, tremor, fatigue,flu-like symptoms, paresthesia, brain fog, insomnia) can occur after abrupt or rapid discontinuation. Medications with shorter elimination half-life have higher withdrawal risk and fluoxetine has the lowest. Slow tapering over weeks to months may be needed. In cases where symptoms occur at minimal available dosing, switching to liquid preparations may allow a more gradual taper (SSRIs and SNRIs should be tapered gradually because withdrawal symptoms (eg, dizziness, headache, tremor, fatigue,flu-like symptoms, paresthesia, brain fog, insomnia) can occur after abrupt or rapid discontinuation. Medications with shorter elimination half-life have higher withdrawal risk and fluoxetine has the lowest. Slow tapering over weeks to months may be needed. In cases where symptoms occur at minimal available dosing, switching to liquid preparations may allow a more gradual taper (21, 22).
Medications for Long-Term Treatment of Depression, Anxiety, and Related Disorders*
Medication | Uses | Half-life (hrs) | CYP substrates | Comments/Precautions |
|---|---|---|---|---|
SSRIs | ||||
CitalopramCitalopram | OCD in children ≥ 7 years | 35 hrs | 2C19, 2D6 | For 2C19 poor metabolizers, lower starting dose, slower titration and 50% reduction of maintenance dose |
Escitalopram (S-enantiomer of citalopram)Escitalopram (S-enantiomer of citalopram) | Major depression in children ≥ 12 years | 27–32 hrs | 2C19, 2D6 | — |
Fluoxetine†Fluoxetine† Norfluoxetine (active metabolite of fluoxetine)Norfluoxetine (active metabolite of fluoxetine) | OCD, GAD, separation anxiety, social anxiety, major depression in children > 8 years | 119–264 hrs Norfluoxetine: 144–384 hrs | 2D6 | — |
FluvoxamineFluvoxamine | GAD, separation anxiety, social anxiety, OCD in children > 8 years | 16 hrs | 2D6 | — |
Paroxetine†Paroxetine† | OCD in children > 6 years | 21 hrs | 2D6 | — |
SertralineSertraline | OCD, GAD, separation anxiety, social anxiety in children ≥ 6 years | 26 hrs | 2C19, 2B6, 2D6 | For 2B6 poor metabolizers, lower starting dose, slower titration and 25% reduction of maintenance dose |
SNRIs | ||||
DuloxetineDuloxetine | GAD in children 7–17 years | 10–12 hrs | 2D6, IA2 | SNRIs: have noradrenergic activity and can increase risk of hypertension |
Venlafaxine, immediate-releaseVenlafaxine, immediate-release | Depression in children ≥ 8 years | 5–11 hrs | 2D6 | SNRIs: limited data about optimal dose; concerns about increased suicidal behavior (in adolescents with pre-existing suicidal ideation); not as effective as other antidepressants, possibly because low doses have been used |
Venlafaxine, extended-releaseVenlafaxine, extended-release | GAD in children > 7 years | — | — | |
* The medications listed are used clinically for all the anxiety disorders, OCD, and depression. FDA approval has been obtained for some conditions; the lack of FDA approval for other conditions is due to a lack of sufficient studies and not due to other reasons. The most commonly used across all conditions are sertraline and escitalopram.* The medications listed are used clinically for all the anxiety disorders, OCD, and depression. FDA approval has been obtained for some conditions; the lack of FDA approval for other conditions is due to a lack of sufficient studies and not due to other reasons. The most commonly used across all conditions are sertraline and escitalopram. | ||||
† Fluoxetine and paroxetine are potent inhibitors of 2D6, decreasing the metabolism of antipsychotics (risperidone, aripiprazole, iloperidone, clozapine), increasing their plasma concentration. They can also inhibit the metabolism of some pain medications to their active metabolite (oxycodone to oxymorphone) but contrary to expectations, not codeine to morphine. Less potent inhibitors of 2D6 (sertraline) may have similar effects at the higher doses.† Fluoxetine and paroxetine are potent inhibitors of 2D6, decreasing the metabolism of antipsychotics (risperidone, aripiprazole, iloperidone, clozapine), increasing their plasma concentration. They can also inhibit the metabolism of some pain medications to their active metabolite (oxycodone to oxymorphone) but contrary to expectations, not codeine to morphine. Less potent inhibitors of 2D6 (sertraline) may have similar effects at the higher doses. Fluoxetine and paroxetine efficacy in treating depression is compromised when combined with trazodone (used to treat insomnia). This is attributed to 2D6 interactions and accumulation of methyl-chloro-piperazine a, trazodone metabolite associated with irritability and depression. Fluoxetine and paroxetine efficacy in treating depression is compromised when combined with trazodone (used to treat insomnia). This is attributed to 2D6 interactions and accumulation of methyl-chloro-piperazine a, trazodone metabolite associated with irritability and depression. Cannabis or cannabidiol (CBD) and tetrahydrocannabinol (THC) are moderate to strong inhibitors of CYP enzymes, increasing SSRI plasma concentrations and contributing to adverse effects (eg, diarrhea, dizziness, fatigue). Cannabis or cannabidiol (CBD) and tetrahydrocannabinol (THC) are moderate to strong inhibitors of CYP enzymes, increasing SSRI plasma concentrations and contributing to adverse effects (eg, diarrhea, dizziness, fatigue). | ||||
CYP = cytochrome P450; FDA = Food and Drug Administration; GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = serotonin reuptake inhibitor.CYP = cytochrome P450; FDA = Food and Drug Administration; GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = serotonin reuptake inhibitor. | ||||
Other medications
Benzodiazepines may be used for acute anxiety (eg, due to a medical procedure), but are not recommended for long-term treatment. Benzodiazepines with a short-half life (eg, lorazepam) are the best choice in general, but the risk of acute withdrawal symptoms may limit their use (Benzodiazepines may be used for acute anxiety (eg, due to a medical procedure), but are not recommended for long-term treatment. Benzodiazepines with a short-half life (eg, lorazepam) are the best choice in general, but the risk of acute withdrawal symptoms may limit their use (23). Agents with longer half-lives (eg, clonazepam) are particularly useful in panic disorder. Buspirone was found to be well tolerated in pediatric patients (ages 6 to 17) with a generalized anxiety disorder; however, evidence supporting its use is limited and mixed (). Agents with longer half-lives (eg, clonazepam) are particularly useful in panic disorder. Buspirone was found to be well tolerated in pediatric patients (ages 6 to 17) with a generalized anxiety disorder; however, evidence supporting its use is limited and mixed (24). Reports of improvement in developmental disorders such as Williams sydrome (25) and autism (26) have generated ongoing investigations.
Some antianxiety effect is reported for clonidine and guanfacine in limited studies (Some antianxiety effect is reported for clonidine and guanfacine in limited studies (27). These may be best considered in tic disorders or disruptive behavioral disorders with comorbid anxiety or attention deficit hyperactivity disorder.
Antipsychotic medications have also been shown to have antianxiety effects and should be considered primarily where anxiety may be contributing to severe disruptive behaviors, aggression, psychoses or in treatment resistant cases.
Treatment references
1. Brent DA, Porta G, Rozenman MS, et al. Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Follow-up. J Am Acad Child Adolesc Psychiatry. 2020;59(7):856-867. doi:10.1016/j.jaac.2019.06.009
2. Strawn JR, Welge JA, Wehry AM, et al. Efficacy and tolerability of antidepressants in pediatric anxiety disorders: A systematic review and meta-analysis. Depress Anxiety. 32(3):149-157, 2015.
3. Ipser JC, Stein DJ, Hawkridge S, et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. (3):CD005170, 2009. doi: 10.1002/14651858.CD005170.pub2
4. Wang Z, Whiteside SPH, Sim L, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis [published correction appears in JAMA Pediatr. 2018 Oct 1;172(10):992. doi: 10.1001/jamapediatrics.2018.3021.]. JAMA Pediatr. 2017;171(11):1049-1056. doi:10.1001/jamapediatrics.2017.3036
5. Walter HJ, Bukstein OG, Abright AR, et al. Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry. 2020;59(10):1107-1124. doi:10.1016/j.jaac.2020.05.005
6. Varghese M, Kirpekar V, Loganathan S. Family Interventions: Basic Principles and Techniques. Indian J Psychiatry. 2020;62(Suppl 2):S192-S200. doi:10.4103/psychiatry.IndianJPsychiatry_770_19
7. Goger P, Weersing VR. Family based treatment of anxiety disorders: A review of the literature (2010-2019). J Marital Fam Ther. 2022;48(1):107-128. doi:10.1111/jmft.12548
8. Ball SG, Kuhn A, Wall D, Shekhar A, Goddard AW: Selective serotonin reuptake inhibitor treatment for generalized anxiety disorder: a double-blind, prospective comparison between paroxetine and sertraline. J Clin Psychiatry. 2005;66(1):94-99. doi:10.4088/jcp.v66n0113
9. Strawn JR, Mills JA, Poweleit EA, Ramsey LB, Croarkin PE. Adverse Effects of Antidepressant Medications and their Management in Children and Adolescents. Pharmacotherapy. 2023;43(7):675-690. doi:10.1002/phar.2767
10. Poweleit EA, Taylor ZL, Mizuno T, et al. Escitalopram and Sertraline Population Pharmacokinetic Analysis in Pediatric Patients. . Escitalopram and Sertraline Population Pharmacokinetic Analysis in Pediatric Patients.Clin Pharmacokinet. 2023;62(11):1621-1637. doi:10.1007/s40262-023-01294-8
11.Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. . Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety.N Engl J Med 359:2753-2766, 2008. doi: 10.1056/NEJMoa0804633
12. Bousman CA, Stevenson JM, Ramsey LB, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2D6, CYP2C19, CYP2B6, SLC6A4, and HTR2A Genotypes and Serotonin Reuptake Inhibitor Antidepressants. Clin Pharmacol Ther. 2023;114(1):51-68. doi:10.1002/cpt.2903
13. Hoffelt C, Gross T. A review of significant pharmacokinetic drug interactions with antidepressants and their management. Ment Health Clin. 2016;6(1):35-41. Published 2016 Mar 8. doi:10.9740/mhc.2016.01.035
14. Sultan MA, Courtney DB. Adjunctive Trazodone and Depression Outcome in Adolescents Treated with Serotonin Re-uptake Inhibitors. . Adjunctive Trazodone and Depression Outcome in Adolescents Treated with Serotonin Re-uptake Inhibitors.J Can Acad Child Adolesc Psychiatry. 2017;26(3):233-240
15.Marken PA, Munro JS. Selecting a Selective Serotonin Reuptake Inhibitor: Clinically Important Distinguishing Features. Prim Care Companion J Clin Psychiatry. 2000;2(6):205-210. doi:10.4088/pcc.v02n0602
16. Anderson LL, Doohan PT, Oldfield L, et al. Citalopram and Cannabidiol: In Vitro and In Vivo Evidence of Pharmacokinetic Interactions Relevant to the Treatment of Anxiety Disorders in Young People. . Citalopram and Cannabidiol: In Vitro and In Vivo Evidence of Pharmacokinetic Interactions Relevant to the Treatment of Anxiety Disorders in Young People.J Clin Psychopharmacol. 2021;41(5):525-533. doi:10.1097/JCP.0000000000001427
17. Vaughn SE, Strawn JR, Poweleit EA, Sarangdhar M, Ramsey LB. The Impact of Marijuana on Antidepressant Treatment in Adolescents: Clinical and Pharmacologic Considerations. J Pers Med. 2021;11(7):615. Published 2021 Jun 29. doi:10.3390/jpm11070615
18. Calarge CA, Mills JA, Janz KF, Burns TL, Coryell WH, Zemel BS. Body Composition in Adolescents During Treatment With Selective Serotonin Reuptake Inhibitors. Pediatrics. 2017;140(1):e20163943. doi:10.1542/peds.2016-3943
19. Zhong Z, Wang L, Wen X, Liu Y, Fan Y, Liu Z. A meta-analysis of effects of selective serotonin reuptake inhibitors on blood pressure in depression treatment: outcomes from placebo and serotonin and noradrenaline reuptake inhibitor controlled trials. Neuropsychiatr Dis Treat. 2017;13:2781-2796. Published 2017 Nov 7. doi:10.2147/NDT.S141832
20. Brent DA, Emslie GJ, Clarke GN, et al. Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study. Am J Psychiatry. 2009;166(4):418-426. doi:10.1176/appi.ajp.2008.08070976)
21. Horowitz MA, Framer A, Hengartner MP, Sørensen A, Taylor D. Estimating Risk of Antidepressant Withdrawal from a Review of Published Data. CNS Drugs. 2023;37(2):143-157. doi:10.1007/s40263-022-00960-y)
22. Shapiro not in Pubmed? https://psychiatryonline.org/doi/full/10.1176/appi.pn.2025.09.9.1?af=R)
23. Szuhany KL, Simon NM. Anxiety Disorders: A Review. JAMA. 2022;328(24):2431-2445. doi:10.1001/jama.2022.22744
24. Strawn JR, Mills JA, Cornwall GJ, et al. Buspirone in children and adolescents with anxiety: A review and Bayesian analysis of abandoned randomized controlled trials. J Child Adolesc Psychopharmacol. 28(1): 2-9, 2018. doi: 10.1089/cap.2017.0060
25. Thom RP, Keary CJ, Waxler JL, et al. Buspirone for the treatment of generalized anxiety disorder in Williams syndrome: A case series. J Autism Dev Disord. 50(2):676-682, 2020. doi: 10.1007/s10803-019-04301-9
26. Ceranoglu TA, Wozniak J, Fried R, et al. A retrospective chart review of buspirone for the treatment of anxiety in psychiatrically referred youth with high-functioning autism spectrum disorder. . A retrospective chart review of buspirone for the treatment of anxiety in psychiatrically referred youth with high-functioning autism spectrum disorder.J Child Adolescent Psychopharmacol. 29(1):28-33, 2018. doi: 10.1089/cap.2018.0021
27. Pringsheim T, Okun MS, Müller-Vahl K, et al. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology. 2019;92(19):896-906. doi:10.1212/WNL.0000000000007466
Prognosis for Anxiety Disorders
Prognosis for anxiety disorders in children depends on severity, availability of competent treatment, and the child’s resiliency. Many children may struggle with anxiety symptoms into adulthood. However, with early treatment, many children learn how to control their anxiety.
Key Points
The most common presentation of an anxiety disorder may be school refusal; many children can present their discomfort in terms of somatic symptoms; these physical symptoms can complicate the evaluation.
Consider anxiety as a disorder in children only when anxiety becomes so exaggerated that it greatly impairs functioning or causes severe distress and/or avoidance.
Behavioral therapy (using principles of exposure and response prevention) is most effective when done by an experienced therapist who is knowledgeable about child development and who tailors these principles to the child.
When cases are more severe or when access to an experienced child behavior therapist is limited, medications (SSRI, SNRI) may be needed.
Commercially available panels testing for CYP variants remain limited.
Drugs Mentioned In This Article
