Pediatric Anxiety Disorders: Pharmacological vs. Behavioral Treatment

Anxiety disorders are among the most common mental, emotional and behavioral problems to occur during childhood and adolescence. About 13 out of every 100 children and adolescents age 9 to 17 experience some kind of anxiety disorder, according to the U.S. National Mental Health Information Center. Girls are affected more than boys. While these disorders may seem minor, if left untreated, they can lead to the inability to finish school, impaired social relations, low self-esteem, and eventually, adult anxiety disorders.

The onset of childhood anxiety usually begins between the ages of six and eight. At this age, children typically lose their fear of the dark and other imaginary dangers, and instead become more afraid and anxious about school performance and interactions with friends.

Some studies suggest that anxiety disorders in children are heritable, particularly from parents that have anxiety disorders themselves. But there is no way to prove whether the disorders are a result of biology, the environment, or both.

Anxiety disorders manifest themselves in several forms. These are the main types of anxiety disorders diagnosable in both children and adolescents:

Overanxious disorder of childhood: Children and adolescents with this disorder engage in unrealistic and extreme worry about almost everything – their academic performance, athletic capability, even punctuality. Tense, self-conscious and having a strong desire for reassurance, these young people may complain about aches and pains that have no physical cause. This is similar to the generalized anxiety disorder (GAD) among adults.

Panic disorder: In children and young teenagers, panic is rare. But rates start to increase in older adolescents, particularly among girls. As is the case with adults, repeated panic attacks can be a sign of panic disorder. These attacks may be accompanied by symptoms that include a pounding heartbeat, dizziness, nausea, and feelings of imminent harm or death accompanied by intense fear.

Obsessive-compulsive disorder (OCD): Similar to OCD adults, children and adolescents with OCD become trapped in patterns of repetitive thoughts and actions that are difficult to stop. These actions may include repeated hand washing, counting, hair pulling, nail biting, repetitive questioning, arranging and rearranging objects, and a strong need to control others and their environment. Children and adolescents often have much higher rates of aggressive obsessions, such as thoughts of harming themselves or others, and sexual acting out. Childhood and adolescent OCD is highly comorbid with mood, anxiety, tic and disruptive behavior disorders.

In all, about 2.5 percent of the general population of children and adolescents meet OCD criteria. The U.S. National Institute of Mental Health suggests that nearly 10 percent of these adult OCD sufferers experienced their first symptoms when they were just 5 to 10 years old. More than 20 percent had their first symptoms by ages 10 to 15. And more than 40 percent were affected by ages 15 to 20.

Separation anxiety disorder: This disorder most often manifests in children as a fear of school, fear of camp, even fear of visiting friends. These children are frequently described as “clingy.” This disorder may be accompanied by sadness, withdrawal or a baseless fear of losing a family member to death or some other permanent separation.

Post-Traumatic Stress Disorder: The symptoms of PTSD in children are similar to those in adults, with additional manifestations such as “monster nightmares” and re-enacting a stressful event through play. Children and adolescents can develop PTSD after experiencing physical or sexual abuse, being a victim of or witnessing violence, and living through a natural or manmade disaster (for example, a destructive hurricane or bombing during a war). In young children, the most common cause of PTSD is domestic violence.

Medication Management of Pediatric Anxiety Disorders

Unfortunately, studies on the medication management of anxiety disorders in youth are few in number, and those that exist are inconclusive. Also, there are few specific guidelines for treatment. Here is some of what we know:

While benzodiazepines such as Valium, Klonopin, Ativan and Xanax are used to treat anxiety and sleeplessness in children, the data supportive of their use is sparse. It is considered unwise to subject children to the potential for getting caught in the addictive grip of these drugs.

Similarly, while anecdotal evidence suggests possible benefits from the use of the anti-anxiety agent Buspar in children, this continues to be unproven.

Antihistamines such as Benadryl and Vistaril have been used for decades to ameliorate anxiety symptoms in psychiatrically disturbed children.

The antidepressants Anafranil, Luvox and Zoloft have FDA indications for children and adolescents in the treatment of OCD.

Experience with the selective serotonin reuptake inhibitors — Prozac, Zoloft, Celexa, Lexapro, etc. — in controlled pediatric studies has led clinicians to consider these agents for treating non-OCD anxiety disorders as well.

Controlled studies and supportive data are significantly lacking in the treatment of pediatric anxiety disorders with the beta-blockers — Inderal, Tenormin, others.

Cognitive-behavioral therapy remains the most uniformly and widely utilized treatment strategy for managing anxiety in children and adolescents. Between 50 percent and 80 percent of children and teens respond to well-designed and effectively employed cognitive-behavioral therapy models. At the completion of treatment, they no longer meet diagnostic criteria for the presenting anxiety disorder.


Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, Psychopharmacology: Straight Talk on Mental Health Medications is available at To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at, or e-mail him at