Pharmacologic treatment for children and adolescents with anxiety disorders

Abnormal functional connectivity of the amygdala-based network in resting-state FMRI in adolescents with generalized anxiety disorder

BACKGROUND

We aimed to investigate the disruptions of functional connectivity of amygdala-based networks in adolescents with untreated generalized anxiety disorder (GAD).

MATERIAL AND METHODS

A total of 26 adolescents with first-episode GAD and 20 normal age-matched volunteers underwent resting-state and T1 functional magnetic resonance imaging (fMRI). We analyzed the correlation of fMRI signal fluctuation between the amygdala and other brain regions. The variation of amygdala-based functional connectivity and its correlation with anxiety severity were investigated.

RESULTS

Decreased functional connectivity was found between the left amygdala and left dorsolateral prefrontal cortex. An increased right amygdala functional connectivity with right posterior and anterior lobes of the cerebellum, insula, superior temporal gyrus, putamen, and right amygdala were found in our study. Negative correlations between GAD scores and functional connectivity of the right amygdala with the cerebellum were also observed in the GAD adolescents.

CONCLUSIONS

Adolescents with GAD have abnormalities in brain regions associated with the emotional processing pathways.

Screening efficiency of the self-report version of the Multidimensional Anxiety Scale for Children in a highly comorbid inpatient sample

BACKGROUND

The Multidimensional Anxiety Scale for Children (MASC) is a widely used self-report questionnaire for the assessment of anxiety symptoms in children and adolescents with well documented predictive validity of the total score and subscales in internalizing and mixed clinical samples. However, no data exist on the screening efficiency in an inpatient sample of adolescents.

AIM

To examine the psychometric properties and screening efficiency of the MASC in a high comorbid inpatient sample.

METHOD

The current study used receiver operating characteristic (ROC) analyses to investigate the predictive value of the MASC total and subscale scores for the Schedule for Affective Disorders and Schizophrenia for School-age children-Present and Lifetime version (K-SADS-PL), DSM-IV diagnoses of generalized anxiety disorder (GAD), separation anxiety disorder (SAD) and social phobia (SoP) in a highly comorbid inpatient sample of adolescents (11-18 years).

RESULTS

The MASC total score predicted any anxiety disorder (AD) and GAD moderately well. Physical symptoms predicted GAD moderately well. Social anxiety and separation anxiety/panic did not predict SoP or SAD, respectively. Physical symptoms and harm avoidance also predicted the presence of major depressive disorder.

CONCLUSIONS

The findings support the utility of the MASC total score to predict the presence of any AD and GAD. However, the utility of the social anxiety and separation anxiety/panic subscales showed limited utility to predict the presence of SAD and SoP, respectively. The MASC has probably a more limited function in screening for AD among a highly comorbid inpatient sample of severely affected adolescents. Our results should be interpreted in the light of a small, mixed sample of inpatient adolescents.

The evidence-based pharmacotherapy of social anxiety disorder

Social anxiety disorder (SAD) is a highly prevalent and often disabling disorder. This paper reviews the pharmacological treatment of SAD based on published placebo-controlled studies and published meta-analyses. It addresses three specific questions: What is the first-line pharmacological treatment of SAD? How long should treatment last? What should be the management of treatment-resistant cases? Based on their efficacy for SAD and common co-morbid disorders, tolerability and safety, selective serotonin reuptake inhibitors (SSRIs) and venlafaxine should be considered the first-line treatment for most patients. Less information is available regarding the optimal length of treatment, although individuals who discontinue treatment after 12-20 wk appear more likely to relapse than those who continue on medication. Even less empirical evidence is available to support strategies for treatment-resistant cases. Clinical experience suggests that SSRI non-responders may benefit from augmentation with benzodiazepines or gabapentin or from switching to monoamine oxidase inhibitors, reversible inhibitors of monoamine oxidase A, benzodiazepines or gabapentin. Cognitive-behavioural is a well-established alternative first line therapy that may also be a helpful adjunct in non-responders to pharmacological treatment of SAD.

Psychopharmacologic treatment of children and adolescents with anxiety disorders

Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.

Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder

Generalized anxiety disorder (GAD) is associated with significant morbidity in children and adolescents, yet only recently have the neuropharmacology and neurophysiology of this condition been studied in youth. Accumulating data suggest structural and functional abnormalities within the brain's fear networks in youth with GAD. Additionally, seven studies examined the efficacy of medications that modulate this system and, in some cases, the direct effects of these medications on structures within these networks (e.g. amygdala, ventrolateral prefrontal cortex [VLPFC]). In this review, we summarize the extant functional, functional connectivity, and structural neuroimaging data in children and adolescents with GAD. In addition, data concerning selective serotonin reuptake inhibitors (SSRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), atypical anxiolytics, benzodiazepines, and psychotherapy are reviewed in the context of the neurophysiology of pediatric GAD. The existing data suggest abnormal activity within the amygdala, VLPFC, and anterior cingulate cortex, as well as the possibility of impaired connectivity among these brain regions. In addition to numerous cognitive behavioral therapy (CBT) trials, five randomized, controlled psychopharmacologic trials primarily in youth with GAD suggest that SSRIs and SSNRIs are effective for this condition. These findings also raise the possibility that functional activity within the amygdala and VLPFC may be altered following successful treatment.

Assessment and treatment of anxiety disorders in children and adolescents

This article reviews the current screening and assessment tools for anxiety disorders in children and adolescents, as well as evidence-based treatment interventions for these disorders. The following anxiety disorders are discussed: separation anxiety disorder, generalized anxiety disorder, specific phobia, panic disorder, social anxiety disorder (social phobia), and selective mutism. There are several well-studied screening and assessment tools to identify childhood anxiety disorders early and differentiate the various anxiety disorders. Evaluations of baseline somatic symptoms, severity, and impairment ratings of the anxiety disorders, and collecting ratings from several sources is clinically helpful in assessment and treatment follow-up. Cognitive-behavioral therapy (CBT) has been extensively studied and has shown good efficacy in treatment of childhood anxiety disorders. A combination of CBT and medication may be required for moderate to severely impairing anxiety disorders and may improve functioning better than either intervention alone. Selective serotonin reuptake inhibitors are currently the only medications that have consistently shown efficacy in treatment of anxiety disorders in children and adolescents. Despite proven efficacy, the availability of CBT in the community is limited. Current research is focusing on early identification of anxiety disorders in community settings, increasing the availability of evidence-based interventions, and modification of interventions for specific populations.

Advances in pharmacotherapy for pediatric anxiety disorders

Pediatric anxiety disorders are prevalent, chronic, and often lead to significant impaired functioning that impacts both short- and long-term outcomes for children and adolescents. Treatment options include pharmacotherapy and psychosocial interventions. This presentation will review treatment advances specifically for pharmacotherapy. Current research supports serotonin reuptake inhibitors as the medication class to be the first-line treatment option for pediatric anxiety disorders. Available evidence for the efficacy of other classes of medications will be reviewed, along with the available approaches to manage partial responders and nonresponders. The risks and benefits of pharmacotherapy will also be reviewed. In addition, recent research has shown the potential promise of novel agents that act upon other neural systems implicated in the development of pediatric anxiety disorders. Novel compounds that affect the glutamate system will be discussed.

[Algorithms for the medical treatment of Attention-Deficit/Hyperactivity Disorder with specific co-morbidities]

BACKGROUND

In clinical practice Attention Deficit Hyperactivity Disorder (ADHD) is a challenge for diagnostic and therapeutic effort due to a number of co-morbidities, e.g., depression, anxiety disorders, Tourette Syndrome and impulsive aggression that can be a complication or a result of the core symptoms or evolve parallel to the basic disorder. The therapeutic strategies incorporate a multimodal access with a combination of psychosocial, psychotherapeutic and medical measures. The combination of various medical substances for an effective treatment of these co-morbidities, especially Serotonin-Reuptake Inhibitors (SSRIs) and atypical neuroleptics with psychostimulants has substantially reduced the occurrence of the main symptoms of the disorder in many cases and thus can also lead to a decrease in the occurrence of co-morbidities. Where this strategy fails to suffice, it is recommended to consider medical treatment strategies in combination with other substances that alternatively or in combination with psychostimulants increasingly positively influence co-morbid symptoms.

OBJECTIVE AND METHOD

Based on a Medline literature search we report the results of combined medical approaches for an effective medical treatment of the ADHD core symptoms accompanied by serious co-morbid symptoms. Hereby we focused on the above cited disorders. Combined treatment options that include psychostimulants are considered in particular. Moreover, recommendations for medical treatment strategies oriented to the clinical cardinal symptoms are presented in the form of algorithms. Evidence-based literature and practical experience are critically reviewed.

RESULTS

In most cases it will be sufficient to begin the treatment with a psychostimulant because co-morbid symptoms also will be significantly reduced. However, if the latter are in the foreground of the clinical picture, antidepressants or neuroleptics are to be considered as primary or equivalent treatment options.

CONCLUSIONS

Since in Germany most of the substances discussed are not licensed for use in paediatric treatment, proofs of efficacy in children are lacking. One also must reckon with the frequent occurrence of side effects. Finally, little data exist on treatments that include the use of psychostimulants.

Comparative efficacy and acceptability of pharmacotherapeutic agents for anxiety disorders in children and adolescents: a mixed treatment comparison meta-analysis

OBJECTIVE

to compare efficacy and acceptability of different pharmacotherapeutic agents for treating anxiety disorders in children and adolescents.

METHODS

A recently conducted Cochrane Review on pharmacotherapy for anxiety disorders in children and adolescents was updated. A mixed treatment comparison meta-analysis using Bayesian Markov Chain Monte Carlo simulation was used to perform the indirect comparison. We calculated relative risk ratios (RR) with 95% credible interval (CrI) using placebo as the common comparator.

RESULTS

Data were combined from 16 clinical trials that randomized children to six different treatment strategies, including placebo. Fluoxetine, fluvoxamine, paroxetine, sertraline, and venlafaxine were more efficacious than placebo. Venlafaxine was significantly less efficacious than fluvoxamine (RR = 0.60; 95% CrI 0.35-0.95) and paroxetine (RR = 0.65; 95% CrI 0.44-0.93). Fluoxetine, fluvoxamine, paroxetine, and sertraline had higher acceptability profile than placebo. Venlafaxine was less tolerated than fluvoxamine (RR = 0.16; 95% CrI 0.01-0.64), paroxetine (RR = 0.21; 95% CrI 0.05-0.59), and sertraline (RR = 0.31; 95% CrI 0.08-0.83). Fluvoxamine had a higher rate of clinical response and acceptability compared to other treatments in the network, with probability of 47.5% and 50.6% of being the most efficacious and well-tolerated treatment, respectively.

CONCLUSION

Clinically important differences exist between commonly prescribed pharmacotherapeutic agents for treating anxiety among children in terms of both efficacy and acceptability in favor of fluvoxamine. Fluvoxamine might be the best choice when starting treatment for anxiety disorders among children and adolescents because it has the most favorable balance between benefits and acceptability.

Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety

BACKGROUND

Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy.

METHODS

In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12.

RESULTS

The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline.

CONCLUSIONS

Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)

Fluoxetine in posttraumatic eating disorder in two-year-old twins

Feeding disorders of infancy or early childhood are relatively uncommon in the pediatric population. In posttraumatic eating disorder, the infant demonstrates food refusal after a traumatic event or repeated traumatic events to the oropharynx or esophagus. We present case reports of 24-month-old twin girls, A and B, who presented to our clinic with food refusal and fear of feeding. Several invasive gastrointestinal procedures were performed when they were 3 months old, and they started to refuse all solid food and some liquids soon after hospitalization. Fluoxetine 0.3 mg/kg per day (5 mg/day) was started to target their anxiety and fear about feeding. In the second month of weekly follow up, the children began to be fed without a nasogastric catheter. A significant decrease in anxiety and fear was observed during feeding. Although the use of serotonin-selective reuptake inhibitors (SSRIs) in preschool children is controversial due to the lack of empirical data in this age group, we observed clinical improvements in anxiety in these two cases. Furthermore, fluoxetine was well tolerated and no side effects were observed.

Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders

This revised practice parameter reviews the evidence from research and clinical experience and highlights significant advancements in the assessment and treatment of anxiety disorders since the previous parameter was published. It highlights the importance of early assessment and intervention, gathering information from various sources, assessment of comorbid disorders, and evaluation of severity and impairment. It presents evidence to support treatment with psychotherapy, medications, and a combination of interventions in a multimodal approach.

Early treatment of acute stress disorder in children with major burn injury

OBJECTIVE

This study examines retrospectively the response rate of pediatric burn survivors with acute stress disorder to either imipramine or fluoxetine.

METHODS

On retrospective chart review, 128 intensive care unit patients (85 boys, 43 girls) with 52%+/- 20% total body surface area burn, length of stay of 32.8+/- 25.2 days, mean age of 9.1+/- 4.7 yrs, and age range of 13 months to 19 yrs met criteria for acute stress disorder after >or=2 days of symptoms and were treated with either imipramine or fluoxetine. If significant improvement did not occur within 7 days, the medication was either increased or switched to the other class.

RESULTS

Initially, 104 patients were treated with imipramine and 24 with fluoxetine. A total of 84 patients responded to imipramine: seven of these patients required a higher dose. A total of 18 patients responded to initial fluoxetine treatment. Of 26 nonresponders to the initial medication, 13 imipramine failures and one fluoxetine failure refused further treatment. The other 12 responded to the second medication. Therefore, 114 of 128 treated patients (89%) responded to either fluoxetine (mean dose, 0.30+/- 0.14 mg/kg) or imipramine (mean dose, 1.30+/- 0.55 mg/kg). Response was independent of sex and age but was less for those with burns of >60% total body surface area. The side effects of each medication were not significant. Most patients continued treatment for >or=3 months; some required 6 months of treatment before successful discontinuation.

CONCLUSIONS

Early treatment of acute stress disorder with either imipramine or fluoxetine is often able to reduce its symptoms. This is a review of a single hospital's experience in managing psychiatric distress in this very high-risk group of burned children. Additional clinical studies are needed before generalizing these findings.

Emerging treatments for child and adolescent social phobia: a review

Social anxiety disorder, or social phobia (SP), is an anxiety disorder characterized by excessive fear of exposure to situations that involve potential scrutiny by others. SP is a common psychiatric problem in children and adolescents, often presenting with comorbid anxiety and mood disorders. Although the onset of SP is typically in late childhood or early adolescence, most afflicted individuals go undiagnosed for years, not seeking treatment until adulthood. First-line treatments for SP in adults support the use of pharmacotherapy and cognitive behavioral therapy. There is new and emerging data in youths with SP to support the use of similar treatments. This paper will review the clinical characteristics, epidemiology, and treatment of SP in youths. Current investigations using selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors, benzodiazepines, and monoamine oxidase inhibitors in youths will be reviewed. Several studies on the use of cognitive behavioral therapy in youths will also be examined. Practical guidelines for clinicians who treat children and adolescents are also presented.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review

OBJECTIVE

To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents.

METHOD

A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports.

RESULTS

Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found.

CONCLUSIONS

Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Pharmacologic management of anxiety disorders in children and adolescents

PURPOSE OF REVIEW

Anxiety disorders constitute a significant problem among children and adolescents, with estimated prevalence of 6 to 10%. Left untreated, anxiety disorders can have major effect on academic, social, and family function, as well as impact on developmental progress. Effective treatment of childhood anxiety disorders with medications may help reduce morbidity and improve functioning and stress management.

RECENT FINDINGS

There are many reviews, but few studies, that examine the effect of psychotropic medication on anxiety disorders in children and adolescents. Most of our understanding comes from extrapolation from literature on adult medication trials. Available data indicate relative effectiveness of serotonin selective reuptake inhibitors in many childhood anxiety disorders, along with minimal side effects and good tolerability. Many other psychotropic medications have been considered and used to manage anxiety, with little data to support in children.

SUMMARY

The serotonin selective reuptake inhibitors are considered a first-line pharmacological treatment for anxiety disorders in children and adolescents. Numerous other psychotropic medications may be considered, alone or in combination. Definitive research is lacking; further research studies are sorely needed to help guide clinical decision making. Because there are few studies of pharmacologic treatment of anxiety in children and adolescents, this article will consider the most current literature and provide an overall summary of the topic.

Anxiety disorders in the child and teen

Several disorders have been reviewed (Table 1). Based upon review of the literature, an algorithm has been developed, supporting the initial use of cognitive behavioral therapy, followed by a psychopharmacology algorithm if treatment is not successful. In this algorithm, severely anxious patients initially may require psychopharmacologic treatment to be able to participate in cognitive behavioral treatment. Nonspecific measures of parent education, general support, and illness education to parents and patients are overarching principles. In this algorithm, the SSRIs are perceived to be first-line interventions, with tricyclic antidepressants and venlafaxine as second-line agents. Buspirone is considered a second- or third-line agent, as are the benzodiazepines. Table 2 reviews psychopharmacologic agents shown to be useful in the management of anxiety disorders in youth. Although much research remains to be done, there is evidence of efficacy of several interventions for anxiety disorders in children and adolescents. There is a need for a holistic and comprehensive management plan. Particular attention must be given to specific psychopharmacologic and psychotherapy needs, family matters, abuse issues, freedom from substance abuse, the use of peer support groups, and the encouragement of healthier lifestyle choices such as exercise. A rising number of well-done, large, placebo-controlled studies are providing increased support for medication and psychotherapy to inform evidence-based treatment. There is a need for teamwork and effective communication among team members in addressing pediatric and adolescent anxiety disorders.

Fluoxetine for the treatment of childhood anxiety disorders

OBJECTIVE

To assess the efficacy and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder, and/or social phobia.

METHOD

Anxious youths (7-17 years old) who had significant functional impairment were randomized to fluoxetine (20 mg/day) (n = 37) or placebo (n = 37) for 12 weeks.

RESULTS

Fluoxetine was effective in reducing the anxiety symptoms and improving functioning in all measures. Using intent-to-treat analysis, 61% of patients taking fluoxetine and 35% taking placebo showed much to very much improvement. Despite this improvement, a substantial group of patients remained symptomatic. Fluoxetine was well tolerated except for mild and transient headaches and gastrointestinal side effects. Youths with social phobia and generalized anxiety disorder responded better to fluoxetine than placebo, but only social phobia moderated the clinical and functional response. Severity of the anxiety at intake and positive family history for anxiety predicted poorer functioning at the end of the study.

CONCLUSIONS

Fluoxetine is useful and well tolerated for the acute treatment of anxious youths. Investigations regarding the optimization of treatment to obtain full anxiety remission and the length of treatment necessary to prevent recurrences are warranted.

The pharmacological treatment of anxiety disorders in children and adolescents

As the recognition of paediatric and adolescent anxiety disorders improves, so does the number of recommended treatments. Newer medications (chiefly serotonergic antidepressants) have emerged as the pharmacological treatment of choice and have largely replaced benzodiazepines and tricyclic antidepressants (TCAs) for these disorders. This review will focus on placebo-controlled and open-label studies concerning the treatment of anxiety in children and adolescents, comparing data from newer antidepressant medications (plus buspirone) with data on TCAs and benzodiazepines in this population. There are few randomised, placebo-controlled trials of medications for anxiety in children and adolescents, with most data coming from open-label trials and case series. Moreover, there are no studies comparing pharmacological versus behavioural treatments. Most recent data concerning the efficacy of selective serotonin reuptake inhibitors suggests that these agents will be effective and safe in the treatment of paediatric anxiety disorders. The potential side effect profiles of these newer agents also makes them an attractive first choice for anxiety when compared to the benzodiazepines or TCAs, each of which poses its own potentially serious adverse effects. More research is needed in the area of psychopharmacological treatments for paediatric and adolescent anxiety, not only to substantiate the current beliefs that serotonergic agents are effective and safe but to pinpoint the factors that might predict responses to particular agents or classes of medications. Future investigations should focus on treatments which have already proven effective for adult anxiety disorders (both medications and psychotherapies), given the apparent links between paediatric and adult anxiety disorders.

Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management

This paper provides an overview of the phenomenology, longitudinal outcome data, assessment and management of separation anxiety disorder (SAD) in children and adolescents. SAD is qualitatively different from early worries, and is characterised by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Longitudinal studies have suggested that childhood SAD may be a risk factor for other anxiety disorders, but whether this link is specific to, for example, panic disorder and agoraphobia, or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated. Most relevant data are reported on nonpharmacological treatments (psychoeducational, behavioural, cognitive-behavioural, family and psychodynamic), and these are the first choice approach in SAD. Controlled studies show efficacy of cognitive-behavioural therapy in children with anxiety disorders and specifically in SAD-school phobia, supporting this approach as the best proven treatment. Pharmacotherapy should be used in addition to behavioural or psychotherapeutic intervention when the child's symptoms have failed to respond to those treatments, and he/she is significantly impaired by the symptoms. Selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRI) have a good adverse effect profile and may be considered as first choice drugs in SAD. When different SSRIs fail to improve symptomatology, a trial with a tricyclic antidepressant (TCA) is indicated, with careful monitoring of cardiac functioning. Because of the adverse effect profile and the potential for abuse and dependence, benzodiazepines should be used only when a rapid reduction of symptomatology is needed, until the SSRI or the TCA have begun to be effective (few weeks). Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer antidepressants (venlafaxine, mirtazapine, nefazodone) in childhood anxiety disorders.

Selective serotonin re-uptake inhibitors for children and adolescents

OBJECTIVES

1) To briefly review the scientific basis for the use of selective serotonin re-uptake inhibitors (SSRIs) in children and adolescents. 2) To review the current data on the efficacy, safety and tolerability in children and adolescents.

METHOD

A Medline search back to 1990 was conducted. Review articles and double blind, placebo controlled trials were critically reviewed. Additional hand searches were performed with key journals and in specific areas of interest for this paper.

RESULTS

Most of the published papers are from North America. There is an increasing use of SSRIs in child and adolescent psychiatry. The main disorders studied are mood and anxiety disorders. The data supporting efficacy is still limited. The most robust data is in the treatment of OCD and depression.

CONCLUSION

Taking the limited data together with clinical experience and with adult studies, there is a valuable role for SSRIs as a component of treatment for various child and adolescent psychiatric disorders.

Childhood anxiety disorders: lessons from the literature

Studies of childhood anxiety disorders have increased in recent years, but the clinical implications of the work are sometimes difficult to discern. This paper reviews salient findings (related to the assessment and management of anxious children) published in the last 5 years. The high comorbidity among disorders, the occurrence of different disorders in the same child over time, recent changes in diagnostic categories, the availability of new anxiety measures, and poor correspondence between parent and child reports of symptoms all underscore the need for thorough assessment. Increasing evidence supports cognitive-behavioural treatments for anxiety disorders, alone or in combination with pharmacotherapy. Other important aspects of management suggested by developmental studies of anxious children include psychoeducation about constitutional factors in the development of anxiety, interventions to address parental anxiety, parenting advice regarding behaviour management and reduction of family conflict, and treatment of child impairment to decrease the risk of depression. Questions requiring further research are identified.

The treatment of anxiety disorders in children and adolescents

Anxiety disorders are the most common psychiatric conditions in the pediatric population, with prevalence estimates ranging from 5-18%. Children and adolescents with excessive anxiety often meet diagnostic criteria for a number of disorders within the DSM-IV. Unfortunately, the current diagnostic system is controversial because of high rates of symptom overlap, comorbidity with other psychiatric disorders, and lack of biological markers that would support a more empirical anxiety nosology. Treatment strategies for pediatric anxiety disorders have important historical roots. Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for pediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder; however, several large, methodologically sound psychopharmacotherapy trials are underway for pediatric anxiety disorders. This update will review the current status of psychosocial and psychopharmacologic treatment of pediatric anxiety disorders. In addition, a brief discussion of nosology, epidemiology, and developmental course of anxiety is included. Preliminary psychopharmacology treatment and CBT treatment algorithms are presented for pediatric anxiety disorders, based on the best available data. Recommendations for future research directions are also discussed.