Psychopharmacologic treatment of anxiety disorders in adolescents and children

Anxiety disorder is more prevalent than attention deficit disorder in children and adolescents, but its current drug treatment is based on inconclusive findings. Treatment of separation anxiety disorder without comorbidity has barely been studied. School absenteeism is often treated with tricyclic antidepressants and benzodiazepines, but the efficacy data are only suggestive for benzodiazepines and not encouraging for antidepressants. Overanxious disorder appears to be responsive to benzodiazepines in open trials but not in controlled studies, and buspirone may have promise. The evidence is weak for treating avoidant disorder with alprazolam or buspirone and for treating panic disorder with antidepressants or benzodiazepines. There are no adequate trials of monoamine oxidase inhibitors. Obsessive compulsive disorder is well documented to respond to clomipramine, but it leaves considerable residual symptoms; fluoxetine also appears to be effective. The anxiety and aggression of post-traumatic stress disorder responded to propranolol in one open trial, but no other drug studies have been reported. Most available trials are small and uncontrolled, are based on an unsatisfactory nosology, and use doses too low for children (who often need higher-than-adult doses to overcome rapid hepatic biotransformation). Comorbid anxiety and mood disorders, substance use, child abuse, development, genetics, and family situational factors must be considered. In view of the limitations of the benzodiazepines and antihistamines, newer antianxiety agents should be investigated, optimally in conjunction with cognitive and behavioral approaches in multimodal treatments. The creation of anxiety disorder clinics for children and adolescents will facilitate more effective research and treatment of this highly prevalent problem.