I was talking with a colleague about her young child who gets very anxious when the school day doesn't go exactly as planned. As a result, she might stop cooperating with teachers and classmates or have a brief tantrum if there is a substitute teacher in the room.
The mother has talked with teachers about the kind of help her daughter might need. She had these questions for me:
- Should we get a proper diagnosis or should we avoid "labeling" her?
- Should she see a doctor about medication or is medication too dangerous for the developing brain?
- Is psychotherapy helpful — and is it even possible to find a competent and caring therapist in the area?
- Is treatment more for the teachers (who are having a hard time with the young student's behavior) than it is for the child?
- How much of her problem is a variation on normal development? Should we wait it out until she reaches the next stage in childhood?
When it comes to many medical and mental health decisions — and especially helping young children with emotional or behavioral problems — there's a certain amount of uncertainty that comes with figuring out the right course of action. Fortunately, there's research to help choose the best treatment for a child with anxiety.
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Medication or Psychotherapy?
When it comes to the mental health treatment of children, there's heated debate over the value of psychotherapy and medication.
Proponents of medication might tell this mother, "Let's find a medication that will reduce the sharpness of her reactions to slightly abnormal conditions. By changing the biology of her fear circuits, she'll feel less distressed. Therefore, she will find it easier to manage her behavior and interact more positively with peers and teachers. In the end, she will feel better about herself and she will enjoy her school relationships more."
And proponents of psychotherapy might say, "Let's teach her to pay attention to her reactions and give her better tools for managing them. As she practices, she'll develop more skill and will feel less distressed. This will free her up to interact more positively with peers and teachers and she will take pride in her achievements. In the end, she will feel better about herself and she will enjoy her relationships more."
Either approach may work, separately and together, as researchers found out in a study published in The New England Journal of Medicine at the end of 2008.
The authors reported on a 12-week, randomized, controlled trial comparing various treatments for children with anxiety disorders, such as separation anxiety, generalized anxiety disorder and social phobia. They compared the following treatments:
- Cognitive behavioral therapy (CBT)
- The antidepressant sertraline (Zoloft)
- A combination of CBT and sertraline
- A placebo drug
Almost 500 children with these disorders, ranging in age from 7 to 17, participated in the research. More than 80% of children receiving combined therapy experienced significant improvement, compared with 60% of children receiving only CBT and 55% of those receiving only sertraline. The difference between CBT alone and sertraline alone was not statistically significant, but both solo treatments were more than twice as effective as the placebo.
This study was funded by the National Institute of Mental Health and conducted at several sites around the United States. Subjects were from diverse ethnic and racial groups. Experienced therapists provided psychotherapy under careful supervision. The children receiving sertraline were evaluated in eight sessions of 30 to 60 minutes each. This design enabled investigators to compare the effectiveness of various treatments.
Researchers also could measure how well the children tolerated the sertraline and any side effects associated with it. Children taking the drug did experience more mild side effects, such as sedation, sleeplessness and fidgeting, when compared with non-medicated children. Reassuringly, given highly publicized concerns about suicide risk (see "Can antidepressants trigger suicide?"), no child attempted suicide. And children taking sertraline did not report suicidal or homicidal ideas more frequently than did children taking placebo.
Can antidepressants trigger suicide?
The evidence suggests that children and adolescents who start an antidepressant may be at increased risk of developing suicidal thoughts or behaviors. This has led the Food and Drug Administration (FDA) to require all antidepressant drug makers to warn of this possible side effect.
The evidence suggests that all antidepressants may cause this problem in a small number of patients.
Fortunately, there has not been an increased risk of death by suicide.
But after this warning, the number of antidepressant prescriptions filled dropped, after which the suicide rate in the United States increased. It is not possible to say whether the change in prescriptions was the cause, but there is strong evidence that people with untreated depression are at higher risk for suicide than people who get treatment.
How a person responds to a particular medicine can be unpredictable. So, watch for signs that depression is getting worse rather than better. If you notice suicidal thoughts or behaviors, whether or not you started a new medication, let the doctor know right away.
This study was encouraging because it provided solid evidence that anxiety treatments work. CBT is a good first option for many children. And for those children who take antidepressant medicine, the study provides more reassurance that, with careful monitoring, medication is a relatively safe option. The extra benefit with the combination of CBT and antidepressant is a boon for the almost half of children who do not get relief from either treatment alone.
The study's good results may be hard to achieve in the real world. Some children do not have access to the kind of care provided in the study. Also, experts don't know what makes these treatments effective. It could be some children felt better because they got to spend more overall time with clinicians.
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Here are my answers to my colleague's questions — as limited as they may be.
- Don't worry too much about diagnostic labels. Instead, define problems in terms of practical solutions. This may take help from a professional. For example, if the problems are distress and tantrums, look for approaches to reduce distress and improve the child's engagement with school.
- Medication and therapy are equally effective, so take your pick. If one doesn't work, change to or add the other approach.
- As long as a teacher is not punitive or disparaging of the child, I would accept this principle: When the child feels better and is doing better, everybody benefits (peers, teachers, parents). It's great if treatment brings about improved relationships in school.
- Most pediatricians and mental health professionals who work with children would say that development is an irrepressible force. It doesn't pay too much attention to the diagnostic manuals. Of course, there is no guarantee that the next stage will be better or easier than the current one. But it is probably more helpful to nourish a child's growth and development rather than going overboard in an effort to treat "symptoms" of one disorder or another.
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The Bottom Line
The goals are for a child to be comfortable in the classroom, enjoy relationships with her peers, and get ready for the challenges ahead, whatever they may be. Parents can be reassured that treatment for anxiety in children can help them reach those goals.
Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.