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2. Are SSRIs safe for my child?
Based on review of 24 short-term (4 to 16 weeks) studies of nine antidepressant medications involving more than 4,400 children and adolescents with major depressive disorder, obsessive-compulsive disorder, or other psychiatric disorders, the U.S. Food and Drug Administration (FDA) issued a warning in October 2004 that antidepressant medications, including SSRIs, may increase suicidal thoughts and behavior in a small number of children and adolescents. Results show that the average risk of suicidal ideation and suicidal behaviors occurred in 4% of patients treated with an antidepressant, compared to 2% of patients who were treated with a placebo, or sugar pill. No suicides occurred in any of the studies. The FDA does not prohibit the use of these medications, but it does alert patients and families to the risks, which must be balanced against clinical need.

Parents and other caregivers are advised to ask their children about suicidal thoughts and to monitor changes in personality or behavior such as agitation, restlessness, or irritability. If these are observed, the prescribing doctor should be contacted to lower the dose or discontinue the medication. Patients should not stop taking medication abruptly because symptoms may worsen. Some limited evidence indicates that suicidal ideation and behaviors occurred most often at the beginning of treatment or when the dosage changes. However, monitoring should occur throughout treatment.

3. How is the clinical need for medication determined?
Medications are used to treat anxiety disorders when symptoms cause significant subjective distress for the child and/or are contributing to persistent functional impairment such as difficulties at school, with peers, or at home. Severity of symptoms will determine when medications are started.  

Some clinicians feel that medications should be used only after children fail to respond to psychotherapy. But others argue that many children with severe anxiety disorders cannot initiate the tasks that must be completed for psychotherapy to be successful. Some children may refuse to talk with a therapist at all; for them it would be reasonable to initiate treatment with a medication before psychotherapy begins.

4. What are the most common side effects of SSRIs?
SSRIs are generally tolerated with minimal or no side effects. The most commonly reported physical side effects include headache, stomachache or nausea, and sleep difficulties. Before prescribing medication, your child’s physician must determine the presence of any physical symptoms; they may be related to medical problems or reflect anxiety. Make sure the physician reviews side effects with you and your child before starting an SSRI and monitors for symptoms at follow-up visits.

5. What if my child develops side effects?
Call your doctor with any questions or concerns about possible side effects during the course of treatment. Some children experience side effects to one SSRI but not to others. A different SSRI may be indicated if side effects develop to the initial medication.

6. How can I tell if the medication is working?
Treatment monitoring begins with a thorough assessment and understanding of your child's anxiety disorder symptoms. A treatment plan should include a patient’s specific target symptoms, which will be assessed for response. Symptom-rating scales may be used as an additional measure of treatment response. And family members, teachers, or other adults are important sources of information about your child's symptoms and response to medication.

7. How long will it take for the medication to work?
A decrease in your child's symptoms of anxiety does not happen immediately. Improvement may occur after about one week, although an initial trial of four to six weeks is best to assess clinical response. Your child must take the SSRI daily, at about the same time each day to achieve stable and effective medication levels.

8. How long will my child need to take medication?
Current recommendations suggest that initial treatment of childhood anxiety disorders with an SSRI should be continued for about one year. Longer medication treatment may be recommended if symptoms persist or reoccur. Symptoms and treatment response should be reassessed at regular intervals. Starting a child on an SSRI does not mean medication for life. Many children do not require more than one course of medication treatment.

9. Will my child become addicted to these medications or have a change in personality?
There is no evidence that the SSRIs are addictive. If medications are discontinued abruptly, symptoms such as dizziness, nausea, headache, and behavioral changes may occur. Medication dosages should not be changed unless directed by a physician.

Treatment with SSRIs should not change your child's personality. Anxiety symptoms and associated distress may cloud features of your child's personality. If prominent changes in your child's behavior and demeanor do occur, check with your physician about possible side effects.

10. What if my child refuses to take the medication?
Children should not be forced to take medications, nor should the medications be disguised or inaccurately described. It is important to try to find out why a child does not want to take the medicine. Questions to consider:

• Does the child have difficulty swallowing pills?
  
• Does the child fear that something may happen if he or she takes the medicine?
  
• Is the child concerned about embarrassment if others learn that he or she is taking a medication for anxiety?

Educate your child about his or her anxiety disorder. Review symptoms that cause difficulties, and if age-appropriate, involve him or her in discussing treatments, emphasizing the goal of improving symptoms. If the child refuses to take a medication, consider cognitive-behavioral therapy or other psychosocial interventions with subsequent review of medication use if symptoms do not improve.

11. Can SSRIs be used with over-the-counter and other medications ?
Check with your physician before adding or changing any of your child's medications to avoid potential negative drug interactions.

12. Are other treatments available besides medication?
Cognitive-behavioral therapy, or CBT, is recommended for all children with anxiety disorders with our without medication treatment. CBT targets the symptoms of anxiety and incorporates a variety of approaches designed to change maladaptive thoughts, beliefs, and behaviors associated with anxiety disorders. Other psychosocial interventions include school support, family therapy, and assessment of potential contributing stressors at home or school. Parents should actively discuss treatment options with their children's health care provider.

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Additional Resources
About Our Kids
American Academy of Child & Adolescent Psychiatry
Caring for Every Child's Mental Health Campaign
The Center for Health and Health Care in Schools