79 Overall, the use of SSRIs remains the first-line treatment, with the best evidence-base. However, for the patients who can not tolerate or do not benefit from SSRIs, a variety of other treatment options can be considered. A proposed treatment algorithm is described in Table II, and is expected to need refinement as clinical evidence grows. Table II. Treatment algorithm for pediatric anxiety pharmacotherapy In June 2003, the FDA recommended against the use of paroxetine

for Major Depressive Disorder in children and adolescents EKG, electrocardiogram, BP, blood pressure, 5-HTa PA, serotonin Inhibitors,research,lifescience,medical partial … Treatment considerations informed by diagnosis Youth diagnosed with one anxiety disorder are quite likely to have multiple anxiety disorders concurrently, including Major Depressive Disorder, Attention Deficit-Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD) and Tourette’s Disorder.36, 80 In CAMS, among youth who met Inhibitors,research,lifescience,medical criteria for one or more anxiety disorders, 46% met criteria for other internalizing disorders, 11.9% for ADHD, 9.4% for ODD, and 2.7% for tic disorders.36 Providers should therefore broadly evaluate anxiety symptoms, and assess the degree of impairment thought to be driven by subtypes in order to prioritize treatment. Attention to these comorbidities is essential for Inhibitors,research,lifescience,medical comprehensive treatment

but may require

a stepwise approach. Risk factors for having a combination of depression and anxiety include Inhibitors,research,lifescience,medical older age and greater severity of anxiety symptoms.80 Although most RCTs of anxiety exclude depressive disorder diagnosis from entry, open-label use of citalopram showed a significantly lower rate of response in patients with comorbid anxiety and depression versus either alone.32 Children with behavioral dysregulation as a result Inhibitors,research,lifescience,medical of anxiety may consequently display features of oppositionality, leading to diagnoses of disruptive behavior disorder or ODD. Anxious children may intently refuse to comply with demands of learn more authority figures, such as leaving the house on time or reading aloud Megestrol Acetate in class, and refrain from communicating the intense and often embarrassing fear that drives this oppositionality. Family psychoeducation and school coordination may thus reduce conflict. Following treatment, features of externalizing disorders should be re-evaluated. Anxiety disorders in children also often co-occur with ADHD.81 Anxious children may have difficulty paying attention because of hypervigilance or preoccupation with peer concerns, as opposed to ADHD-related impairments. Careful assessment is therefore essential to address the core symptomatology, and also to monitor for potential anxiogenic effects of medications during stimulant trials.