When is medication the answer for kids with anxiety?
January 11, 2016 7:32 AM   Subscribe

My son (8) struggles with anxiety (separation and generalized) and negative thinking/depression. How do you know when it is time to start treating it with medication?

He has gone to a therapist in the past but the person was largely ineffective at helping him learn how to handle his feelings outside of their settings. I have a lead on a new therapist who uses CBT to treat children and he will start seeing her soon.

His GP asked if we thought he should take medication but I was hesitant to say yes until we could get him in to see a child psychiatrist. It turns out the earliest he can see one in the area is mid-May. Four months is a really long time for a kid who is so worried about being alone that he pops awake from a deep sleep every time I attempt to leave his room at night. He is struggling at school because his anxiety prevents him from being able to focus. He also recently has lost interest in nearly all food (except bacon and orange juice). He has fun playing with friends but he frequently descends into a spiral of negative self talk after play dates that is just heart breaking.

Reading the above paragraph I seems like trying medication is a no-brainer. He is clearly suffering but I have heard so many horror stories about SSRIs that I am having trouble making the decision to use medication. Did you decide to medicate/not medicate your anxious child? What was the outcome?
posted by a22lamia to Health & Fitness (25 answers total) 8 users marked this as a favorite
My son started taking Lexapro for anxiety when his grades started plummeting. It takes about 6 weeks to kick in (which is enough to really screw up your first year of high school gpa!) and it made a big big difference. Our pediatrician wouldn't prescribe anything so it took us forever to find a doctor and get through this. I'd say maybe get the GP to prescribe something and then when you see the psychiatrist either you'll have something that's already helping and the new doctor can evaluate from there or you'll be able scratch one of the meds off the list and can try the next thing with more info.
(He's older than your son and ended up also taking ADD medicine and it has made him a different kid. He was a grump who just wanted to stare grumpily at the computer all day and night and got weepy if you asked him to do anything and now he does the dishes without being asked (sometimes) and talks to me so much omg I will watch the daily show don't recite it to me. YMMV. He also broke up with his girlfriend so that helps too. He literally went from As to Ds to As. From almost not making retention last year to pissing off his friends for screwing up the curve by getting 103 on the test everyone did badly on.)
posted by artychoke at 7:47 AM on January 11, 2016

Where are you located? If you still looking for treatment options, the BU Center in Boston has a good collection of resources for child anxiety.
posted by alms at 7:52 AM on January 11, 2016

After consulting with our son's doc (who is WONDERFUL and typically opposed to medicating kids if anything else can be done), we put him on a small dose SSRI. Honestly, it had gotten to the point that his anxiety was causing him to literally chew off the ends of his fingers so something had to be done.

And it's been one of the best decisions we've ever made as parents. If you've got a doc you trust, I say give it a shot. It's done wonders for my son.
posted by youandiandaflame at 7:55 AM on January 11, 2016 [1 favorite]

I don't understand waiting until May to see a child psychiatrist. I looked you up and see that you live in Western Mass. Can you not go to Boston or NYC to see a psychiatrist? I know one who can probably see you next week!

On the other hand, You're saying that your child's therapist didn't help him because his feelings and their expression weren't controlled. I wonder how long he stayed in therapy. CBT can seem great because we believe in "strategies" and "controls" and so do CB Therapists. That's why CBT is the therapy Americans love. But your son may benefit from a therapy that doesn't dwell on quick "results" but more on allowing your child to get to know himself and express himself without the goals that parents (and therapists) have. Sometimes a good goal is to express what you're feeling and to, sometimes, actually get to the Why. Often kids don't express the Why more because they know that things that are bothering them (school, other people) can't (won't) be changed, so they get stuck in a loop of people wanting to help them but being powerless to change their environment in ways that would actuallly help them. So what's left? Being depressed and anxious in a way that seems incomprehensible to the adults around them.

So -- when medication? When a lot else fails, and you may not be there yet.

On the other hand, why not try to get in to see a psychiatrist earlier? Childhood depression and anxiety are serious and may demand more urgent action and money out of your pocket.

I am not your therapist.
posted by DMelanogaster at 7:57 AM on January 11, 2016 [6 favorites]

This sounds a lot like my 10 year old daughter.

Is the new therapist with a practice would be able to prescribe? Our daughter has been seeing a therapist since September, and she's part of a team that is able to recommend medication. She's been taking Hydroxyzine (without much success) since November. We'll be talking to the team tomorrow about possibly changing to something else. If that medication also fails in combo with CBT, then we'll look at SSRI.

So yes, SSRI can be a big step, but maybe there are little steps in between that will help.
posted by saffry at 8:00 AM on January 11, 2016

Did the GP specifically mention SSRI's? There might be something else that can help instead. Just as an example, I have depression but wasn't responding particularly well to my anti-depressant. Then when I got on ADHD meds, it made a huge difference - so much so that I think the ADHD meds alone would be enough.
posted by dawkins_7 at 8:16 AM on January 11, 2016

There are new studies saying that fermented foods help tremendously with anxiety and depression. if he tolerates milk products make sure he has some yogurt every day. or another fermented food. or supplements.

(but of course continue discussing treatment with your doctor)
posted by cda at 8:36 AM on January 11, 2016 [1 favorite]

You don't mention it in your post, but I am assuming you have already done exercising, getting out in nature, finding self expression though hobby/art, lifestyle overwhelm (cacophony of toys, activities, sounds, other stimulus), safe expression of fears, etc.?

The 'when' would most likely come after all that. And still in conjunction with the above, of course.
posted by Vaike at 8:44 AM on January 11, 2016 [2 favorites]

Would you consider family therapy as well? I had anxiety and depression as a kid that was directly related to issues in my parents marriage, my dad's poor handling of work stress, and unaddressed fears I had about the future of my family. I got the whole child therapist and psychiatrist rigamorole, which was not that helpful, and it took me a long time as an adult to figure out that my feelings had been related to real stuff that had been going on. It was the 90s so I was told again and again I had a "chemical imbalance." My mom now recognizes I was sensitive and responding to our family climate, and wishes someone had suggested family therapy back then, as it probably would have helped more people in the family than just me. I'm a psychotherapist now, and I tend to think of kids as barometers to their environment. They are almost always responding to something, and it is usually easier and more beneficial to everyone involved to make changes to the overall family system than just the kid. I also know firsthand and in my clinical work that it can be very damaging to get the message as a kid that you are the only problem, when that is not the case...
posted by amileighs at 8:51 AM on January 11, 2016 [17 favorites]

My daughter started taking an SSRI at age six after several months of meeting with a psychiatrist at Boston Children's Hospital. I was very hesitant, and I wouldn't have done it if the anxiety wasn't causing a serious health issue (refusing to go to the bathroom), but now I'm glad I did. It solved the main problem, and she's so much healthier and happier all around. The only noticeable side effect has been an increase in restlessness, but it isn't bad enough to cause any major problems. She's still doing fine in school.
posted by diogenes at 8:54 AM on January 11, 2016

The answer is: When your docs and you have determined that it's appropriate.

You've tried some non-chemical interventions, it may be time to try a low dose of a drug. Talk to your son's pediatrician and see what she recommends. Your pediatrician knows your kid and has experience with dosing.

I only wish I had this option when I was a kid. My life would have been better.
posted by Ruthless Bunny at 8:59 AM on January 11, 2016 [3 favorites]

When is medication the answer for kids with anxiety?

When you have multiple opinions from medical professionals all saying the same thing.
posted by Cool Papa Bell at 9:14 AM on January 11, 2016 [5 favorites]

I'm certainly not pro-medication-for-everyone-all-the-time-no-matter-the-circumstances, and I actually underwent quite a few horror stories myself, but here's how I remember my childhood: my anxiety was worse than it is now as an adult. I was crazier. I had all the build-in, out-of-the-box mental illness I'll be dealing with all my life, but none of the coping skills or maturity to handle it.

Kudos to you for getting your child help as early as possible. We have this image of children, as quirky and resilient, that doesn't always match the reality. Adults with mental illness often didn't magically have issues crop up when they turn 18.

I'm not going to say "yes, give him medication!" or "no, try more therapy first!" because I'm not your doctor. I just want to let you know, he has a grown-up issue going on, and it's ok to use grown-up measures to treat it.
posted by Juliet Banana at 9:14 AM on January 11, 2016 [8 favorites]

Thank you so much for your responses. A few replies below:

For a number of reasons driving to Boston and/or paying out of pocket aren't reasonable but it is good to know about the program at BU in case it becomes more doable in the near future.

My son went to therapy for just under a year until he asked to stop going. That was in April of last year. In December he said he wanted to see someone again which is when I reached out to my local network of parents for referrals. He is very good about identifying where his concerns are coming from he has a very had time being able to control the worry loops once they start which is why CBT seems like a better fit for him. We would definitely be open to family therapy. There is a family history of anxiety and I am sure that he has been affected both genetically and environmentally. That said we are a pretty open and communicative family and he seems to feel comfortable talking to both of his parents.

We make sure he exercises regularly, try to get out in nature often and keep his toys limited and organized(mostly - legos are hard to corral). Until very recently he has been a daily yogurt eater.

Why I am struggling is because our family doctor mentioned it but is leaving the ultimate decision up to us.
posted by a22lamia at 9:16 AM on January 11, 2016

One more thing - all of those things that should help - exercising, nature, activities help in the moment but just like playdates he often crashes afterward.
posted by a22lamia at 9:28 AM on January 11, 2016

Would it help to think of medication as something to try temporarily, rather than some sort of all or nothing decision?

If you decide not to try medication just now, that doesn't mean you can't try it next month.

If you decide to try medication next week, that doesn't mean you have to keep doing it forever.

With a good doctor and good communication with your kid (which it sounds like you have), you can make a plan that says, "if we try medication, here are the things we'd look for that would make us want to continue, and here are the things we'd look out for that would make us want to stop and try something else." That can make it easier to move forward.

Best of luck, this is a heartbreaking thing to try to help your kid deal with, and it sounds like you are being thoughtful and attentive.
posted by Ausamor at 9:55 AM on January 11, 2016 [2 favorites]

Is his anxiety interfering with his ability to learn? If so, there may be services available to him through your public school. Maybe not ideal, but actually the only therapist my son has ever connected with was his school therapist, who had the bonus of being able to actually observe him in his day to day life (in class, interacting with other students) and being able to provide guidance to him based on his observations.
posted by anastasiav at 10:32 AM on January 11, 2016

This is such a tough one. I think you know it's time to seriously consider an SSRI when you've worked with a psychiatrist and considered all options. I would trial an SSRI on a kid only if I was doing it with the help of a psychiatrist.

*I know a kid who presented similarly to your son at around the same age. He was able to face his day but it began to get harder and harder to get him to attend school or when he did go, he cried in the nurse's office much of the day. That was when the parents knew they needed to seriously consider medication.

The kid went on Celexa and within a few weeks was able to access therapy. In his case, the SSRI was a life-changer.

**Disclaimer: I am not referring to myself or any of my children.
posted by yes I said yes I will Yes at 12:32 PM on January 11, 2016

I don't know jack about kids, but looking back on my life once I got on meds that helped me, I probably should have asked for something for my anxiety, depression, and ADHD a lot sooner in life than I did. (Don't be like me, kids - get help *before* your anxiety gives you a delusional episode!) He seems articulate - does he have an understanding of what meds might mean/do? and how does he feel about the idea?

(Oh, and I'm not trying to imply that your son is going to be damaged and crazy if he doesn't get meds, or anything like that - just that I wish I'd spoken up sooner, and I'm glad he has and that you're listening! I know my parents would have listened, but I didn't realize I should say something, and 90% of it didn't show, so they didn't know on their own until things got a lot worse. You're catching things now, whatever you decide to do, and that's great!)
posted by dust.wind.dude at 2:24 PM on January 11, 2016 [1 favorite]

I'm not sure if getting there will be an issue, but URI has a child anxiety program on a sliding scale.
posted by Ruki at 3:32 PM on January 11, 2016

I just want to say thank you for working through this with him. I was an extremely anxious child and it wasn't til my mid 30s I discovered that it could be treated with medication. Life-changing, but also saddening since I suffered so long unnecessarily with what I thought was a personal flaw and I can't even begin to think what options I would have had if I didn't live with a constant underlying feeling of dread.

I agree with those saying after multiple professionals advise that option and also it is not an irrevocable decision but one that can be a tool with future treatment.

Best wishes to your family.
posted by kitten magic at 3:55 PM on January 11, 2016

Medication for a medical condition like anxiety is a life changer. It can take some time to get the right dosage of the right medication so I don't recommend getting it from the family doctor, who doesn't have the time or the skill set to follow up properly. From what you are describing, it does seem like now is the right time to start medication. Treating him now, before the anxiety becomes his personality, is the right thing to do. Don't hesitate, but do do it correctly. Find a doctor who specializes in children with psychological issues and who can see your child as needed, even if as needed is twice a week until the medication is where it should be.
posted by myselfasme at 5:09 PM on January 11, 2016

FWIW, family docs are fine for getting psych meds when there is an urgent need (to tide you over until you can get in with a psychiatrist) or after you have worked with a psychiatrist to get the particular medication and dosage dialed in.

Also, a family doctor you mesh well with is better than a psychiatrist who you don't, no matter how qualified the latter is. A psychiatrist or therapist you aren't copacetic with is worse than none at all, tbh. A psychiatrist that you feel doesn't hear you or is unwilling to meet your needs can easily put you in a terrible head space.

Lastly, outcomes are significantly better when both medication and therapy are combined. And if there isn't some reason not to use them in children, SNRIs like Effexor are effective for both anxiety and depression. I wouldn't be terribly comfortable with dosages on the upper end of the range, but 75mg a day would be unlikely to produce the side effects they are known for. I would be more concerned if your doc reccomends benzodiazapenes like Ativan or Xanax, not because they are necessarily bad for you when used appropriately, but because it is likely other kids will discover your kid is on them and either pressure him to "share" or straight up steal them.
posted by wierdo at 6:14 PM on January 11, 2016

I'm a psych nurse who works with children and adolescents. What your son is going through sounds heartbreaking; I'm so sorry.

I don't think there is a definitive answer to your question-- there is no 'correct' time to trial medication, or 'correct' way for a family to handle a child's mental health crisis. From what you've written I get the sense that your gut feeling is he needs medication right now to get him through, but you have a lot of ambivalence about meds. If that's the case, I think you should probably go with your gut and ask your GP for a prescription. A medication trial is not a permanent decision. If the child psychiatrist, when you see him, thinks a different tactic is better, then you can switch things up then. If side effects are an issue, you can always taper down and stop the med. Psychiatric medication is really complex and you are right to get your kid to a specialist, but in the interim you are going to have to make do with your family doctor.

The first-line approach to anxiety in children is SSRI medication, usually at a very low dose to start. There are two main concerns with SSRIs. First, physical side effects: nausea, headache, sleep disturbance, etc. These tend to be worst in the beginning and become more tolerable over time. Honestly, from your description nausea sounds a lot easier to endure than that kind of overwhelming anxiety. If the physical side effects are too great, you can switch to a different medication or decrease the dose. The greater concern is that sometimes people have an adverse psychological response to SSRIs, which includes greater activation and suicidality. This is something that you'll want to be aware of and paying attention to, but again: if the medication is worsening anxiety you can stop it.

Unfortunately, there haven't been a huge amount of studies on anxiolytics in children. A lot of the research that does exist focuses on OCD anxiety (which your son may have elements of, such as that food-related anxiety). Generally, the best evidence we have points to SSRI medication as being fairly safe and effective. Benzos are sometimes used for anxiety, but due to the potential for addiction and sedation they really aren't a good first choice. Other meds like guanfacine, hydroxyzine, and buproprion can potentially be helpful, but haven't been studied extensively.

And I know you are already doing this, but the best thing available to you right now is exercise. Regular, repetitive, vigorous exercise. This will be important even once you get settled in with your new therapist and psychologist. CBT has not been studied as extensively in children as in adults. While effective, it can be difficult for kids at times because it relies heavily on executive function, which is often underdeveloped in kids with mood disorders. Techniques-- like exercise-- that are able to affect patients on a deeper, more instinctive level may be more effective. If you're interested in this, look up some of the work being done on the nuerosequential model of development. A lot of it is focused on trauma and PTSD, but people with anxiety disorders experience similar overwhelming fears.

Good luck, and keep fighting the good fight.
posted by bookish at 8:31 PM on January 11, 2016 [3 favorites]

Thank you all so much for your thoughtful responses!
posted by a22lamia at 10:43 AM on January 13, 2016

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