Kids and Anxiety: Medication for anxiety disorder - A choice with lingering doubts

By KARA YORIO STAFF WRITER | The Record

For a parent of a child seeking treatment for an anxiety disorder, there is often a difficult internal debate if a therapist recommends medication.

“You really think to yourself, ‘I don’t want to medicate my kid until they’re 18, until they finish growing, until they can make the decision for themselves,’” said a Bergen County mother of a 13-year-old girl with anxiety.

Watching their child struggle and wanting to get off the draining emotional roller coaster are factors that push many parents past any guilt or bias involving mental health medications.

“If they had some other disease, you would put them on medication,” said the mother, who decided to put her daughter on the antidepressant Zoloft and does not regret it.

The medications for anxiety fall under the category of selective serotonin re-uptake inhibitors. They work by blocking a receptor in brain cells that reabsorbs serotonin, a chemical produced by the body that works as a neurotransmitter. The result is improved mood, behavior and overall outlook on life. Common SSRIs include Zoloft, Prozac, Lexapro and Paxil.

Kids are started on small doses, and it can take several weeks for SSRIs to become effective. Children are watched closely for side effects, and the dosage is slowly brought up to sufficient levels.

“It doesn’t always go so smoothly,” said psychiatrist Lisa Kotler, medical director of the New York University Child Study Center in Hackensack. “Sometimes there are side effects,

and it’s really important to work closely with the psychiatrist and have the medication monitored.”

The main side effects children experience are upset stomach, sleep difficulties and headaches, which can be managed by the prescribing psychiatrist, Kotler said.

Experts say parents must have a doctor who is experienced in giving these medications for anxiety, who knows the proper doses and who watches closely for side effects. Parents also need to know this isn’t a lifetime prescription. Most kids can be weaned off the drugs after mastering the coping skills from therapy and functioning well for six months to a year.

Medication should also be used in conjunction with therapy, not alone, studies and experts say.

Research backs up the combination of therapy and medication as effective treatment. The Child/Adolescent Anxiety Multimodal Study, financed by the National Institute of Mental Health, showed that among those in combination cognitive behavioral therapy and medication treatment, 81 percent showed improvement. Sixty percent in the CBT-only group improved, and 55 percent in the medication-only group improved.

“I almost never would just start medication, it would always be in combination with the therapy,” said Kotler. “In cognitive behavioral therapy, the beginning is education about anxiety and relaxation and coping skills. Then you have to move to challenging the anxious thoughts and exposures. You have to be in pretty good shape to do that, and if that process shuts down, you say wait a minute, we have to have medication. Sometimes the medicine helps them make better use of the therapy.”

Every therapist — and parent — has ideas about when and why to use medication.

“My personal philosophy is I’d rather not try medication intervention [first],” said Cresskill child psychologist Matthew Goldfine. “If that’s not effective, we can add a medication,”

Persuading parents

The biggest hurdle for doctors is often getting parents’ acceptance. Educating parents about the drugs and the process is a big part of the therapists’ job. They “medicalize” the situation, according to Kotler, equating the mental health condition with a physical issue that would require medication.

“If parents were told your children have high cholesterol, try diet and exercise. And it’s not working, and the pediatrician says, ‘Look I’d like to start a medicine.’ They would just do it,” said Kotler. “They wouldn’t sit around beating themselves up. With diabetes, if they say your child needs an insulin pump or your child needs to take shots, you just do it, you don’t even think. You don’t blame yourself.”

But while the medications can be effective, the decision is rarely clear-cut for parents.

“We know there are a lot of really good medications out there that have been shown to be effective in kids — not without side effects, not without drawbacks,” said Goldfine. “That’s a personal decision. A parent might say, ‘Whatever will help my son or daughter, I don’t care, let’s do it. My son or daughter is suffering. I’m going to help them.’ Others say, ‘Eww, I’d rather not.’”

Some psychiatrists would rather not, as well.

“Most anxiety in children — and most of my work is with children — it does respond to medication but not well and not for long and not permanently,” said Dr. Nathanial Donson, an Englewood psychiatrist who will prescribe medication to some patients with other issues.

For Kotler, it comes down to the child’s ability to function.

“In terms of medication, when we see patients, we’re always looking at what’s going on, and we’re always looking at impairment,” she said. “Once a child’s not going to school, once a child’s not functioning, we have to say, “Wait a minute, cognitive behavioral therapy is a great treatment, but it doesn’t work right away. It’s going to take weeks, and we don’t have weeks.’ If a child is not going to school and weeks are going by, that’s really impairing academically, socially, for families. So we have to work quicker.”

The father of one of Goldfine’s patients struggled with the decision to put his son on medication a few years ago and said he still struggles with it.

“It was very hard for me,” said the third-grader’s father, himself a psychologist. “It felt a little bit like a crutch or a cheat or a copout. If he just takes a pill, how is he going to learn to get through it on his own?

“But also, it made it also so much bigger for me. Not that it wasn’t real before that or wasn’t an issue before that. It was like ‘OK, now it’s another doctor, now it’s prescriptions.’ … I know people who take medications every day for the rest of their lives, and I don’t want that for my, at the time, 6-year-old.”

The son was not fazed by the decision his dad saw as a big turning point.

“The medication definitely helped,” the father said, “but I don’t think it was this groundbreaking thing for him. But for me, as a parent, it was like ‘OK, I can no longer explain this away as him being a little quirky or stubborn or rigid.’ This is major league stuff and there was a lot of discomfort and guilt and just that well, crap, what’s his life going to be like now? How are we going to manage this on sleepovers and play dates and trips?

“Everything just becomes that much more complicated,” he continued. “But, in time, I’ve become a little more comfortable with it, if only because I do see how much it helps.”