Sertraline in children and adolescents with social anxiety disorder: an open trial

Advances in Pharmacotherapy for Pediatric Anxiety Disorders

The evidence base for psychopharmacologic interventions in children and adolescents with anxiety disorders has significantly increased, and our understanding of the relative efficacy and tolerability of interventions has expanded contemporaneously. Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacologic treatment for pediatric anxiety due to their robust efficacy although other agents may have efficacy. This review summarizes the data concerning the use of SSRIs, serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, atypical anxiolytics (eg, 5HT_1A agonists, alpha agonists), and benzodiazepines in pediatric anxiety disorder cases (ie, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and panic disorder). The extant data suggest that SSRIs and SNRIs are effective and well tolerated. SSRIs as monotherapy and SSRIs + cognitive behavioral therapy reduce symptoms in youth with anxiety disorders. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the 5HT_1A agonist, buspirone, in pediatric anxiety disorder cases.

The Oxford Agoraphobic Avoidance Scale

BACKGROUND

Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms.

METHOD

The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test-retest reliability was assessed with 264 participants.

RESULTS

An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24-5.43; distress: a = 1.60-5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test-retest reliability, and validity.

CONCLUSIONS

The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.

Selective Serotonin Reuptake Inhibitors and Clozapine: Clinically Relevant Interactions and Considerations

The monoamine hypothesis of depression attributes the symptoms of major depressive disorders to imbalances of serotonin, noradrenaline, and dopamine in the limbic areas of the brain. The preferential targeting of serotonin receptor (SERT) by selective serotonin reuptake inhibitors (SSRIs) has offered an opportunity to reduce the range of these side effects and improve patient adherence to pharmacotherapy. Clozapine remains an effective drug against treatment-resistant schizophrenia, defined as failing treatment with at least two different antipsychotic medications. Patients with schizophrenia who display a constellation of negative symptoms respond poorly to antipsychotic monotherapy. Negative symptoms include the diminution of motivation, interest, or expression. Conversely to the depressive symptomology of interest presently, supplementation of antipsychotics with SSRIs in schizophrenic patients with negative symptoms lead to synergistic improvements in the function of these patients. Fluvoxamine is one of the most potent inhibitors of CYP1A2 and can lead to an increase in clozapine levels. Similar increases in serum clozapine were detected in two patients taking sertraline. However, studies have been contradictory as well, showing no such increases, which are worrying. Clinicians should be aware that clozapine levels should be monitored with any coadministration with SSRIs.

Psychopharmacology of Pediatric Anxiety Disorders: A Narrative Review

Anxiety disorders are common among children and adolescents; almost one-third of this population has an anxiety disorder. The most common anxiety disorders in this population are specific phobia (19.3%), social anxiety disorder/ social phobia (9.1 %), and separation anxiety disorder (7.6 %). Pediatric anxiety disorders are often associated with poor psychosocial functioning, academic underachievement, learning difficulties, substance abuse, relationship problems, and suicide behaviors. Psychotherapy, particularly cognitive behavioral therapy as a stand-alone treatment or in combination with medication, is found to be efficacious in the treatment of various anxiety disorders. The early recognition and treatment of anxiety disorders result in better long-term outcomes in children and adolescents. This article summarizes the evidence-based pharmacologic treatments for anxiety disorders in youth, including social anxiety disorder generalized anxiety disorder, separation anxiety disorder, and panic disorder.

Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis

Importance

Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use.

Objectives

To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders.

Data Sources

We searched MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and SciVerse Scopus from database inception through February 1, 2017.

Study Selection

Randomized and nonrandomized comparative studies that enrolled children and adolescents with confirmed diagnoses of panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, or separation anxiety and who received CBT, pharmacotherapy, or the combination.

Data Extraction and Synthesis

Independent reviewers selected studies and extracted data. Random-effects meta-analysis was used to pool data.

Main Outcomes and Measures

Primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse events.

Results

A total of 7719 patients were included from 115 studies. Of these, 4290 (55.6%) were female, and the mean (range) age was 9.2 (5.4-16.1) years. Compared with pill placebo, selective serotonin reuptake inhibitors (SSRIs) significantly reduced primary anxiety symptoms and increased remission (relative risk, 2.04; 95% CI, 1.37-3.04) and response (relative risk, 1.96; 95% CI, 1.60-2.40). Serotonin-norepinephrine reuptake inhibitors (SNRIs) significantly reduced clinician-reported primary anxiety symptoms. Benzodiazepines and tricyclics were not found to significantly reduce anxiety symptoms. When CBT was compared with wait-listing/no treatment, CBT significantly improved primary anxiety symptoms, remission, and response. Cognitive behavioral therapy reduced primary anxiety symptoms more than fluoxetine and improved remission more than sertraline. The combination of sertraline and CBT significantly reduced clinician-reported primary anxiety symptoms and response more than either treatment alone. Head-to-head comparisons were sparse, and network meta-analysis estimates were imprecise. Adverse events were common with medications but not with CBT and were not severe. Studies were too small or too short to assess suicidality with SSRIs or SNRIs. One trial showed a statistically nonsignificant increase in suicidal ideation with venlafaxine. Cognitive behavioral therapy was associated with fewer dropouts than pill placebo or medications.

Conclusions and Relevance

Evidence supports the effectiveness of CBT and SSRIs for reducing childhood anxiety symptoms. Serotonin-norepinephrine reuptake inhibitors also appear to be effective based on less consistent evidence. Head-to-head comparisons between various medications and comparisons with CBT represent a need for research in the field.

Generic versus disorder specific cognitive behavior therapy for social anxiety disorder in youth: A randomized controlled trial using internet delivery

The study examined whether the efficacy of cognitive behavioral treatment for Social Anxiety Disorder for children and adolescents is increased if intervention addresses specific cognitive and behavioral factors linked to the development and maintenance of SAD in young people, over and above the traditional generic CBT approach. Participants were 125 youth, aged 8-17 years, with a primary diagnosis of SAD, who were randomly assigned to generic CBT (CBT-GEN), social anxiety specific CBT (CBT-SAD) or a wait list control (WLC). Intervention was delivered using a therapist-supported online program. After 12-weeks, participants who received treatment (CBT-SAD or CBT-GEN) showed significantly greater reduction in social anxiety and post-event processing, and greater improvement in global functioning than the WLC but there was no significant difference between CBT-SAD and CBT-GEN on any outcome variable at 12-weeks or 6-month follow-up. Despite significant reductions in anxiety, the majority in both treatment conditions continued to meet diagnostic criteria for SAD at 6-month follow-up. Decreases in social anxiety were associated with decreases in post-event processing. Future research should continue to investigate disorder-specific interventions for SAD in young people, drawing on evidence regarding causal or maintaining factors, in order to enhance treatment outcomes for this debilitating condition.

The Effect of Sertraline on the Quality of Life for Children and Adolescents with Anxiety Disorder

INTRODUCTION

In this study, we aimed to determine the changes in quality of life of children/adolescents with anxiety disorders during six months of sertraline treatment, to investigate parent-child/adolescent concordance in perception of quality of life and to examine the effect of treatment on children/adolescents.

METHODS

In this study, 30 patients with anxiety disorders according to criteria specified in Diagnostic and Statistical Manual of Mental Disorders, 4^th. Edition (DSM-IV) were assigned to sertraline treatment. The patients were evaluated using the Pediatric Quality of Life Inventory (PedsQL), State-Trait Anxiety Inventory for Children, Clinical Global Impression Scale (CGI) and the Children's Global Assessment Scale (CGAS) at 0th, 2^nd and 6^th months.

RESULTS

PedsQL total scores increased significantly with the treatment in children and adolescents (p<.001), however, no differences were observed in parent proxy report (p=.326). The mean CGAS score was 59.85±7.73 at the beginning of treatment and 73.70±7.01 at the end of treatment (p<.001). The average CGI score decreased from 4.68±.96 to 2.27±.84.

CONCLUSION

It was observed that perception of quality of life in children and adolescents with anxiety disorders increased with the treatment.

Clinical evaluation of the efficacy and safety of tandospirone versus sertraline monotherapy for social anxiety disorder: a randomized open-label trial

OBJECTIVE

Although selective serotonin reuptake inhibitors are now established as first-line pharmacotherapy for social anxiety disorder (SAD), other agents with different mechanisms have shown promise in treating SAD. The aim of this study was to examine the efficacy and safety of tandospirone in treating adolescents with SAD.

METHODS

Adolescent patients meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for SAD were randomly assigned (1:1) to open-label treatment with either tandospirone or sertraline for 8 weeks. The primary outcome measures were changes from baseline in the Hamilton Anxiety (HAM-A) scale and response using the Clinical Global Impression of Improvement (CGI-I) scale.

RESULTS

The adjusted mean change in HAM-A scores from baseline was indicating a significant improvement over baseline in both treatment arms (p < 0.0001). The mean CGI-I scale score at week was with no significant difference between the two arms (p = 0.42). Rates of response were 48.6% for tandospirone and 55.6% for sertraline using the CGI-I. Response rates were 37.1% for tandospirone and 41.7% for sertraline using a HAM-A response criterion (≥50% reduction). The adjusted mean change in Social Phobia Inventory scores from baseline was indicating a significant improvement over baseline in both treatment arms (p < 0.0001).

CONCLUSIONS

Tandospirone is safe and effective and appears non-inferior to sertraline for SAD in youths.

Evaluation of the pharmacokinetics, safety and clinical efficacy of sertraline used to treat social anxiety

INTRODUCTION

Social anxiety disorder (SAD) is an emerging, often invalidating, syndrome with deep personal, social and psychological implications. While multiple treatment strategies exist, presently none of them can be considered superior to all others.

AREAS COVERED

The aim of this review is to provide the latest information on sertraline (SRT), one of the most important selective serotonin reuptake inhibitors (SSRIs) currently used for the pharmacological therapy of SAD. A literature search was carried out with the keywords 'sertraline', 'social anxiety', 'social phobia' and 'clinical trials'. In this process, particular attention is paid to the pharmacokinetic characteristics of the drug and its safety in clinical use.

EXPERT OPINION

SRT is an effective drug in the treatment of SAD, especially when used in combination with some form of psychological support. While it does not seem to be significantly more effective than other SSRIs, SRT could offer some peculiar advantages: for example, it has a long half-life, allowing a single daily administration, and seems to be particularly indicated for the control of specific symptoms of SAD.

Psychopharmacologic treatment for pediatric anxiety disorders

Anxiety is an innate emotion that all humans experience, especially during early childhood in periods of significant growth and development. Treatment strategies exist for anxiety disorders that cause significant dysfunction and impairment in youth. This article provides a current overview of the literature on psychopharmacologic management of pediatric anxiety disorders. Potential side effects and complications of psychotropic medications are reviewed. The treatment of anxiety disorders in patients with comorbid conditions is explored, addressing the impact on treatment course and pharmacologic recommendations. A clinical vignette describing a 10-year-old boy with increasing anxiety is presented describing in-hospital and outpatient treatment and therapies.

Outpatient treatment of children and adolescents with antidepressants in Croatia

OBJECTIVE

This study is aimed to determine the prevalence and patterns of antidepressants prescription in outpatient setting in Croatia.

METHODS

Retrospective analysis of outpatient visits to child psychiatrists by persons aged 18 and younger that included prescription of antidepressants during the year 2010. Antidepressant prescription data were identified by medication class, drug entity and were analyzed in relation to age group, gender, psychiatric diagnosis.

RESULTS

Antidepressants were prescribed to 139 youths (0.24‰), significantly more to adolescents than pre-adolescents and for the treatment of depressive disorders in females, and mixed disorders of emotions and conduct in males. Sertraline was the most prescribed antidepressant for the treatment of major depressive disorder, followed by fluvoxamine and tianeptine. Fluvoxamine was the most prescribed antidepressant for the treatment of anxiety disorders and mixed disorders of emotions and conduct. Off-label prescribing of antidepressants was found in 85.6% of young patients.

CONCLUSIONS

This study found considerably lower prevalence and higher off-label rate of antidepressant prescriptions to young people in Croatia to that in other European Countries and in the United States. Selective serotonine reuptake inhibitors comprise most of the antidepressant medications prescribed to young people, reflecting trends in the developed countries.

Psychopharmacologic treatment of children and adolescents with anxiety disorders

Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.

A randomized controlled trial of sertraline to prevent posttraumatic stress disorder in burned children

BACKGROUND

This study evaluated the potential benefits of a centrally acting selective serotonin reuptake inhibitor, sertraline, versus placebo for prevention of symptoms of posttraumatic stress disorder (PTSD) and depression in burned children. This is the first controlled investigation based on our review of the early use of a medication to prevent PTSD in children.

METHODS

Twenty-six children aged 6-20 were assessed in a 24-week double-blind placebo-controlled design. Each child received either flexibly dosed sertraline between 25-150 mg/day or placebo. At each reassessment, information was collected in compliance with the study medication, parental assessment of the child's symptomatology and functioning, and the child's self-report of symptomatology. The protocol was approved by the Human Studies Committees of Massachusetts General Hospital and Shriners Hospitals for Children.

RESULTS

The final sample was 17 subjects who received sertraline versus 9 placebo control subjects matched for age, severity of injury, and type of hospitalization. There was no significant difference in change from baseline with child-reported symptoms; however, the sertraline group demonstrated a greater decrease in parent-reported symptoms over 8 weeks (-4.1 vs. -0.5, p=0.005), over 12 weeks (-4.4 vs. -1.2, p=.008), and over 24 weeks (-4.0 vs. -0.2, p=0.017).

CONCLUSIONS

Sertraline was a safe drug, and it was somewhat more effective in preventing PTSD symptoms than placebo according to parent report but not child report. Based on this study, sertraline may prevent the emergence of PTSD symptoms in children.

Diretrizes da Associação Médica Brasileira para o tratamento do transtorno de ansiedade social

INTRODUÇÃO: O transtorno de ansiedade social (TAS) é o transtorno de ansiedade mais comum, freqüentemente sem remissões, sendo comumente associado com importante prejuízo funcional e psicossocial. A Associação Médica Brasileira (AMB), através do "Projeto Diretrizes", busca desenvolver consensos de diagnóstico e tratamento para as doenças mais comuns. O objetivo deste trabalho é apresentar os achados mais relevantes das diretrizes relativas ao tratamento do TAS, servindo de referência para o médico generalista e especialista. MÉTODO: O método utilizado foi o proposto pela AMB. A busca foi realizada nas bases de dados do MEDLINE (PubMed), Scopus, Web of Science e Lilacs, entre 1980 e 2010. A estratégia utilizada baseou-se em perguntas estruturadas na forma P.I.C.O (acrônimo das iniciais "paciente ou população"; "intervenção, indicador ou exposição"; "controle ou comparação" e; "outcome ou desfecho"). RESULTADOS: Estudos evidenciam que o tratamento farmacológico de primeira linha para adultos e crianças são os inibidores seletivos de recaptação de serotonina e os inibidores de recaptação de serotonina e noradrenalina, enquanto que a terapia cognitivo-comportamental é apontada como melhor tratamento psicoterápico. Além disso, algumas comorbidades psiquiátricas foram associadas a uma pior evolução do TAS. CONCLUSÕES: Apesar da alta prevalência, o TAS acaba por não receber a devida atenção e tratamento. A melhor escolha para o tratamento de adultos é a associação psicoterapia cognitivo-comportamental com inibidores seletivos de recaptação de serotonina e os inibidores de recaptação de serotonina e noradrenalina. Outras opções como benzodiazepínicos ou inibidores da monoamino-oxidase devem ser usados como segunda e terceira opção respectivamente.

Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods

OBJECTIVE

To present the design, methods, and rationale of the Child/Adolescent Anxiety Multimodal Study (CAMS), a recently completed federally-funded, multi-site, randomized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy (CBT), sertraline (SRT), and their combination (COMB) against pill placebo (PBO) for the treatment of separation anxiety disorder (SAD), generalized anxiety disorder (GAD) and social phobia (SoP) in children and adolescents.

METHODS

Following a brief review of the acute outcomes of the CAMS trial, as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders, the design and methods of the CAMS trial are described.

RESULTS

CAMS was a six-year, six-site, randomized controlled trial. Four hundred eighty-eight (N = 488) children and adolescents (ages 7-17 years) with DSM-IV-TR diagnoses of SAD, GAD, or SoP were randomly assigned to one of four treatment conditions: CBT, SRT, COMB, or PBO. Assessments of anxiety symptoms, safety, and functional outcomes, as well as putative mediators and moderators of treatment response were completed in a multi-measure, multi-informant fashion. Manual-based therapies, trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity. A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial, study protocols and quality assurance.

CONCLUSIONS

CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls. CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidenced-based psychosocial (CBT) and pharmacologic (SSRI) treatments to date for the most commonly occurring pediatric anxiety disorders. Primary and secondary results of CAMS will hold important implications for informing practice-relevant decisions regarding the initial treatment of youth with anxiety disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00052078.

Effectiveness and tolerability of citalopram for the treatment of depression and anxiety disorders in children and adolescents: an open-label study

To assess the effectiveness and tolerability of citalopram for the acute treatment of children and adolescents suffering from depression and/or anxiety disorders. As much as 78 outpatients, aged 7-18 years with a diagnosis of depressive and/or anxiety disorder, completed an 8-week open trial with citalopram (20-40 mg/day). Outcome, side effects and suicidality were assessed weekly to bi-weekly using appropriate rating scales. At endpoint 56% of subjects were found to be responders (Clinical Global Impression-Improvement [CGI-I] Scale <or= 2). Subjects with less severe psychopathology and subjects with anxiety disorders showed a more favorable response. As much as 43% of depressed and 51% of anxious subjects had a 50% or greater reduction in scores on our secondary outcome measures, Children's Depression Rating Scale-Revised (CDRS-R) and Screen for Child Anxiety Related Emotional Disorders (SCARED). Most reported adverse events were mild to moderate and did not affect medication adherence. No increase in suicidality was observed during the study. Citalopram was moderately effective, generally well tolerated and safe for the acute treatment of depressed and anxious children and adolescents.

Pediatric generalized anxiety disorder: epidemiology, diagnosis, and management

Pediatric generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about a variety of events and is accompanied by physical symptoms such as headaches, tension, restlessness, gastrointestinal distress, and heart palpitations. Symptoms impose marked distress and interfere with social, emotional, and educational functioning. GAD occurs in over 10% of children and adolescents, has an average age of onset of 8.5 years, and is more often reported in girls. Common co-occurring conditions include separation anxiety disorder and social phobia. Assessment involves a multi-informant, multi-method approach involving the child, parents, and school teachers. A clinical interview should be conducted to assess for the three primary ways anxiety presents: behaviors, thoughts, and somatic symptoms. Several semi-structured diagnostic interviews are available, and the Anxiety Disorders Interview Schedule is increasingly used. Rating scales completed by the patient, caregivers, and teachers provide useful information for diagnosis and symptom monitoring. Several scales are available to assess patients for the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) GAD diagnosis; however, instruments generally cannot distinguish children with GAD from children with similar anxiety disorders. Both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) have demonstrated efficacy for the treatment of pediatric anxiety disorders including GAD. Evidence suggests that the combination of CBT plus sertraline offers additional benefit compared with either treatment alone. With pharmacotherapy, systematic tracking of treatment-emergent adverse events such as headaches, stomach aches, behavioral activation, worsening symptoms, and emerging suicidal thoughts is important. Recommended starting doses are fluvoxamine 25 mg/day, fluoxetine 10 mg/day, and sertraline 25 mg/day, though lower starting doses are possible. Dosing can be adjusted as often as weekly with the goal of achieving a high-quality response, while minimizing side effects. Long-term treatment with medication has not been well studied; however, to achieve optimal long-term outcome extended use of medication may be required. It is recommended to continue medication for approximately 1 year following remission in symptoms, and when discontinuing medication to choose a stress-free time of the year. If symptoms return, medication re-initiation should be considered seriously.

Pharmacotherapy of social anxiety disorder

A range of medications have been shown effective for the treatment of social anxiety disorder. The largest trials to date have been with various selective serotonin reuptake inhibitors (SSRIs). Several of these agents have been registered for the treatment of social anxiety disorder with agencies such as the FDA or EMEA, meta-analyses confirm their efficacy and safety, and expert consensus guidelines have often recommended them as a first-line pharmacotherapy of choice. Despite such advances, there are many unanswered questions in the pharmacotherapy of social anxiety disorder, including the optimal pharmacotherapy of patients refractory to first-line intervention, and the optimal sequencing of pharmacotherapy and psychotherapy. Translational research has already had an impact on concepts of treatment, and may ultimately lead to novel interventions.

Depression and anxiety in children and adolescents with epilepsy: prevalence, risk factors, and treatment

Among the psychiatric comorbid conditions in children and adolescents with epilepsy, depression and anxiety disorders require further attention because they carry the risk of reduced quality of life and life-threatening complications (e.g., suicide). Research in recent years has shed light on both the prevalence of emotional problems in youth with epilepsy and the safety and efficacy of treatment options. A number of challenges exist in treating patients with epilepsy. This is particularly true when seizures are difficult to control and medication regimens are more complex. Some pharmaceutical options may provide assistance with both seizures and emotional distress, but care is needed when considering such treatment approaches. In addition, integration of mental health professionals into the care of patients is necessary when cases are complicated and risk factors are high. Thorough methods to accurately diagnose emotional conditions and regular monitoring of symptoms can help prevent serious problems that can negatively affect the success of children and adolescents in everyday life. Collaboration between disciplines offers the best hope for early identification and treatment of these conditions.

Efficacy of cognitive-behavioral and pharmacological treatments for children with social anxiety

Childhood social anxiety is associated with significant social and academic impairment. The purpose of this study was to compare and contrast the efficacy of two major treatments for social anxiety disorders in children: cognitive-behavioral therapy and selective serotonin reuptake inhibitor (SSRI) drug treatment. Treatment studies in the literature were evaluated using meta-analytic techniques to compare pre- and post-treatment measures of social anxiety symptoms, general anxiousness, social competency, and impairment. Results indicate that the core symptoms of social anxiety and impairment were reduced by both cognitive-behavioral treatment (ES=0.86 and 1.56) and SSRI treatment (ES=1.30 and 2.29), respectively. Similarly, peripheral symptoms of general anxiousness were reduced by both cognitive-behavioral treatment (ES=0.75) and SSRI treatment (ES=1.29). Finally, both cognitive-behavioral (ES=0.68) and SSRI treatment (ES=0.68) resulted in moderate improvements in social competence. Implications and the limitations of these meta-analytic findings are discussed with respect to the evidence-based intervention movement.

Prospective open-label pilot trial of mirtazapine in children and adolescents with social phobia

Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.

SET-C versus fluoxetine in the treatment of childhood social phobia

OBJECTIVE

To determine the efficacy of fluoxetine, pill placebo, and Social Effectiveness Therapy for Children (SET-C) for children and adolescents with social phobia.

METHOD

Youths ages 7 to 17 were randomly assigned to one of the treatment conditions. Outcome was evaluated using self-reports, parent ratings, independent evaluator ratings, and behavioral assessment.

RESULTS

Both fluoxetine and SET-C were more efficacious than placebo in reducing social distress and behavioral avoidance and increasing general functioning. SET-C was superior to fluoxetine on each of these measures and was the only treatment superior to placebo in terms of improving social skills, decreasing anxiety in specific social interactions, and enhancing ratings of social competence. Furthermore, whereas fluoxetine appears to exert maximum effect by 8 weeks, SET-C provides continued improvement through week 12.

CONCLUSIONS

Both fluoxetine and SET-C are efficacious for social phobia, although SET-C appears to provide added benefit by enhancing social skills.

An open-label trial of escitalopram in children and adolescents with social anxiety disorder

Social anxiety disorder (SAD) is a highly prevalent and disabling disorder in children and adolescents. This study was designed to evaluate the efficacy and safety of a highly potent and selective serotonin reuptake inhibitor, escitalopram, in the treatment of SAD in children and adolescents. Twenty outpatients with a primary diagnosis of SAD were treated in a 12-week open trial with escitalopram. The primary outcome variable was the change from baseline to end point in Clinical Global Impression-Improvement scale (CGI-I). Secondary efficacy measures included the CGI-Severity scale (CGI-S), the Social Phobia and Anxiety Inventory for Children (SPAI-C), the Screen for Child and Anxiety Related Emotional Disorders (SCARED)-Child and Parent version, and The Youth Quality of Life Instrument-Research Version (Y-QOL-R). On the CGI-I scale, 13 of 20 patients (65%) had a score < or =2, meaning response to treatment. All symptomatic and quality of life measures showed improvements from baseline to week 12, with large effect sizes ranging from 0.9 to 1.9 (all p < 0.001). Escitalopram was generally well-tolerated. These results suggest that escitalopram may be an effective and safe treatment for pediatric SAD. Future double-blind, placebo-controlled, randomized clinical trials are warranted.

A Randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder

BACKGROUND

Social anxiety disorder, which occurs in 2% to 5% of children and adolescents, is associated with significant distress and functional impairment.

METHODS

The objective of the randomized, masked controlled trial conducted in 48 academic and community centers in the United States was to evaluate the efficacy of venlafaxine ER in children and adolescents with generalized social anxiety disorder. A volunteer sample of 293 outpatients, age 8 to 17, who met diagnostic criteria for social anxiety disorder and were enrolled between February 2000 and March 2003 participated. Venlafaxine ER or placebo was titrated from a starting dose of 37.5 mg to a maximum dose of 225 mg over 16 weeks. The primary dependent measures were the Social Anxiety Scale, child or adolescent version (SAS-CA) and for responder analysis, a (dichotomized) Clinical Global Impressions-Improvement (CGI-I) score.

RESULTS

Compared with placebo, intent-to-treat random regression analyses indicated a statistically significant advantage for venlafaxine ER (p = .001) on the SAS-CA. On the CGI-I responder analysis, 56% (95% confidence interval [CI], 47%-64%) of venlafaxine ER treated subjects responded, which was statistically superior to placebo (37% [95% CI, 29%-45%]). Three venlafaxine ER and no placebo patients developed treatment-emergent suicidality; there were no completed suicides.

CONCLUSIONS

Venlafaxine ER is an effective and reasonably well-tolerated treatment for generalized social anxiety disorder in children and adolescents. As with other antidepressants, careful clinical monitoring for adverse events, including treatment-emergent suicidality, is essential.

Social anxiety disorder in children and adolescents: epidemiology, diagnosis, and treatment

Social anxiety disorder (SOC) is characterized by marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny. The person fears that she or he might act in a way that will be humiliating or embarrassing. Children and adolescents with this disorder often have great impairment in their academic performance, social skills, peer relationships, and family life. Early diagnosis is vital. Primary care providers are in a unique situation to first diagnose and treat SOC in children and adolescents. There is evidence of successful pharmacologic and psychosocial treatment in pediatric SOC. Serotonin reuptake inhibitors, which are considered first-line medications for SOC, have shown promising results in open-label and double-blind trials. Studies have demonstrated that psychosocial treatments, specifically cognitive-behavioral therapy and group therapy, are efficacious in pediatric SOC. There is some evidence that the use of combination therapy, both pharmacology and psychosocial treatment, is beneficial in the management of pediatric SOC.

The pharmacological management of childhood anxiety disorders: a review

RATIONALE

Pediatric anxiety is a prevalent psychiatric disorder that may have important implications for school, social, and academic function. Psychopharmacological approaches to the treatment of pediatric anxiety have expanded over the past 20 years and increasing empirical evidence helps guide current clinical practice.

OBJECTIVE

To review studies which examine the pharmacological treatment of pediatric anxiety disorders, including obsessive-compulsive disorder and to summarize treatment implications.

METHODS

All relevant studies were searched using MEDLINE and PsycINFO search engines, supplemented by a manual bibliographical search; studies published between 1985 and 2006 that met inclusion criteria were examined.

RESULTS

This article provides a systematic review of the psychopharmacological treatment of pediatric anxiety disorders based on available empirical evidence, with a focus on randomized controlled trials. General treatment principles and pharmacological management of specific pediatric anxiety disorders are also reviewed.

CONCLUSION

There is good evidence to support the efficacy of several pharmacological agents including the selective serotonin reuptake inhibitors to treat pediatric anxiety and obsessive-compulsive disorder, although there are still many unanswered questions.

The Social Phobia Inventory: Validity and reliability in an adolescent community sample

Social anxiety disorder and social anxiety are highly prevalent psychological conditions in youth. Because of the known risks associated with the spectrum of social anxiety in youth, early detection with valid and reliable assessment measures is imperative. Self-report measures have become the most widely used method of assessment for child and adolescent social anxiety. Because research to date on self-report measures of social anxiety disorder in adolescents is limited, the primary objective of the present study was to contribute to the literature by examining the validity and reliability of a new self-report measure, the Social Phobia Inventory (SPIN), in a community sample of adolescents. The SPIN is a 17-item measure purported to assess the full spectrum of social anxiety disorder symptomatology. Previously, psychometric research on the SPIN in adult populations has demonstrated its validity and reliability. In the current psychometric examination, results revealed strong support for the temporal stability, internal consistency, and construct validity of the SPIN, suggesting it is an appropriate screening measure for the assessment of social anxiety disorder in adolescents.

Selective serotonin reuptake inhibitor use in the treatment of the pediatric non-obsessive-compulsive disorder anxiety disorders

The non-OCD (obsessive-compulsive disorder) anxiety disorders in the pediatric population- separation anxiety disorder, generalized anxiety disorder, and social phobia and others- are arguably the most common psychiatric disorders in this age group. Anxiety disorders, in addition to being common, also significantly impair the affected child at home, school, and with peers. A small developing evidence base suggests the selective serotonin reuptake inhibitors (SSRIs) are the pharmacological treatment of choice for pediatric non-OCD anxiety disorders. In clinical trials, SSRIs are often very effective in reducing symptoms and improving functioning and generally well tolerated. The U.S. Food and Drug Administration's (FDA) review of the safety of antidepressants in the pediatric population suggest a small, but significant, increased relative risk for suicidality adverse events on antidepressant versus placebo. Despite the apparent increased risk, the larger magnitude of benefit of the SSRIs for pediatric non-OCD anxiety disorders compared to depression suggests the benefit/risk ratio for anxiety disorders is more favorable than that for depression. This paper will review available studies on the treatment of non-OCD childhood anxiety disorders with antidepressants, including the SSRIs, and discuss pertinent safety issues.

Treatment benefit and the risk of suicidality in multicenter, randomized, controlled trials of sertraline in children and adolescents

OBJECTIVE

The aim of this study was to examine the balance between the benefits of treatment and the risk of suicidality in children and adolescents in multicenter, randomized, controlled trials of sertraline versus placebo.

METHOD

The published literature was searched for multicenter, randomized, placebo-controlled trials of sertraline for pediatric mental disorders. Four trials were identified: Two (pooled) in pediatric major depressive disorder (MDD; Wagner 2003) and two in obsessive-compulsive disorder (OCD; March et al. 1998; POTS Team 2004). Using intent-to-treat (ITT) analysis populations, the authors calculated the number needed to treat (NNT) for response and remission and the number needed to harm (NNH) for suicidality, and their ratio, for each clinical trial.

RESULTS

NNTs ranged from 2 to 10, indicating clinically meaningful benefits. Benefit was greater for OCD than for MDD, and for adolescents as compared with children in MDD. No age effect was apparent for OCD. Suicidality was reported in 8 patients (5 assigned to sertraline and 3 assigned to placebo). All but 1 (a placebo-treated patient in the Pfizer OCD trial) were enrolled in the sertraline MDD trial. The NNH for suicidality in MDD was 64. Treatment emergent suicidality was more common in children (NNH 28.7) than in adolescents (NNH 706.3). Because no patient developed suicidality in sertraline-treated OCD patients, the NNH for sertraline in OCD approaches infinity.

CONCLUSIONS

With the stipulation that doctor and patient preferences necessarily play a critical role in the choice of treatment, NNT to NNH ratios indicate a positive benefit-to-risk ratio for sertraline in adolescents with MDD and in patients of all ages with OCD.

Psychopharmacology interventions for pediatric anxiety disorders: a research update

Pediatric anxiety disorders are commonly occurring mental health disorders of childhood and are associated with significant distress, impairment, and risk for ongoing morbidity. During the past decade, significant progress has been made in developing safe and effective therapeutic approaches to these disorders. This article focuses on the scientific literature supporting the use of a variety of medication approaches to the treatment of the various anxiety disorders of childhood and adolescence.

Childhood social anxiety disorder: from understanding to treatment

Childhood social anxiety disorder is a condition of complex origins. Longitudinal studies of shyness and behavioral inhibition, and twin and family history studies, support a genetic component, but experiences such as family environment, parenting, and traumatic conditioning also are observed. Many children with significant shyness and behavioral inhibition do not develop social anxiety disorder, reinforcing the need for longitudinal studies exploring resiliency and risk factors that can be incorporated into diathesis stress models. Efficacy data regarding cognitive and behavioral therapies and pharmacotherapy are promising, and their effectiveness awaits further research. These studies will need to incorporate a multiplicity of perspectives to ensure the long-term sustainability of interventions for social anxiety disorder in children and adolescents.

Emerging treatments for child and adolescent social phobia: a review

Social anxiety disorder, or social phobia (SP), is an anxiety disorder characterized by excessive fear of exposure to situations that involve potential scrutiny by others. SP is a common psychiatric problem in children and adolescents, often presenting with comorbid anxiety and mood disorders. Although the onset of SP is typically in late childhood or early adolescence, most afflicted individuals go undiagnosed for years, not seeking treatment until adulthood. First-line treatments for SP in adults support the use of pharmacotherapy and cognitive behavioral therapy. There is new and emerging data in youths with SP to support the use of similar treatments. This paper will review the clinical characteristics, epidemiology, and treatment of SP in youths. Current investigations using selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors, benzodiazepines, and monoamine oxidase inhibitors in youths will be reviewed. Several studies on the use of cognitive behavioral therapy in youths will also be examined. Practical guidelines for clinicians who treat children and adolescents are also presented.

The Kutcher Generalized Social Anxiety Disorder Scale for Adolescents: assessment of its evaluative properties over the course of a 16-week pediatric psychopharmacotherapy trial

OBJECTIVE

This study investigated the psychometric properties of a new clinician-rated scale designed to assess the severity of social phobia and measure treatment outcome in adolescents: the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A).

METHODS

Two hundred fifty-one (251) adolescents (11-17 years; mean age 14.2 years) with DSM-IV social phobia enrolled in a multicenter, 16-week, double-blind, placebo-controlled study of paroxetine. Efficacy assessments were conducted at baseline and at weeks 4, 8, 12, and 16 with the K-GSADS-A, three other clinician-rated scales (including the Clinical Global Impression of Severity scale), and a self-rated social phobia scale. Additionally, the Clinical Global Impression of Improvement scale was administered at each postbaseline assessment, and the Children's Depression Rating Scale-Revised was administered at baseline and at week 16. These data were used to assess the internal consistency, convergent and divergent validity, and sensitivity to change of the K-GSADS-A.

RESULTS

The internal consistency of the K-GSADS-A was adequate, and supportive evidence was obtained for its convergent validity with other severity measures, and its divergent validity with respect to depression. The K-GSADS-A also demonstrated good sensitivity to changes in severity.

CONCLUSIONS

These results suggest that the K-GSADS-A is a valid measure of treatment outcome in adolescents with DSM-IV social phobia.

Selective serotonin reuptake inhibitor-induced sexual dysfunction in adolescents: a review

OBJECTIVE

To review the existing literature on selective serotonin reuptake inhibitor (SSRI)-induced sexual dysfunction in adolescents.

METHOD

A literature review of SSRI-induced adverse effects in adolescents focusing on sexual dysfunction was done. Nonsexual SSRI-induced adverse effects were compared in adult and pediatric populations. Information regarding SSRI-induced sexual dysfunction was extracted from pediatric SSRI clinical trials, clinical reviews, treatment guidelines, case reports, and MedWatch reports.

RESULTS

Although the incidences of nonsexual SSRI-induced adverse effects seemed to be similar for both adult and pediatric populations, only one male of 1,346 pediatric subjects receiving an SSRI reported sexual dysfunction. Approximately one third of the clinical reviews and treatment guidelines reviewed raised some concern about SSRI-induced sexual dysfunction. In 11 years, only eight MedWatch reports regarding SSRI-induced sexual dysfunction in adolescents have been filed. Only one letter to the editor describing impaired sexual functioning in three of five adolescents on SSRIs could be found.

CONCLUSIONS

Information on SSRI-induced sexual dysfunction in adolescents is lacking. Researchers and clinicians may be failing to ask adolescents about sex and sexual functioning in the context of SSRI treatment.

Pharmacotherapy of social phobia

OBJECTIVE

To review placebo-controlled medication trials in social phobia (SP).

METHOD

Published and/or presented placebo-controlled trials of medication were reviewed and summarized.

RESULTS

Phenelzine is effective in 60-70% of patients with SP and always superior to placebo. Although reversible inhibitors of monoamine oxidase type A (RIMAs) are safer, their benefits are unpredictable. SSRIs, fluvoxamine, paroxetine and sertraline are superior to placebo in generalized SP. Gabergic drugs are useful, e.g. clonazepam, gabapentin and pregabalin. Promising effects have been found with venlafaxine, a serotonin-norepinephrine reuptake inhibitor, and the results of larger studies should be forthcoming in the next 2 years. Drugs such as buspirone, tricyclics and beta-blockers are either ineffective or have limited use. SP is a chronic disorder, and early termination of successful pharmacotherapy is associated with a greater likelihood of relapse. Studies with paroxetine, clonazepam, sertraline and brofaromine show that continued treatment is associated with better maintenance of response. Special populations that require further study include children, those with comorbid Axis I disorders and the population with discrete (non-generalized) SP.

CONCLUSION

MAOI and SSRI are most uniformly effective in treating SP. Clonazepam and gabapentin may also be useful. Other drugs are of more limited value. Long-term treatment is recommended to reduce rates of relapse.

Diagnosis and measurement of anxiety disorder in adolescents: a review of commonly used instruments

As part of a comprehensive review of clinical research tools used in adolescent psychiatric disorders, a survey of 200 recent studies of adolescent anxiety (publication dates of December 1994 to May 2001) identified 70 different diagnostic and symptom measurement instruments. The design features and psychometric properties of the 15 most commonly used instruments were reviewed, and their strengths and weaknesses were evaluated. The conclusions arising from this review are: (1) too many different instruments are being used by investigators; (2) more than 20% of studies did not report the use of developmentally appropriate (i.e., child/adolescent-specific) diagnostic instruments; (3) another 15% of these studies relied on diagnostic instruments that demonstrate substantial weaknesses in reliability and validity; (4) the concordance between anxiety disorder diagnoses from different interview schedules is unknown; (5) the relative validity of diagnoses and ratings of anxiety severity based on information yielded by parents versus information yielded by adolescents is unclear; (6) clinician-rated symptom severity scales specific to anxiety disorder are rarely utilized; (7) the most commonly used self-report measures discriminate poorly between anxiety and depression, and their items are not indexed to specific anxiety disorders; and (8) some newer self-report anxiety instruments discriminate well between anxiety and depression and have diagnostic validity for specific anxiety disorders.

Parental opinions regarding treatment for social anxiety disorder in youth

This study surveyed parents' opinions about treatment for childhood social anxiety disorder and assessed variables that may affect treatment acceptability. A 20-item survey assessing treatment attitudes and a semistructured interview were administered to 190 parents of children (8-17 years) who were randomly selected from a pediatric primary care setting. An exploratory factor analysis of the treatment attitudes survey yielded four factors: medication acceptability, counseling acceptability, counseling feasibility, and general beliefs about social anxiety treatment. Findings revealed that parents endorsed favorable attitudes toward counseling and somewhat neutral beliefs about medication. White parents were more accepting of medication and counseling and also perceived counseling as more feasible than nonwhite parents. Treatment acceptance was associated with past mental health utilization but not with severity of social anxiety. Further research is necessary to determine if clinical interventions for child anxiety disorders may be more efficacious if parents' attitudes and beliefs about prescribed treatments are addressed.

Pharmacologic management of anxiety disorders in children and adolescents

PURPOSE OF REVIEW

Anxiety disorders constitute a significant problem among children and adolescents, with estimated prevalence of 6 to 10%. Left untreated, anxiety disorders can have major effect on academic, social, and family function, as well as impact on developmental progress. Effective treatment of childhood anxiety disorders with medications may help reduce morbidity and improve functioning and stress management.

RECENT FINDINGS

There are many reviews, but few studies, that examine the effect of psychotropic medication on anxiety disorders in children and adolescents. Most of our understanding comes from extrapolation from literature on adult medication trials. Available data indicate relative effectiveness of serotonin selective reuptake inhibitors in many childhood anxiety disorders, along with minimal side effects and good tolerability. Many other psychotropic medications have been considered and used to manage anxiety, with little data to support in children.

SUMMARY

The serotonin selective reuptake inhibitors are considered a first-line pharmacological treatment for anxiety disorders in children and adolescents. Numerous other psychotropic medications may be considered, alone or in combination. Definitive research is lacking; further research studies are sorely needed to help guide clinical decision making. Because there are few studies of pharmacologic treatment of anxiety in children and adolescents, this article will consider the most current literature and provide an overall summary of the topic.

Childhood anxiety disorders and developmental issues in anxiety

Anxiety disorders are common disorders in childhood, and developmental differences must be considered when diagnosing and treating patients in this age group. Recent research has illuminated the course of childhood anxiety disorders, including how they can be precursors to continued anxiety and mood problems in adulthood. Recent studies of cognitive-behavioral therapy, the first-line psychosocial treatment for childhood anxiety, have focused on the following issues: the relative efficacy of group versus individual cognitive-behavioral therapy; the role of parent involvement; and the application of specific techniques to certain diagnostic groups (eg, social skills techniques in social phobia). Selective serotonin reuptake inhibitors have been associated with high acute response rates in controlled studies of children with anxiety disorders, and more recent evidence suggests they are efficacious and well tolerated when taken for longer periods. This article will review significant diagnostic and developmental issues, and highlight recent studies in psychosocial and pharmacologic therapies of pediatric anxiety disorders.

Fluoxetine for the treatment of childhood anxiety disorders

OBJECTIVE

To assess the efficacy and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder, and/or social phobia.

METHOD

Anxious youths (7-17 years old) who had significant functional impairment were randomized to fluoxetine (20 mg/day) (n = 37) or placebo (n = 37) for 12 weeks.

RESULTS

Fluoxetine was effective in reducing the anxiety symptoms and improving functioning in all measures. Using intent-to-treat analysis, 61% of patients taking fluoxetine and 35% taking placebo showed much to very much improvement. Despite this improvement, a substantial group of patients remained symptomatic. Fluoxetine was well tolerated except for mild and transient headaches and gastrointestinal side effects. Youths with social phobia and generalized anxiety disorder responded better to fluoxetine than placebo, but only social phobia moderated the clinical and functional response. Severity of the anxiety at intake and positive family history for anxiety predicted poorer functioning at the end of the study.

CONCLUSIONS

Fluoxetine is useful and well tolerated for the acute treatment of anxious youths. Investigations regarding the optimization of treatment to obtain full anxiety remission and the length of treatment necessary to prevent recurrences are warranted.

Single-factor repeated-measures designs: analysis and interpretation

In this column we discussed the selection and interpretation of appropriate statistical tests for single-factor within-subjects/ repeated-measures designs and provided an example from the literature. The parametric tests that we discussed were the t test for paired or correlated samples and the single-factor repeated-measures ANOVA. We also mentioned four nonparametric tests to be used in single-factor within-subjects/repeated-measures designs, but they are relatively rare in the literature. The Compton et al. (2001) article did not provide effect size measures, but they could be computed from the means and standard deviations. Remember that a statistically significant t or ANOVA (even ifp < .001) does not mean that there was a large effect, especially if the sample was large. In the Compton example, the sample was quite small (N = 14), and the findings do reflect a large effect size.

Pharmacotherapy of childhood anxiety disorders

Anxiety disorders are among the most common psychiatric disorders of childhood, yet limited data is available regarding the use of psychotropic medications for these conditions. Until recently, much of the data on the pharmacologic treatment of pediatric anxiety disorders has consisted of case reports and small open-label studies, with the exception of pediatric obsessive-compulsive disorder (OCD), which has had a comparatively rich literature consisting of several double blind trials. This void has been lessening, however, with four double blind, placebo-controlled studies published in the past year alone. Although the majority of pharmacologic studies of pediatric anxiety continue to focus on the treatment of OCD, additional reports on treatment of generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder have recently been published. This article will review significant pharmacologic studies published in the prior year, and the role of pharmacotherapy in the treatment of pediatric anxiety disorders.