Read the article and answer the question on the CADTH appraisal tool. No yes/no answers please, answer yes or no and support the answer with 2-3 sentences with evidence from the article with the page number from the article for easy reference.
VERY VERY IMPORTANT. Give a summary of at least 2 strengths and 2 weaknesses of the guideline.
Guide to the Critical Appraisal of
Clinical Practice Guidelines (CPG)
Student Name:
Faculty name:
Reference of CPG:
|
1. WHAT QUESTION ARE YOU TRYING TO ANSWER? |
|
Patients |
|
Intervention |
|
Comparison |
|
Outcome(s) |
2. ARE THE RESULTS OF THE GUIDELINES VALID?
Questions that need asking
What is this, and where do I find this information?
Details from Assigned CPG
Include page number as applicable
Is the group, committee, or organization that developed the guidelines clearly identified?
Yes / No
Can’t tell
This information is usually located either right at the front of the guidelines, or in the back of the document in an appendix. For some guideline groups, this information is located on their website at point of download of the guideline itself.
Did authors declare conflicts of interest among all parties involved in guideline preparation and consensus?
Yes / No
Can’t tell
Conflict of interest is essential to locate within a clinical practice guideline (CPG) to ensure validity. Sometimes the writers of CPGs have financial or expert relationships with pharmaceutical companies or are extensively involved in other research studies that might negatively bias the development of objective CPGs. Conflict of interest should ideally be stated up front within the guideline, but may also be included in a paragraph at the very back of a document.
Is there proof of a systematic literature search and strategic selection of articles for review?
(Was it a SYSTEMATIC PROCESS?)
Yes / No
Can’t tell
All CPGs need to describe the literature review (and the timeline; example 2000-2009) whereby evidence was located. Specific databases where the search occurred should be cited (e.g., Medline, PubMed, Embase, Cochrane). Again, this should be noted within the first few pages of the CPG.
Have evidence ratings or indicators of value been indicated for each guideline?
Yes / No
Can’t tell
CPGs should be developed by consensus. In doing so, there should be a specific scale to rate the quality and strength of evidence and also the consensus result. This might look like “Grade 1a,” which might suggest a highly rated recommendation and a highly rated consensus among the CPG committee. This should be noted
for each and every guideline
within the CPG and be noted throughout the document.
To what extent has expert opinion been identified for particular guidelines – is it extensive?
Yes / No
Can’t tell
Sometimes, background research is just not available to help inform CPGs on particular topics. In these instances, guideline groups or committees sometimes choose to create a statement or guideline that is based solely on expert opinion or experience of experts. While a few statements of this nature are usually accepted within guidelines, a high percentage of statements within a CPG may be inappropriate. Further, clinicians using these guidelines must consider the risks and value of using expert opinion-based guidelines to make clinical decisions.
|
3. WHAT ARE THE RESULTS? |
|
|
Is there a clear message on the clinical importance and practical value for use of these guidelines? |
All CPGs must be written in practical and implementable statements. They must not be vague or generic; they are intended to be actionable and easy to understand without risk of misinterpretation. |
|
Is there discussion of benefits, harm, risks, and cost impacts? |
High-quality CPGs provide specific information within the guidelines about patient-specific benefits, harms/risks, and also cost of implementation of the guidelines in clinical settings. This is essential to note because it informs the prospective user of the CPG of what implementation aspects might warrant further review. |
|
Are these guidelines of recent age? Do the results include reference to currently available treatments or interventions? |
Most clinical practices note changes every 5 years or so. As such, a CPG that is older than this timeframe may not be appropriate, particularly if there is mention of older and less-used medications particular to your clinical practice setting. |
|
4. WILL THE RESULTS HELP ME IN CARING FOR MY PATIENT? |
|
|
Response |
What is this? |
|
Are the guidelines presented in a user-friendly and easy-to-follow format? |
Guidelines that are difficult to understand or hard to follow can be prone to misinterpretation. There is also greater likelihood that the CPG will not be embraced and used consistently in clinical settings if it is hard to interpret. |
|
Do the guidelines offer next steps for practical implementation; recognition of implementation barriers? |
Most good CPGs include suggestions for next steps including a standardized documentation, standing-orders form, or audit assessment sheet, for example. This may also include a sample patient or family education pamphlet, posters for health care professionals, electronic flags for charts, or other resources. It is a good sign that some suggestions and tools are provided for implementation by guideline developers. |
|
Is there discussion of clinical flexibility for application in multiple or diverse clinical settings? |
Remember that CPGs created exclusively for implementation in large tertiary facilities may not be directly applicable in smaller or community-based health care settings. A strong CPG should identify some general recommendations of special implementation for different settings. As an example, a CPG intended for use in hospitals may not necessarily be effective for implementation in rural clinic settings. |
Overall Appraisal: In one succinct paragraph, give a narrative overall appraisal that includes a summary of the strengths and weaknesses of the guideline, as well as its use for the identified PICO question.
Guide to the Critical Appraisal of Clinical Practice Guidelines Page 1 of 2
Guide to the Critical Appraisal of Clinical Practice Guidelines Page 2 of 2
AACAP OFFICIAL ACTION
Clinical Practice Guideline for the Assessment and
Treatment of Children and Adolescents With Anxiety
Disorders
Heather J. Walter, MD, MPH, Oscar G. Bukstein, MD, MPH, A. Reese Abright, MD,
Helene Keable, MD, Ujjwal Ramtekkar, MD, MPE, MBA,
Jane Ripperger-Suhler, MD, Carol Rockhill, MD, PhD, MPH
Anxiety disorders are among the most common psychiatric disorders in children and adolescents. As reviewed in this guideline, both cognitive-behavioral
therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication have considerable empirical support as safe and effective short-term
treatments for anxiety in children and adolescents. Serotonin norepinephrine reuptake inhibitor (SNRI) medication has some empirical support as
an additional treatment option. In the context of a protracted severe shortage of child and adolescent�trained behavioral health specialists, research
demonstrating convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatments for child and adolescent
anxiety disorders is an urgent priority. The comparative effectiveness of anxiety treatments, delineation of mediators and moderators of effective anxiety
treatments, long-term effects of SSRI and SNRI use in children and adolescents, and additional evaluation of the degree of suicide risk associated with
SSRIs and SNRIs remain other key research needs.
Key Words: clinical practice guideline, anxiety, child psychiatry, assessment, treatment
J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124.
T
Journal of t
Volume 59
he objective of this Clinical Practice Guideline is
to enhance the quality of care and clinical out-
comes for children and adolescents with anxiety
disorders as defined by the Diagnostic and Statistical Manual
of Mental Disorders.1 The primary aim of the guideline is to
summarize empirically based guidance about the psycho-
social and psychopharmacologic treatment of anxiety. A
secondary aim is to summarize expert-based guidance about
the assessment of anxiety as an integral part of treatment
and the implementation of empirically based treatments in
clinical practice.
Anxiety disorders are among the most common psy-
chiatric disorders in children and adolescents. At any given
time, nearly 7% of youths worldwide have an anxiety dis-
order2; estimated lifetime prevalence in the United States
approximates 20% to 30%.3,4 For specific anxiety disorders
among youths 13 to 18 years old, lifetime prevalence rates
approximate 20% for specific phobia, 9% for social anxiety,
8% for separation anxiety, and 2% each for agoraphobia,
panic, and generalized anxiety.3
The median age of onset of anxiety disorders approxi-
mates 11 years5; however, each anxiety disorder often (but
not always) onsets during a specific developmental phase:
he American Academy of Child & Adolescent Psychiatry
/ Number 10 / October 2020
separation anxiety during the preschool/early school-age
years; specific phobias in the school-age years; social anxi-
ety in the later school-age and early adolescent years; and
generalized anxiety, panic, and agoraphobia in the later
adolescent/young adult years.6 The development of an
anxiety disorder may be foreshadowed by behavioral inhi-
bition,7 autonomic hyperreactivity,8 or negative affectivity.9
Parent/parenting factors,10 stressful/traumatic exposures,11
and insecure attachment12 also may play important etio-
logic roles. Anxiety disorders (especially generalized anxiety)
are highly comorbid with each other and with other psy-
chiatric disorders,13,14 particularly depression15 but also
bipolar, attention-deficit/hyperactivity disorder (ADHD),
learning/language, behavior, obsessive-compulsive, eating,
and substance-related disorders. For comorbid occurrences,
multifaceted treatment plans likely are necessary.16
Although onset can be acute, the course of anxiety tends
to be chronic,17 often with waxing and waning, and exhibits
both homotypic (prediction of a disorder by the same dis-
order) and heterotypic (prediction of a disorder by a
different disorder) continuity.18 Likely reflecting a common
underlying vulnerability (eg, “negative valence systems”),19
examples of heterotypic continuity are the prediction of
www.jaacap.org 1107
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jaac.2020.05.005&domain=pdf
http://www.jaacap.org
AACAP OFFICIAL ACTION
panic and depressive disorders in adolescence and adulthood
by separation anxiety in childhood, and the prediction of
social anxiety in adolescence and adulthood by selective
mutism in childhood.
The sequelae of untreated child and adolescent anxiety
disorders are manifold, including impairments in social,
educational, occupational, health, and mental health out-
comes extending from childhood into adulthood.20-22
Among adolescents with anxiety, 9% were reported
to have had suicidal ideation, and 6% made suicide
attempts23; panic disorder24 and generalized anxiety dis-
order with comorbid depression25 may convey the great-
est risk.
Despite the availability of effective treatments for anx-
iety,26 less than one-half of youths needing mental health
treatment receive any care, and fewer still receive evidence-
based care.27-30 Better identification, assessment, and
treatment of anxiety disorders by clinicians from multiple
disciplines could have a substantial impact on the individual
and public health burden of mental illness in children and
adolescents.
OVERVIEW OF THE GUIDELINE DEVELOPMENT
PROCESS
Authorship, Source, and Scientific Review
The authors of this guideline (the Guideline Writing
Group) are co-chairs and members of the AACAP
Committee on Quality Issues (CQI) (https://www.
aacap.org/AACAP/Resources_for_Primary_Care/Practice_
Parameters_and_Resource_Centers/Practice_Parameters.
aspx).31 The CQI is charged by AACAP with the devel-
opment of Clinical Practice Guidelines in accordance with
standards promulgated by the Institute of Medicine
(IOM)32 and the Appraisal of Guidelines Research &
Evaluation (AGREE) Next Steps Consortium.33 Both
standard sets emphasize rigor (critically appraised empirical
evidence) and transparency (minimization of conflicts of
interest and well-delineated guideline development process).
CQI chairs are nominated by the AACAP president based
upon their expertise and experience in the synthesis of
psychiatric knowledge and their lack of relevant conflicts of
interest. CQI members are nominated by CQI co-chairs to
broadly represent AACAP members in geographic, gender,
and professional practice type, duration and setting do-
mains, and to have no relevant conflicts of interest. Pro-
spective CQI members are reviewed and approved by the
AACAP president.
In this guideline, statements about the treatment of
anxiety disorders are based upon empirical evidence derived
from a critical systematic review of the scientific literature
1108 www.jaacap.org
conducted by the Mayo Clinic Evidence-based Practice
Center under contract with the Agency for Healthcare
Research and Quality (AHRQ).34-36 (Because selective
mutism was not included as a primary disorder in studies
included in the AHRQ/Mayo review, the treatment of this
disorder is not addressed in this guideline). Insofar as
available, evidence from meta-analyses published since the
AHRQ/Mayo review are presented to support or refute the
AHRQ/Mayo findings.37-43
Because of sparse or absent empirical evidence, clinical
guidance about the assessment of anxiety disorders and
about the implementation of empirically based treatments is
based primarily upon expert opinion and consensus as
presented in chapters in leading textbooks of child and
adolescent psychiatry,44-61 the DSM-5,1 previously pub-
lished clinical practice guidelines,62-65 and government-
affiliated prescription drug information websites (https://
dailymed.nlm.nih.gov/dailymed/66; https://www.fda.gov/
Drugs67).
The peer review and approval process for the draft
guideline spanned the period February 1, 2019, to March
11, 2020, and included reviewers representing the following
stakeholder groups (see end of this document for complete
list): 1) topic experts; 2) other members of the AACAP
CQI; 3) other relevant AACAP committees; 4) the AACAP
Assembly of Regional Organizations; 5) relevant external
organizations; and 6) AACAP members. All suggested edits
were considered; however, the CQI Guideline Writing
Group exercised editorial authority as to whether the sug-
gested edits were included in the final document. Final
approval of the guideline as an AACAP Official Action
rested with the AACAP Council.
ASSESSMENT OF ANXIETY
Diagnostic evaluation is an essential prerequisite for the
treatment of an anxiety disorder. Specialized clinical edu-
cation, training, and experience are necessary to conduct a
diagnostic evaluation of a child or adolescent in accordance
with current psychiatric nomenclature (DSM-51). A diag-
nostic evaluation identifies the following: symptoms; syn-
dromal symptom combinations; symptom frequency,
severity, onset, and duration; degree of associated distress
and functional impairment; developmental deviations; and
physical signs. Clinical expertise is required to differentiate
anxiety disorders from normal psychological processes
common to human experience.
Identification
At present, there is no empirically based (eg, U.S. Preventive
Services Task Force) recommendation for universal
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
https://dailymed.nlm.nih.gov/dailymed/
https://dailymed.nlm.nih.gov/dailymed/
https://www.fda.gov/Drugs
https://www.fda.gov/Drugs
http://www.jaacap.org
aDSM-5 Anxiety Disorders with International Classification of Diseases–
10 code: Separation Anxiety Disorder (ICD F93.0); Selective Mutism (ICD
F94.0); Specific Phobia (Animal: ICD F40.218, Natural environment: ICD
F40.228, Fear of blood: ICD F40.230, Fear of injections and transfusions:
F40.231, Fear of other medical care: F40.232, Fear of injury: F40.233,
Situational: F40.248, Other: F40.298); Social Anxiety Disorder (F40.10);
Panic Disorder (F41.0); Agoraphobia (F40.00); Generalized Anxiety Dis-
order (F41.1); Substance/Medication-Induced Anxiety Disorder (see
substance-specific codes), Anxiety Disorder Due to Another Medical
Condition (F06.4); Other Specified Anxiety Disorder (F41.8); and Un-
specified Anxiety Disorder (F41.9).
AACAP OFFICIAL ACTION
screening for anxiety disorders in children and adolescents.
However, in primary care, school, or other child-serving
settings, freely available general social�emotional
screening instruments (eg, Pediatric Symptom Checklist
[https://www.massgeneral.org/psychiatry/treatments-and-
services/pediatric-symptom-checklist/68]; Strengths and
Difficulties Questionnaire [http://www.sdqinfo.com69]) can
be deployed systematically to standardize identification of
anxiety concerns. Early identification of an anxiety concern,
if confirmed as a problem upon follow-up assessment, can
facilitate early intervention, including guided self-
management and focused intervention for subclinical and
mild presentations.
In the context of a psychiatric evaluation, symptoms of
anxiety typically are identified through spontaneous youth
or parent report (the presenting problem or chief
complaint), during the clinician’s review of psychiatric
symptoms, the conduct of the mental status examination, or
through input from referral sources. However, because of
the variability inherent in nonsystematic methods of
identification, a more standardized approach may be
useful. As one option, the American Psychiatric Association
(APA) developed the freely available parent- and self-rated
Level 1 Cross-Cutting Symptom Measures (https://www.
psychiatry.org/psychiatrists/practice/dsm/educational-resources/
assessment-measures70) to screen for multiple psychiatric
disorders including anxiety. These instruments could be
included in intake packets to systematically and efficiently
gather information about presenting problems prior to the
evaluation. The parent and self-rated versions of the Level 1
Cross-Cutting measure have demonstrated good reliability
in the DSM-5 field trials conducted in pediatric clinical
samples across the United States.71
Evaluation
Clinically significant anxiety (ie, an anxiety disorder) must
be distinguished from everyday worries and fears, which are
common to the human experience and normative (even
when exaggerated) in specific developmental stages (eg,
being startled and exposure to strangers in infants, separa-
tion from caregiver in toddlers, supernatural creatures in
preschoolers, physical well-being and natural disasters in
school-aged children, and social and existential concerns in
adolescents). In DSM-5,1 mental disorders are defined as “a
syndrome characterized by clinically significant disturbance
in an individual’s cognition, emotion regulation, or
behavior that reflects a dysfunction in the psychological,
biological, or developmental processes underlying mental
functioning.” By DSM convention, a mental disorder is
diagnosed if all or a threshold of diagnostic criteria for the
given disorder are met. Included in most diagnostic criteria
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
sets is the requirement for a specific frequency and duration
of symptoms as well as clinically significant distress and
functional impairment, along with the caveat that alterna-
tive mental, medical, and substance-related explanations for
the symptom presentation must have been ruled out before
the diagnosis is applied.
In DSM-5,1 diagnostic criteria are provided for 11
anxiety disorders (one with 8 subcategories).a Although the
boundaries between psychiatric disorders are now recog-
nized as porous, such that different disorders within and
across categories may share similar symptoms, risk factors,
and neural substrates, diagnostic precision nonetheless is
key for understanding disorder course and prognosis and for
guiding empirically based treatment recommendations.
According to DSM-5,1 separation anxiety is character-
ized by developmentally inappropriate, excessive worry or
distress associated with separation from a primary caregiver
or major attachment figure. Selective mutism is character-
ized by absence of speech in certain social situations despite
the presence of speech in other situations (usually at home).
Specific phobia is characterized by excessive fear or worry
about a specific object or situation. Social anxiety is char-
acterized by excessive fear or worry about being negatively
evaluated by others in social situations. Panic (ie, abrupt
surge of intense fear or discomfort) is characterized by
recurrent unexpected panic attacks with physical and
cognitive manifestations. Agoraphobia is characterized by
excessive fear or worry about being in situations (eg, crowds,
enclosed spaces) in which the individual may be unable to
escape or get help should panic-like or other overwhelming
or embarrassing symptoms occur. Generalized anxiety is
characterized by excessive, uncontrollable worries regarding
numerous everyday situations or activities. Substance/
medication-induced anxiety and anxiety due to another
medical condition are characterized by anxiety occurring in
the context of substance/medication use or a physical illness.
When diagnostic criteria are not fully met for a given
anxiety disorder or if a precise diagnosis is not possible due
to limited information or other factors, DSM-5 includes
“other specified” and “unspecified” diagnoses to be applied
in these circumstances. The “unspecified” diagnosis may be
the best diagnostic choice for nonbehavioral health
www.jaacap.org 1109
https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist/
https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist/
http://www.sdqinfo.com
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
http://www.jaacap.org
AACAP OFFICIAL ACTION
clinicians, who may not possess detailed knowledge of
DSM-5 criteria for specific anxiety disorders.
Evaluation Structure. A diagnostic interview for anxiety
includes the parent/guardian and patient, either separately
or together or both as developmentally and clinically indi-
cated. Interview of the patient requires a developmentally
sensitive approach that may use multiple age-appropriate
assessment techniques (eg, direct and indirect questioning,
interactive and projective techniques, symptom rating
scales, behavioral approach tests). Family assessment can
reveal environmental reinforcements for anxiety, and ob-
servations of parenting styles and behaviors can identify
those that are potentially anxiogenic. Input from collateral
sources (records, interviews, rating scales), including (as
applicable and with parent/guardian�patient consent) other
family members, teachers, primary care and behavioral
health clinicians, and/or child agency workers, can add
depth and breadth to diagnostic information. Because of the
multiple sources of information, a diagnostic evaluation of a
child or adolescent may involve more than one session as
allowed by current diagnostic billing code (Current Proce-
dural Codes [CPT] 90791, 90792) specifications.
As lack of appropriate linguistic ability or interpreter
support has been associated with misdiagnosis as well as
adverse clinical outcomes,72 it is optimal to conduct the
diagnostic evaluation in the language in which the child and
parents/guardians are proficient. If live interpreter services
are not available, telephonic or televideo interpreter services
may be an alternative.
Differential Diagnosis. The primary goal of the history of
present illness is to determine whether DSM-51 diagnostic
criteria for a specific anxiety disorder are met, and to rule
out alternative explanations (“masqueraders”) for the
symptom presentation. In addition, characterization of
previous anxiety presentations and response to previous
treatments will inform current treatment choice.
Medical conditions associated with anxiety include (but
are not limited to) hyperthyroidism, caffeinism, migraine,
asthma, diabetes, chronic pain/illness, lead intoxication,
hypoglycemic episodes, hypoxia, pheochromocytoma, cen-
tral nervous system disorders, cardiac arrhythmias, cardiac
valvular disease, systemic lupus erythematosus, allergic re-
actions, and dysmenorrhea. Although laboratory testing is
not routine in the evaluation of a suspected anxiety disorder,
in collaboration with the child’s primary care practitioner,
testing (eg, glucose, thyroid function) can be completed if
suggested by signs and symptoms of a medical condition.
For anxious youths presenting with somatic symptoms, the
nature and severity of those symptoms are noted at baseline
1110 www.jaacap.org
so that the somatic symptoms are not falsely attributed to
adverse effects of medication treatment.
Medications that can cause anxiety include (but are not
limited to) bronchodilators, nasal decongestants and other
sympathomimetics, antihistamines, steroids, dietary sup-
plements, stimulants, antidepressants, antipsychotics, and
withdrawal from benzodiazepines (particularly short-acting).
Medication reconciliation is a routine part of an evaluation
for a suspected anxiety disorder.
A wide array of licit and illicit substances can cause
anxiety, including (but not limited to) marijuana, cocaine,
anabolic steroids, hallucinogens, phencyclidine, and with-
drawal from nicotine, alcohol, and caffeine. Environmental
etiologies such as exposure to organophosphates and
ingestion of metals (eg, lead, arsenic) can also be considered.
Although drug and toxin testing are not routine in the
evaluation of a suspected anxiety disorder, testing can be
considered if exposure is reported.
Mental conditions that may include symptoms that are
similar to those of anxiety disorders are ADHD (distracti-
bility, restlessness), depression (distractibility, insomnia,
somatic complaints), bipolar disorder (distractibility, rest-
lessness, irritability, insomnia), obsessive-compulsive disor-
der (intrusive thoughts, avoidance, reassurance seeking),
psychotic disorders (restlessness, agitation, social with-
drawal, distractibility), autism spectrum disorder (social
withdrawal, social skills deficits, distractibility), and learning
disorders (worries about school performance).
Psychiatric Comorbidities. Anxiety disorders commonly
co-occur with each other; other common comorbidities
include (but are not limited to) depression, ADHD, and
behavior, bipolar, obsessive-compulsive, eating, learning,
language, and substance-related disorders. With selective
mutism, developmental and communication disorders
frequently co-occur. Comorbidities may heighten distress
and functional impairment and may worsen treatment
outcomes. Each comorbid disorder may require a separate
treatment plan and may influence the selection of treatment
for the anxiety disorder.
Use of the Parent- and Self-Rated Level 1 Cross-
Cutting Symptom Measures70 or screening questions
embedded in structured interview guides can standardize
and enhance the efficiency of the psychiatric review of
symptoms to assess for psychiatric comorbidities. If screen
questions on these instruments are positively endorsed, the
ensuing interview can ascertain whether full diagnostic
criteria are met for the given disorder. Each condition for
which full diagnostic criteria are met are diagnosed as such,
unless DSM-5 hierarchical rules1 apply.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
AACAP OFFICIAL ACTION
Medical Comorbidities. Children and adolescents with
anxiety disorders are more likely to present with a variety of
health problems, including headaches, asthma, gastrointes-
tinal disorders, and allergies. The anxiety and physical dis-
orders variously can be coincidental, in which the anxiety
that precedes or follows the physical disorder is related to
factors other than the illness itself, or can be causal, in which
the anxiety contributes to or results from the physical
illness. Examples of the latter include physical/physiological
pathology secondary to anxiety symptoms, anxiety symp-
toms secondary to physical pathology/physiology, and
anxiety as a reaction to physical illness and/or treatment.
Whatever the presumed type of association, each disorder,
whether physical or psychological, is separately assessed and
treated.
Structured Interview Guides. Although the use of
completely structured interview guides is infrequent in
nonresearch settings, such guides have been shown to
substantially enhance the reliability of psychiatric diagnosis
over unstructured clinician interviews, which are vulnerable
to a number of information collection biases.73 Structured
interview guides for children and adolescents have generally
similar, moderately acceptable psychometric properties;
hence, the decision to use a structured interview as part of a
diagnostic evaluation will depend upon consideration of the
advantages (eg, enhanced diagnostic accuracy) and disad-
vantages (eg, time, cost, burden) specific to each situation
and setting. The use of computerized versions of interview
guides could enable a psychiatric symptom review before
the first appointment (ideally at home through a secure
portal) as a structured, comprehensive first step in eluci-
dating the differential diagnosis.74
The proprietary Anxiety Disorders Interview Schedule
(ADIS), considered in research settings to be a gold standard
for assessing childhood anxiety, addresses all DSM-IV anx-
iety disorders; in addition, screening sections for other
psychiatric disorders are included to allow assessment of
comorbidities.75 A freely available option for structured
assessment is the K-SADS PL (Present and Lifetime) DSM-
5 interview guide (https://www.pediatricbipolar.pitt.edu/
sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_
Final 76), which includes sections assessing panic,
agoraphobia, separation anxiety, social anxiety, selective
mutism, specific phobia, and generalized anxiety disorders.
The K-SADS-PL DSM-5 also includes screening and
follow-up questions for other disorder categories, which can
facilitate efficient identification of potential anxiety mas-
queraders and comorbidities.
Symptom Rating Scales. Although not diagnostic, stan-
dardized symptom rating scales can be useful to support an
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
anxiety diagnosis, to characterize the nature and breadth of
specific symptoms, and to quantify pretreatment symptom
severity as a baseline for tracking response to treatment
over time. Moreover, in some situations, individual or
combinations of multi-informant symptom rating scales
may predict anxiety diagnoses as well as the ADIS struc-
tured interview, thereby reducing assessment burden.77
Several anxiety rating scales with acceptable psychometric
properties are freely available, both for the general
construct of anxiety as well as for specific anxiety disorders;
for example:
� Screen for Child Anxiety Related Emotional Disorders
(SCARED), parent and child versions https://www.
pediatricbipolar.pitt.edu/resources/instruments78
� Spence Children’s Anxiety Scale (SCAS), parent and child
versions https://www.scaswebsite.com79
� Preschool Anxiety Scale, parent version https://www.
scaswebsite.com79
� Generalized Anxiety Disorder�7 (GAD-7), teen/adult
version https://www.phqscreeners.com80
In addition, the APA offers the field-tested1 parent- and
self-rated Level 2 Cross-Cutting Symptom Measures for
Anxiety that explore anxiety endorsed on the Level 1
Measure (“mild” or greater on any anxiety item) in greater
depth, and the self-rated Disorder-Specific Severity Mea-
sures for clinically diagnosed separation anxiety, specific
phobia, social anxiety, agoraphobia, and generalized anxiety
disorders to track response to treatment over time (https://
www.psychiatry.org/psychiatrists/practice/dsm/educational-
resources/assessment-measures70).
There is poor to moderate agreement between parent
and youth reports on structured interview guides and
symptom rating scales.81,82 However, discrepancies between
informants are to be expected, as they reveal each in-
formant’s unique view of the child’s anxiety symptoms,
which are internal and may not be readily or accurately
discerned by others. Although the youth’s report is generally
considered to be paramount for internalizing disorders, 83,84
the simple rule of regarding a symptom as being present by
any informant’s report can be an acceptable resolution of
discrepancies.
Mental Status Examination. In the mental status exami-
nation, signs of anxiety can include fastidious or disheveled
appearance, poor eye contact, poor engagement/uncooper-
ativeness, shy demeanor, clinginess, tremor, fidgetiness/
restlessness, “nervous” habits, hypervigilance, poverty of or
pressured speech, perseverative or ruminative thought pro-
cesses, worry- or fear-laden thought content, distractibility,
irritability/agitation, and poor insight and judgment.
www.jaacap.org 1111
https://www.pediatricbipolar.pitt.edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final
https://www.pediatricbipolar.pitt.edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final
https://www.pediatricbipolar.pitt.edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final
https://www.pediatricbipolar.pitt.edu/resources/instruments
https://www.pediatricbipolar.pitt.edu/resources/instruments
https://www.phqscreeners.com
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
http://www.jaacap.org
AACAP OFFICIAL ACTION
Because these signs are nonspecific to anxiety (and may be
absent), they are largely adjunctive to other diagnostic
information.
Clinical Formulation. Beyond diagnosis, the contextual (eg,
stressors, strengths, environmental supports, cultural/spiri-
tual/gender/sexual orientation) and historical (eg, medical,
developmental, educational, family, social) sections of the
diagnostic evaluation guide the development of a clinical
formulation, which summarizes hypotheses regarding the
biological, psychological, and social factors that may have
predisposed, precipitated, or perpetuated the symptom
presentation.
Key biological vulnerabilities for anxiety include family
history of an anxiety disorder signaling inherited vulnera-
bilities in brain structure and function; acquired insult to
the developing brain; autonomic hyperreactivity; tempera-
ment characterized by negative affectivity, behavioral inhi-
bition, or sleeping/eating irregularity; and chronic medical
conditions. Hypothesized psychological vulnerabilities
include those derived from attachment theory (insecure
attachment), cognitive-behavioral theory (maladaptive
cognitive schemas, information-processing errors, negative
self-evaluations, disconnects between feelings and behav-
iors), psychodynamic theory (ego deficits, problems in
internalized object relations, unconscious conflicts), and
mindfulness theory (instability of affect management). Key
social vulnerabilities include stressful/traumatic life events,
anxiogenic parenting behaviors (overprotection/overcontrol,
high rejection/criticism, modeling anxious thoughts), social
skills deficits, peer rejection, inappropriate expectations for
achievement, lack of support/opportunities for competency
development, and sociodemographic/cultural discordance
with prevailing norms (poor “fit” in a given environment).
The biopsychosocial formulation can be organized to
reflect predisposing, precipitating, perpetuating, and pro-
tective (ameliorating) factors (“4 P’s”) influencing the
development of psychopathology.85 Predisposing factors are
areas of vulnerability that increase the risk for psychopa-
thology and encompass primarily the biological factors of
the biopsychosocial formulation. Precipitating factors are
stressors or other contextual events that have a chronologic
association with symptom onset. Perpetuating factors are
any aspects of the patient, family, or community that serve
to perpetuate the symptoms. Protective (ameliorating) fac-
tors include the patient’s own areas of strength as well as
strengths in the family and community. The cross-
organization of both biopsychosocial and 4P factors can
optimize the comprehensiveness of the treatment plan.
Safety. Safety risks, including but not limited to suicidal
thoughts and behaviors, self-harm, risk-taking behaviors,
1112 www.jaacap.org
and impulsivity, are assessed both at the time of evaluation
and during treatment of an anxiety disorder, as these risks
have been associated both with anxiety and more rarely with
its treatment with antidepressant medications. Anxiety dis-
orders in general and separation anxiety in particular may
suggest the need for exploration of exposure to traumatic
events. In the case of abuse or neglect, reporting to the state
child welfare authority is required. Gathering information
from multiple sources and by varied culturally and devel-
opmentally sensitive techniques may be needed in evalu-
ating safety risks. Assessment culminates in two basic
questions: Is the patient at current risk? Are the patient and
family able to adhere to recommendations regarding su-
pervision, safeguarding, and follow-up care? The answers to
these questions can lead to the appropriate level and in-
tensity of care. Psychiatric hospitalization is likely indicated
when the youth actively voices intent to harm and in the
context of altered mental status (including severe anxiety/
agitation), multiple previous self-harm attempts, previous
unsuccessful treatment, and caregiver incapacity.
Treatment Planning. Treatment planning derives from the
diagnoses and clinical formulation. High-quality treatment
plans are safe, timely, effective, efficient, feasible, equitable,
and child and family centered.86 A range of potentially
effective treatments and other interventions are explained in
accordance with the cognitive/linguistic/cultural level of the
parents/guardians and patient, prioritized according to the
acuity, severity, distress, and impairment associated with
each diagnosed disorder. Reviewing the patient and parent/
guardian preferences regarding the treatment options pre-
sented can increase the likelihood of engagement and
adherence to the plan. Level of care decisions are informed
by diagnosis, the current severity of symptoms, the presence
of comorbid medical or psychiatric disorders, the assessment
of the child’s risk to self or others, the child’s prior illness
course and complications, the child’s potential supports,
and the treatment alliance between the clinician and the
child and family.
In clinical practice, five components that generally are
included in a discussion seeking to obtain informed consent
for treatment are as follows87: 1) the diagnosis; 2) the nature
and purpose of the proposed treatment; 3) the attendant
risks and benefits of the proposed treatment; 4) alternative
treatments and their risks and benefits; and 5) the risks and
benefits of declining treatment. Strategies for improving
parent/guardians’ and patients’ comprehension of risks and
benefits can include providing written educational mate-
rials, multimedia presentations, decision-making work-
sheets, and standardized consent forms; asking for a “repeat
back” of information provided; and engaging in back-and-
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
bPsychotherapy treatments: cognitive-behavioral therapy, parent-child
interaction therapy, problem-solving therapy, third-wave (mindfulness)
therapy, psychodynamic psychotherapy, family therapy, attention
modification, motivational interviewing, eye movement desensitization
reprocessing therapy (EMDR); pharmacologic treatments: sertraline,
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, venlafax-
ine, atomoxetine, reboxetine, duloxetine, alprazolam, chlordiazepoxide,
clonazepam, imipramine, clomipramine, mebicarum, buspirone, mirta-
zapine, and nefazodone.
AACAP OFFICIAL ACTION
forth discussions until understanding is achieved. Docu-
mentation of the informed consent process provides evi-
dence that the patient and parent/guardian were adequately
prepared to provide assent/consent for treatment.
The incorporation of cultural and spiritual values, be-
liefs, and attitudes in treatment interventions can enhance
the child’s and family’s participation in treatment and
treatment effectiveness.72 Treatment recommendations can
draw from those proved to be effective in the minority
population in question, and reflect ethnopharmacologic
factors (eg, pharmacogenomic, dietary, herbal) that may
influence the child’s response to medications or experience
of adverse effects.
Successful treatment is a collaborative effort among all
involved parties with well-defined roles and responsibilities,
including the clinician’s role in generating motivation in the
child and parents/guardians to adhere to the treatment plan.
Inquiring about the parents’ understanding of the outcomes
of the assessment, addressing any questions or concerns, and
discussing the logistics of treatment recommendations im-
proves the chance that barriers to treatment are adequately
addressed. If treatment will be elsewhere, assisting the
family with the referral improves the likelihood of referral
completion. Parents/guardians who themselves struggle
with anxiety can benefit from additional psychoeducation
and support in fostering their child’s successful anxiety
management; a referral for parental treatment may be
appropriate.
Feedback to the patient’s medical care team is
generally permissible with basic consent for treatment,
although definitions of care team and regulations vary by
state. If parents/guardians specifically consent, feedback to
child-serving systems with which the patient is involved
(medical, educational, juvenile justice, child welfare) can
facilitate coordination of care. Prompt, concise, and
jargon-free feedback is most helpful; for example, feed-
back might include reiteration of the presenting problem/
reason for referral, a brief description of the assessment
process, the diagnoses given, and the treatments
recommended.
TREATMENT OF ANXIETY
Development of Treatment Statements From the
AHRQ/Mayo Systematic Review
The objective of the AHRQ/Mayo review34-36 was to
evaluate the effectiveness of psychotherapy and pharmaco-
therapy for the treatment of specific child and adolescent
anxiety disorders and to evaluate the safety concerns asso-
ciated with these treatments. In August 2017, the AHRQ/
Mayo systematic review34 was made available in its entirety
on the Internet and as a synopsis in a pediatric journal.35
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
Errata from the original review were published in July
2018.36
To be eligible for the AHRQ/Mayo review, studies
must have met all of the following criteria: 1) included
children and adolescents between 3 and 18 years old with a
confirmed diagnosis of panic, social anxiety, specific phobia
(including school phobia), generalized anxiety, or separation
anxiety disorder who 2) received any psychotherapy or
pharmacotherapy, alone or combined; and 3) reported
specified outcomes. Specified outcomes included the
following: 1) primary anxiety symptoms from measures
completed by the patient, parent, or clinician; 2) secondary
anxiety outcomes such as coping, avoidance, or anxious
thoughts; 3) global function; 4) social function; 5) satis-
faction with treatment; 6) response to treatment; and 7)
remission of the disorder (see AHRQ/Mayo review for
measures used for each outcome category36). Both ran-
domized controlled trials (RCTs) and comparative obser-
vational studies were included for effectiveness outcomes;
case reports or case series were also used to identify adverse
events (AEs).
The key questions of the AHRQ/Mayo review were
twofold: 1) what is the comparative effectiveness of the
available treatmentsb for panic, social anxiety, specific
phobia (including school phobia), generalized anxiety, and
separation anxiety disorders? 2) What are the comparative
potential harms regarding the available treatments for these
disorders?
AHRQ/Mayo Systematic Review Rating Procedure. The
strength of evidence (SOE) for each measured outcome (eg,
parent-rated anxiety symptoms) within each comparison
(eg, fluoxetine vs. CBT) across all studies included in the
AHRQ/Mayo review was rated via a consensus process by
the Mayo reviewers in accordance with the AHRQ Methods
Guide for Effectiveness and Comparative Effectiveness Re-
views.88 Randomized controlled trials (RCTs) started with
high SOE; observational studies started with low SOE.
Initial SOE ratings based upon study type were then raised
or lowered in accordance with the SOE assessed across five
additional domains: 1) risk of bias (impact on inference); 2)
precision (sample size, confidence intervals); 3) directness
(relevance to patient); 4) consistency (degree of heteroge-
neity of findings); and 5) publication bias (nonpublication
www.jaacap.org 1113
http://www.jaacap.org
AACAP OFFICIAL ACTION
of study results). For RCTs, risk of bias was assessed using
the Cochrane Risk of Bias tool89 (assessing random sequence
generation; allocation concealment; blinding of participants,
personnel, and outcome assessors; attrition bias; incomplete
outcome data; selective reporting). For observational studies,
risk of bias was assessed using the Newcastle�Ottawa Scale90
(assessing representativeness of the study population; selec-
tion of cohorts; ascertainment of exposure and outcomes;
adequacy of follow-up; possible conflicts of interest). If
insufficient evidence was available to determine SOE, that
finding was noted. The AHRQ/Mayo review process,
including the flow chart, search strategy, study inclusion/
exclusion criteria, and individual study characteristics are
presented in detail in the published review.36
CQI Treatment Statement Rating/Grading Procedure.
Based upon the findings from the AHRQ/Mayo review, the
CQI Guideline Writing Group via a consensus process
developed treatment statements for each comparison for
which sufficient evidence was available. Each treatment
statement was assigned a numerical rating for SOE and a
letter grade for the balance of benefits and harms as
described below. If insufficient evidence was available, no
treatment statement was developed; instead, the comparison
was noted as in need of additional research.
The treatment statement SOE ratings were determined
by arraying the AHRQ/Mayo SOE ratings for each indi-
vidual outcome across six key outcomes as available (ie,
child-rated anxiety symptoms; parent-rated anxiety
symptoms; clinician-rated anxiety symptoms; response;
remission; global function).
� If the preponderance of AHRQ/Mayo SOE ratings
across the six key outcomes for a given comparison was
high, the SOE rating for the corresponding treatment
statement was high (denoted by the letter A).
� If the preponderance of AHRQ/Mayo SOE ratings
across the six key outcomes was moderate, the SOE
rating for the treatment statement was moderate
(denoted by the letter B).
� If the preponderance of AHRQ/Mayo SOE ratings
across the six key outcomes was low, the SOE rating
for the treatment statement was low (denoted by the
letter C).
The treatment statement benefit/harm grades were
determined by the CQI Guideline Writing Group via a
consensus process in accordance with the Grading of
Recommendations Assessment, Development, and
1114 www.jaacap.org
Evaluation (GRADE)91 convention by weighing the poten-
tial benefits and harms of each treatment statement action
and the level of confidence in that determination based
upon the underlying SOE.
� A recommendation statement (denoted by the nu-
meral 1) indicates confidence that the benefits of the
action clearly outweigh the harms.
� A suggestion statement (denoted by the numeral 2)
indicates greater uncertainty, in that the benefits of
the action are considered likely to outweigh the
harms, but the balance is more difficult to judge.
The extent to which AHRQ/Mayo review�derived
treatment statements were supported or refuted by more
recent meta-analyses37-43 was presented as additional evi-
dence after each statement.
Treatment statements underwent iterative blind voting
by the CQI Guideline Writing Group members until at
least majority consensus was achieved. If a voting outcome
had not been unanimous, a dissenting opinion could have
been written to accompany the statement.
Applicability of Treatment Findings From the AHRQ/
Mayo Review. The treatment findings from the AHRQ/
Mayo review36 were stated to be “likely widely applicable to
a heterogeneous population of children and adolescents
with separation anxiety, generalized anxiety, social anxi-
ety, panic, and specific phobia disorders, with minimal
psychiatric comorbidities, who are on average 8 to
18 years old and have ready access to mental health
professionals who can provide CBT or have access to
medical professionals who are willing to prescribe SSRIs
or SNRIs.”
Of the disorders named above, because specific
phobia was not represented as the primary disorder in
medication studies included in the AHRQ/Mayo review,
this disorder was not included in the AACAP medication
treatment statements. Although the AHRQ/Mayo find-
ings were said to apply to children and adolescents who
were “on average” 8 to 18 years old, both medication and
therapy studies in the AHRQ/Mayo review included
children as young as 6 years old. Accordingly, the treat-
ment statements in this guideline extend downward to age
6. Although the majority of studies in the AHRQ/Mayo
review were conducted with populations that were pre-
dominantly of White ethnicity, there is no compelling
rationale for rendering the treatment statements inappli-
cable to minority populations.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
AACAP OFFICIAL ACTION
Treatment Statementsc
1. AACAP recommends (1C) that cognitive-behavioral
therapy (CBT) be offered to patients 6 to 18 years
old with social anxiety, generalized anxiety, separa-
tion anxiety, specific phobia, or panic disorder.
Benefits and Harms. Of the psychotherapy treatments
eligible for the AHRQ/Mayo review, only CBT had suffi-
cient outcome data for planned comparisons. A total of 60
RCTs and 3 nonrandomized comparative studies compared
CBT to waitlist/no treatment, 29 RCTs and one non-
randomized comparative study compared CBT to attention
control/treatment as usual, and 3 RCTs compared CBT to
pill placebo (see AHRQ/Mayo review36 for study details).
Overall, 6,978 patients were included (47.9% male; mean
age 11.2 years, range 6�18 years).
Compared to inactive controls (waitlist/no treatment),
CBT improved primary anxiety symptoms (child, parent,
and clinician report), global function, and response to
treatment (all moderate SOE), and may have improved
remission of disorder (low SOE). However, there was
evidence of publication bias for studies using the waitlist/
no treatment comparison, which lowered their SOE. CBT
did not separate from waitlist/no treatment for satisfaction
with care and secondary measures (both low SOE), and
there was insufficient evidence for social function.
Compared to active controls (attention control/treat-
ment as usual), CBT improved only primary anxiety (child
report) (moderate SOE); CBT did not separate from
attention control/treatment as usual for primary anxiety
(parent and clinician report), satisfaction, secondary mea-
sures, or remission of disorder (all low SOE). There was
insufficient evidence for global function, social function,
and response to treatment.
CBT did not separate from pill placebo for primary
anxiety (child report) or secondary measures (all low SOE).
There was insufficient evidence for primary anxiety (clini-
cian report), global function, or social function.
Except as noted, CBT did not separate from pill pla-
cebo, waitlist/no treatment, or attention control/treatment
as usual with respect to any short-term AEs (all low SOE).
Compared to pill placebo, CBT reduced dropouts (low
SOE) and compared to waitlist/no treatment, CBT reduced
dropouts due to AEs (low SOE).
cThe treatment statements below are intended to apply to the named
anxiety disorders for which all diagnostic criteria are met, including the
requirements for duration, frequency/severity, and clinically significant
distress and/or functional impairment. Although the AHRQ/Mayo review
findings were insufficient to recommend or suggest the sequence in
which treatments should be offered, prudent sequencing may prioritize
CBT over SSRI for recent onset of milder, less distressing, and less
functionally impairing anxiety presentations.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
Additional Support. This recommendation was supported
by the findings from four meta-analyses published since
the AHRQ/Mayo review.40-43 No meta-analyses or sys-
tematic reviews published since the AHRQ/Mayo review
refuted this recommendation. One of the recent meta-
analyses43 suggested the possible superiority of group CBT
over all other assessed psychotherapies and control
conditions.
Differences of Opinion. There were no differences of
opinion. The CQI Guideline Writing Group voted unan-
imously in favor of this recommendation.
Quality Measurement Considerations. CBT should be
considered among treatments offered to patients 6 to 18
years old with social anxiety, generalized anxiety, separation
anxiety, specific phobia, or panic disorders.
Implementation. CBT is a diverse group of interventions
targeted at the three primary dimensions of anxiety:
cognitive (eg, cognitive distortions about the likelihood of
harm), behavioral (eg, avoidance of potentially harmful
situations), and physiologic (eg, autonomic arousal and
other somatic symptoms). Therapeutic interventions are
individually tailored to illustrate connections among worries
and fears, thoughts, and behaviors, and are strategically
directed toward eliminating emotional and physical distress,
changing maladaptive beliefs and attitudes, and alleviating
avoidance behavior. CBT typically is organized according to
an agenda that involves homework assignments for practice
opportunities that reinforce skills and generalize them to the
natural environment. Treatment is characterized by
collaboration among the patient, family, and therapist, and,
in some cases, school personnel. The goal of structured
CBT is to achieve meaningful symptomatic and functional
improvement within 12 to 20 sessions. Systematic assess-
ment of treatment effectiveness using standardized symp-
tom rating scales can supplement the clinical interview, as
use of these scales has been shown to optimize therapists’
ability to accurately assess treatment response and
remission.92
Specialized education, training, and experience are
necessary for the effective delivery of CBT. Specific CBT
elements for anxiety disorders can include the following:
education about anxiety; behavioral goal setting with
contingent rewards; self-monitoring for connections be-
tween worries/fears, thoughts, and behaviors; relaxation
techniques including deep breathing, progressive muscle
relaxation, and guided imagery; cognitive restructuring that
challenges distortions such as catastrophizing, over-
generalization, negative prediction, and all-or-nothing
thinking; graduated exposure incorporating graded
www.jaacap.org 1115
http://www.jaacap.org
AACAP OFFICIAL ACTION
exposure to a feared stimulus; and problem-solving and so-
cial skills training relevant to anxiogenic situations. The
number and combination of these elements vary according
to the specific anxiety disorder being treated and the pa-
tient’s clinical presentation. Graduated exposure, in which
the patient creates a fear hierarchy that is then mastered in a
stepwise manner, is the cornerstone of treatment for anxiety
generated by a specific situation, such as in separation anx-
iety, specific phobias, and social anxiety. Developmentally
appropriate modifications of graduated exposure may
include use of real-life desensitization (in vivo), emotive
imagery (narrative stories), live modeling (demonstration of
nonfearful response), and contingency management (posi-
tive reinforcement). Exposure is tailored to the individual
and calibrated in intensity in a manner similar to dosage
calibration in medication management.93
Although CBT emphasizes cognitive, behavioral, and
physiologic processes that lead to and maintain anxiety
symptoms, these processes are learned and function in a
social context. As such, family-directed interventions that
improve parent�child relationships, strengthen family
problem-solving and communication skills, reduce parental
anxiety, and foster anxiety-reducing parenting skills often
supplement individual treatment. In addition, school-
directed interventions that educate teachers about the stu-
dent’s anxiety and how to foster effective problem-solving,
coping, and anxiety management strategies in the school
setting can be part of the treatment plan. Specific plans for
anxiety management at school can be written into the stu-
dent’s 504 plan or individualized education plan (eg,
graduated school re-entry with contingent rewards for sep-
aration anxiety; graduated practice opportunities for social
anxiety).
2. AACAP recommends (1B) that selective serotonergic
reuptake inhibitors (SSRIs) be offered to patients 6 to
18 years old with social anxiety, generalized anxiety,
separation anxiety, or panic disorder.
Benefits and Harms. In the AHRQ/Mayo review (see
AHRQ/Mayo review36 for study details), 13 RCTs
compared SSRIs to pill placebo. Overall, 1,708 patients
were included (54.1% male; mean age 11.6 years, range:
6�18 years).
Compared to pill placebo, SSRIs as a class improved
primary anxiety symptoms (parent and clinician report),
response to treatment, and remission of disorder (all mod-
erate SOE), as well as global function (high SOE). SSRIs
did not separate from pill placebo for primary anxiety
symptoms (child report), secondary measures, or social
function (all low SOE).
1116 www.jaacap.org
Except as noted, SSRIs as a class did not separate from
pill placebo with respect to short-term AEs (all moderate to
low SOE). Insufficient data precluded assessment of AEs
related to suicidal ideation or behavior. Insufficient data also
precluded assessment of AEs related to neurologic or oral
(dry mouth) AEs.
Additional Support. This recommendation was supported
by the findings from three meta-analyses published since the
AHRQ/Mayo review.37-39 No meta-analyses or systematic
reviews published since the AHRQ/Mayo review refuted
this recommendation.
Differences of Opinion. There were no differences of
opinion. The CQI Guideline Writing Group voted unan-
imously in favor of this recommendation.
Quality Measurement Considerations. A medication from
the SSRI class should be considered among treatments
offered to patients 6 to 18 years old with social anxiety,
generalized anxiety, separation anxiety, and panic disorders.
Implementation. Serotonergic function is believed to play a
key role in the ability of the brain to modulate fear, worry,
and stress as well as to facilitate cognitive processing of those
emotions.94 The SSRI medication class is a group of
chemically and pharmacologically different compounds that
inhibit the presynaptic reuptake of serotonin in the brain,
thereby increasing availability of serotonin at the synaptic
cleft. This blockade over time is believed to lead to a
downregulation of inhibitory serotonin autoreceptors,
which eventually heightens the serotonergic neuronal firing
rate, which in turn leads to increased serotonin release. This
multistep process is hypothesized to be related to the delay
in onset of the SSRI treatment effect.
Medications from the SSRI class currently marketed in
the United States are citalopram, escitalopram, fluoxetine,
fluvoxamine, paroxetine, sertraline, and vilazodone. In the
AHRQ/Mayo review, the SSRIs for which sufficient data
were available for comparisons were fluoxetine, fluvoxamine,
paroxetine, and sertraline. Although mechanisms of action
vary somewhat across SSRIs (eg, effects on other neuro-
transmitter receptors affecting degree of serotonin selectivity),
the primary mechanism was deemed in the AHRQ/Mayo
review to be sufficiently similar across individual medications
to warrant extension of the findings to the medication class.
Although there is substantial empirical support for the
effectiveness and safety of the SSRI class of medications for
the treatment of anxiety, no specific SSRIs have U.S. Food
and Drug Administration (FDA) approval for this indica-
tion. The choice of a specific SSRI is governed by consid-
erations such as pharmacokinetics, pharmacodynamics,
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
AACAP OFFICIAL ACTION
tolerability, cost, insurance formularies, and unique risks
leading to warnings or precautions.
At present, there is no clear role for pharmacogenomic
testing in medication selection, although this may change as
additional evidence accumulates.95
Limited data are available on drug pharmacokinetics
and pharmacodynamics for SSRIs in young people. Most
SSRIs (particularly fluoxetine because of its active metabo-
lite) have sufficiently long elimination half-lives to permit
single daily dosing. However, at low doses of sertraline96
and at any dose of fluvoxamine, youths may require
twice-daily dosing.
The best-fitting model for SSRI response may be a
logarithmic model demonstrating statistically (but not
clinically) significant improvement in anxiety symptoms
within 2 weeks of treatment initiation, clinically significant
improvement by week 6, and maximal improvement by
week 12 or later.38 This pharmacodynamic profile supports
slow up-titration to avoid unintentionally exceeding the
optimal medication dose.
As a group, the SSRIs are generally well tolerated by
children and adolescents. Most adverse effects emerge
within the first few weeks of treatment, and can include
(but are not limited to) dry mouth, nausea, diarrhea,
heartburn, headache, somnolence, insomnia, dizziness, vivid
dreams, changes in appetite, weight loss or gain, fatigue,
nervousness, tremor, bruxism, and diaphoresis. Potentially
serious adverse effects include (but are not limited to) sui-
cidal thinking and behavior, behavioral activation/agitation,
hypomania, mania, sexual dysfunction, seizures, abnormal
bleeding, and serotonin syndrome.
All of the SSRIs have a boxed warning for suicidal
thinking and behavior through age 24 years. The pooled
absolute rates for suicidal ideation across all antidepressant
classes and all non-OCD anxiety indications have been re-
ported to be 1% for youths treated with an antidepressant
and 0.2% for youths treated with a placebo.97 The pooled
risk difference has been reported to be 0.7% (95% confi-
dence interval �0.4% to 2%; p ¼ .21), yielding a number
needed to harm (NNH) of 143 (compared to a number
needed to treat [to achieve response] of 3).97 Despite the
low apparent risk, close monitoring for suicidality is rec-
ommended by the FDA, especially in the first months of
treatment and following dosage adjustments. Although the
margin of safety of SSRIs in overdose is greater than for
other antidepressants, deaths have been reported following
very large ingestions.
Behavioral activation/agitation98 (eg, motor or mental
restlessness, insomnia, impulsiveness, talkativeness, dis-
inhibited behavior, aggression), more common in younger
children than adolescents and in anxiety disorders compared
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
to depressive disorders, may occur early in SSRI treatment,
with dose increases, or with concomitant administration of
drugs that inhibit the metabolism of SSRIs. The potential
for dose-related behavioral activation/agitation early in
treatment supports slow up-titration and close monitoring
(particularly in younger children), and underscores the
importance of educating parents/guardians and patients in
advance about this potential side effect.
As with other antidepressants, there have been rare re-
ports of mania/hypomania that can be difficult to distin-
guish from behavioral activation. In general, behavioral
activation may be more likely to occur early in treatment
(first month) or with dose increases, whereas mania/hypo-
mania may appear later. Moreover, behavioral activation
usually improves quickly after SSRI dose decrease or
discontinuation, whereas mania may persist and require
more active pharmacological intervention. Sexual dysfunc-
tion (erectile dysfunction, delayed ejaculation, anorgasmia)
can occur with SSRIs in adolescents. Because seizures have
been observed in the context of SSRI use, SSRIs should be
used cautiously in patients with a history of a seizure dis-
order. Abnormal bleeding, especially with concomitant
administration of aspirin or nonsteroidal anti-inflammatory
drugs, can occur with SSRIs; rare bleeding events include
ecchymosis, hematoma, epistaxis, petechiae, and
hemorrhage.
Serotonin syndrome, caused by elevated brain serotonin
levels, can be triggered when serotonergic medications are
combined.99 Symptoms can arise within 24 to 48 hours
after combining medications and are characterized by
mental status changes (confusion, agitation, anxiety);
neuromuscular hyperactivity (tremors, clonus, hyperreflexia,
muscle rigidity); and autonomic hyperactivity (hyperten-
sion, tachycardia, arrhythmias, tachypnea, diaphoresis,
shivering, vomiting, diarrhea). Advanced symptoms include
fever, seizures, arrhythmias, and unconsciousness, which
can lead to fatalities. Treatment is hospital based and in-
cludes discontinuation of all serotonergic agents and sup-
portive care with continuous cardiac monitoring.
Monoamine oxidase inhibitors (MAOIs), including phe-
nelzine, isocarboxazid, moclobemide, isoniazid, and line-
zolid play a role in most cases of serotonin syndrome and
should be avoided in combination with any other seroto-
nergic drug, including another MAOI. Moreover, caution
should be exercised when combining two or more non-
MAOI serotonergic drugs, including antidepressants (eg,
SSRIs, SNRIs, TCAs, atypical antidepressants); opioids and
other pain medications (eg, tramadol, meperidine, metha-
done, fentanyl); stimulants (eg, amphetamine and possibly
methylphenidate classes); cough/cold/allergy medications
(eg, dextromethorphan, chlorpheniramine); other over-the-
www.jaacap.org 1117
http://www.jaacap.org
AACAP OFFICIAL ACTION
counter products (eg, St. John’s wort, L-tryptophan, diet
pills); and illicit drugs (eg, ecstasy, methamphetamine,
cocaine, LSD). Caution entails starting the second non-
MAOI serotonergic drug at a low dose, increasing the
dose slowly, and monitoring for symptoms, especially in the
first 24 to 48 hours after dosage changes.
Each SSRI has special prescribing considerations. Par-
oxetine, fluvoxamine, and sertraline have been associated
with discontinuation syndrome100 (see below for syndrome
description). As noted below, fluvoxamine may have greater
potential for drug�drug interactions. Citalopram may cause
QT prolongation associated with Torsade de Pointes, ven-
tricular tachycardia, and sudden death at daily doses
exceeding 40 mg/d and should be avoided in patients with
long QT syndrome. Paroxetine has been associated with
increased risk of suicidal thinking or behavior compared to
other SSRIs.
SSRIs vary in their potential for drug�drug in-
teractions.101 Concomitant administration of any of the
SSRIs with any of the monoamine oxidase inhibitors
(MAOIs) is contraindicated because of increased risk of
serotonin syndrome. SSRIs (especially citalopram) also may
interact with drugs that prolong the QT interval; fluoxetine,
paroxetine, and sertraline may interact with drugs metabo-
lized by CYP2D6, and fluvoxamine may interact with drugs
metabolized by CYP1A2, CYP2C19, CYP2C9, CYP3A4,
and CYP2D6. Citalopram/escitalopram may have the least
effect on CYP450 isoenzymes compared with other SSRIs
and as such may have a lower propensity for drug
interactions.
Medical education, training, and experience are
necessary to safely and effectively prescribe antidepressant
medications. A conservative medication trial for mild to
moderate anxiety presentations may entail increasing the
dose as tolerated (if adherence is confirmed) within the
therapeutic dosage range in the smallest available in-
crements at approximately 1- to 2-week intervals when
prescribing shorter half-life SSRIs (eg, sertraline, cit-
alopram, escitalopram) to approximately 3- to 4-week
intervals when prescribing longer half-life SSRIs (eg,
fluoxetine) until the benefit-to-harm ratio is optimized
and remission is achieved. Faster up-titration may be
indicated as tolerated for more severe anxiety pre-
sentations; however, it is not clear that dose of medica-
tion is related to magnitude of response, and higher doses
or blood concentrations can be associated with more
adverse effects.38 Because an initial adverse effect of SSRIs
can be anxiety or agitation, it may be advisable to start
with a subtherapeutic dose as a “test” dose. Systematic
assessment of treatment response using standardized
symptom rating scales can be considered as a supplement
1118 www.jaacap.org
to the clinical interview, along with reported and
observed adverse events. If a concerning adverse effect is
reported or observed that could reasonably be linked to
the medication, in general the dose of medication would
be reduced, and if the concerning adverse effect persists,
the medication would be discontinued. For all SSRIs,
medical monitoring can include height and weight; no
specific laboratory tests are recommended. The optimal
duration of pharmacologic treatment of anxiety disorders
for continued symptom remission is unclear, but a
generally accepted approach would be to continue an
effective, tolerated dose for approximately 12 months
after remission, monitoring for several months after
discontinuation for re-emergence of symptoms. Discon-
tinuation generally should occur during a relatively stress-
free period. Some youths with severe and chronic anxiety
presentations may require lengthier medication treatment.
Determinants of nonadherence to medication regi-
mens are multidetermined, including social/economic,
health system, illness, patient, and treatment factors.102
Although evidence is mixed, some effective strategies
include behavioral (motivational), educational (informa-
tion pamphlets), integrated care (care coordination), self-
management (illness management skills), risk communi-
cation (harm avoidance), and packaging/daily reminder
(physical or technological) approaches.102 In children and
adolescents, parental oversight of medication regimens is
of paramount importance.
A discontinuation syndrome characterized variously by
dizziness, fatigue, lethargy, general malaise, myalgias, chills,
headaches, nausea, vomiting, diarrhea, insomnia, imbal-
ance, vertigo, sensory disturbances, paresthesias, anxiety,
irritability, and agitation has been reported following missed
doses or acute discontinuation of shorter-acting SSRIs,
notably paroxetine but also (to a lesser extent) fluvoxamine
and sertraline.103 Accordingly, these medications warrant
close adherence to the prescribed regimen and a slow
discontinuation taper. In contrast, fluoxetine, likely because
of the long half-life of its active metabolite, is unlikely to be
associated with discontinuation syndrome and has not been
associated with withdrawal symptoms when doses are
missed.
There is no definitive empirical guidance for switching
from one SSRI to another.104 Although the most conser-
vative approach would entail tapering and discontinuing the
first SSRI before adding the second (with a washout interval
if the first SSRI is fluoxetine), this approach entails the risk
of exacerbation of the original symptoms, or discontinua-
tion symptoms if the first SSRI (other than fluoxetine) is
stopped abruptly. Cross-tapering may avoid these outcomes,
but should be closely monitored.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
AACAP OFFICIAL ACTION
3. AACAP suggests (2C) that combination treatment
(CBT and an SSRI) could be offered preferentially
over CBT alone or an SSRI alone to patients 6 to 18
years old with social anxiety, generalized anxiety,
separation anxiety, or panic disorder.
Benefits and Harms. In the AHRQ/Mayo review, two
RCTs compared combination treatment (CBT and an
SSRI) to either treatment alone (see AHRQ/Mayo review36
for study details). These 2 studies included 550 patients
(52.6% male; mean age 12.2 years, range 7�17 years).
Compared to CBT alone and to sertraline alone,
combination CBT plus sertraline improved primary anxiety
(clinician report), global function, response to treatment,
and remission of disorder (all moderate SOE).
Combination CBT plus fluoxetine did not separate
from CBT alone for global function, secondary measures, or
response to treatment (all low SOE) and may have reduced
remission of disorder compared to CBT alone (low SOE).
Except as noted, combination CBT plus sertraline did
not differ from CBT alone with respect to short-term AEs
including suicidal ideation or behavior (all low SOE).
Compared to CBT alone, combination CBT plus sertraline
increased AEs related to behavior activation (moderate
SOE) and increased any AEs and AEs related to sleep (both
low SOE).
Except as noted, combination CBT plus sertraline did
not differ from sertraline alone with respect to short-term
AEs (all low SOE). Compared to sertraline alone, combi-
nation CBT plus sertraline increased AEs related to behavior
activation and reduced AEs due to fatigue/somnolence
(both moderate SOE). Insufficient evidence precluded
assessment of AEs related to suicidal ideation or behavior.
Compared to CBT alone, combination CBT plus
fluoxetine did not differ with respect to dropouts
(low SOE).
Additional Support. This suggestion was not supported or
refuted by the findings from any meta-analyses or systematic
reviews published since the AHRQ/Mayo review.
Differences of Opinion. There were no differences of
opinion. The CQI Guideline Writing Group voted unan-
imously in favor of this suggestion.
Quality Measurement Considerations. Combination
treatment (CBT plus an SSRI) can be considered among
treatments offered to patients 6 to 18 years old with social
anxiety, generalized anxiety, separation anxiety, and panic
disorders.
Implementation. Because there were only two studies with
conflicting results, the AHRQ/Mayo review did not find
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
definitive evidence for the superiority of combination
treatment over monotreatment (therapy or medication
alone). Largely derived from the findings from one of the
studies (the Child-Adolescent Anxiety Multimodal Study
[CAMS]),105 expert consensus generally supports the pri-
oritization of combination treatment over monotreatment.
In CAMS,106 youths who received combination treatment
had significantly higher rates of remission compared to
monotreatment with SSRI or CBT or with placebo treat-
ment at week 12 and week 24. In clinical practice, com-
bination treatment may be favored if there is a need for
acute symptom reduction in a severe, functionally impairing
disorder or a partial response to monotreatment.
Combination treatment typically involves concurrent
administration of psychotherapy (CBT in the AHRQ/
Mayo-included studies) and medication (an SSRI in the
AHRQ/Mayo-included studies). Optimally, combination
treatment would be delivered in the same facility to enhance
convenience for the patient and family as well as commu-
nication between treatment providers.
Naturalistic follow-up of the CAMS study (Child/
Adolescent Anxiety Multimodal Extended Long-term Study
[CAMELS])107 failed to demonstrate long-term mainte-
nance of the initial superiority of combination over mon-
otreatment. However, a strong predictor of long-term
outcome was initial response to treatment, which, in the
CAMS study, was significantly superior in the combination
treatment compared to the monotreatment arms.106 This
finding may suggest the importance of delivering what may
be the most potent treatment (combination) early in the
treatment course.
4. AACAP suggests (2C) that serotonin norepinephrine
reuptake inhibitors (SNRIs) could be offered to pa-
tients 6 to 18 years old with social anxiety, general-
ized anxiety, separation anxiety, or panic disorder.
Benefits and Harms. In the AHRQ/Mayo review, 4 RCTs
compared SNRIs to pill placebo (see AHRQ/Mayo review36
for study details). These studies included 911 patients
(63.4% male; mean age 12.4 years, range 6�17 years).
Compared to pill placebo, SNRIs as a class improved
primary anxiety symptoms (clinician report) (high SOE).
SNRIs did not separate from pill placebo for primary anx-
iety (parent report) or global function (both low SOE).
Insufficient data precluded assessment of primary anxiety
(child report).
Except as noted, SNRIs as a class did not separate from
pill placebo with respect to short-term AEs including sui-
cidal ideation or behavior (all moderate to low SOE).
Compared to pill placebo, SNRIs were associated with
www.jaacap.org 1119
http://www.jaacap.org
AACAP OFFICIAL ACTION
increased fatigue/somnolence (moderate SOE). Insufficient
data precluded assessment of AEs related to infections.
Additional Support. This suggestion was supported by the
findings from three meta-analyses published since the
AHRQ/Mayo review.37-39 There were no meta-analyses or
systematic reviews published since the AHRQ/Mayo review
that refuted this suggestion.
Differences of Opinion. There were no differences of
opinion. The CQI Guideline Writing Group voted unan-
imously in favor of this suggestion.
Quality Measurement Considerations. A medication from
the SNRI class can be considered among treatments offered
to patients 6 to 18 years old with social anxiety, generalized
anxiety, separation anxiety, and panic disorders.
Implementation. The SNRI medication class is a group of
chemically and pharmacologically different compounds that
inhibit the presynaptic reuptake of both norepinephrine and
serotonin in the brain.94 Stress responses including alert-
ness, arousal, attentiveness, and vigilance are believed to be
modulated by noradrenergic neurons. Although associated
with the stress response (“fight or flight”) and the generation
of fear and anxiety, paradoxically noradrenergic medications
have been shown empirically to be effective in the treatment
of anxiety disorders, likely because of complex interactions
with other neurotransmitters including serotonin.
Medications from the SNRI class currently marketed in
the United States are venlafaxine, desvenlafaxine, dulox-
etine, and levomilnacipran. In the AHRQ/Mayo review, the
SNRIs for which sufficient data were available for com-
parisons were venlafaxine and duloxetine. Atomoxetine (a
selective norepinephrine reuptake inhibitor) also was
included in the AHRQ/Mayo review under the SNRI class;
however, at present, the effectiveness of atomoxetine for the
treatment of anxiety as the primary disorder has not been
established, and as such atomoxetine is not further
addressed in this guideline.
Although mechanisms of action vary somewhat across
SNRIs (eg, effects on other neurotransmitter receptors
affecting degree of serotonin and norepinephrine selec-
tivity), the primary mechanism was deemed in the AHRQ/
Mayo review to be sufficiently similar across individual
medications to warrant extension of the findings to the
medication class.
Duloxetine is the only SNRI to have an FDA indication
for the treatment of any anxiety disorder (specifically,
generalized anxiety disorder in children and adolescents
7�17 years old). However, the choice of medication for
anxiety within the SNRI class may also be governed by
other considerations such as pharmacokinetics,
1120 www.jaacap.org
pharmacodynamics, tolerability, cost, insurance formularies,
and unique risks leading to warnings or precautions. At
present, there is no clear role for pharmacogenomic testing
in medication choice, although this may change as evidence
accumulates.
Limited data are available on drug pharmacokinetics
and pharmacodynamics of SNRIs for young people. Ven-
lafaxine extended release, desvenlafaxine, and duloxetine
have sufficiently long elimination half-lives to permit single
daily dosing. Because of its short elimination half-life,
venlafaxine immediate release may require twice- or
thrice-daily dosing.
Adverse effects of SNRIs can include (but are not
limited to) diaphoresis, dry mouth, abdominal discomfort,
nausea, vomiting, diarrhea, dizziness, headache, tremor,
insomnia, somnolence, decreased appetite, and weight loss.
The SNRIs also have been associated with sustained clinical
hypertension, increased blood pressure, and increased pulse.
As described above for SSRIs, uncommon but poten-
tially serious adverse effects across the SNRI class include
suicidal thinking and behavior (through age 24 years),
behavioral activation/agitation, hypomania, mania, sexual
dysfunction, seizures, abnormal bleeding, and serotonin
syndrome. In addition, individual SNRI medications have
also been associated with distinctive, potentially serious
(albeit rare) adverse effects.
Venlafaxine may be associated with greater suicide risk
than the other SNRIs,108,109 and both venlafaxine and
desvenlafaxine have been associated with overdose fatalities.
Venlafaxine also has been associated with discontinuation
symptoms.
Duloxetine has been associated with hepatic failure
presenting as abdominal pain, hepatomegaly, and elevation
of transaminase levels. Cholestatic jaundice also has been
reported. Duloxetine should be discontinued and not
restarted in patients who develop jaundice or other evidence
of clinically significant liver dysfunction. Severe skin re-
actions, including erythema multiforme and
Stevens�Johnson syndrome, can occur with duloxetine;
accordingly, duloxetine should be discontinued and not
restarted at the first appearance of blisters, peeling rash,
mucosal erosions, or other signs of hypersensitivity.
SNRIs vary in their potential for drug�drug in-
teractions. Concomitant administration of any of the SNRIs
and any of the MAOIs is contraindicated because of
increased risk of serotonin syndrome. Duloxetine may
interact with drugs metabolized by CYP1A2 and CYP2D6.
Compared to SSRIs, venlafaxine may have the least effect on
the CYP450 system.110
Medical education, training, and experience are neces-
sary to safely and effectively prescribe antidepressant
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.jaacap.org
AACAP OFFICIAL ACTION
medications. The recommendations for an adequate SNRI
trial are the same as those delineated above for SSRIs. For all
SNRIs, medical monitoring should include height, weight,
pulse, and blood pressure; no specific laboratory tests are
recommended.
As with SSRIs, a discontinuation syndrome has been
reported103 following missed doses or acute discontinuation
of SNRIs. Accordingly, SNRIs also warrant a slow discon-
tinuation taper.
Areas for Additional Treatment Research
For many important domains of treatment for anxiety
(listed below), the AHRQ/Mayo review yielded insufficient
information to draw conclusions about the benefits or
harms of the treatment. As such, treatment statements for
these domains are not offered. Research is urgently needed
to support additional treatment statements in these domains
for future guidelines.
� Circumstances suggesting preferential use of SSRIs
or CBTd
� Preferential sequencing of SSRIs and CBTe
� Treatment effect modifiers (eg, child/family characteris-
tics, treatment setting, disorder severity, comorbidities)f
� Use of non-CBT psychotherapiesg
� Use of benzodiazepinesh
� Long-term safety risks of pharmacologic treatmenti
� Effectiveness of psychosocial and pharmacologic treat-
ments in underserved populations and minoritiesj
LIMITATIONS
The limitations of the Treatment section of this guideline
reflect the derivation of the treatment statements from the
findings of a single, time-limited, critical systematic review
of the literature by the AHRQ-contracted Mayo Clinic
Evidence-based Practice Center in which reviewers’ judg-
ment played a role in rating the strength of the empirical
evidence. Despite the rigor and transparency of the sys-
tematic review process as delineated in the AHRQ/Mayo
review,36 differences in professional judgment are possible.
However, any differences are deemed unlikely to affect the
overall conclusions of the guideline. Other limitations of the
AHRQ/Mayo review are as follows:
dAHRQ/Mayo review: equivocal head-to-head comparisons of SSRI
vs CBT
eAHRQ/Mayo review: no data
fAHRQ/Mayo review: equivocal subgroup analyses
gAHRQ/Mayo review: excluded from analyses due to heterogeneity of
therapies
hAHRQ/Mayo review: one poor quality trial of BZP versus placebo
iAHRQ/Mayo review: no data
jAHRQ/Mayo review: no data
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
� Relatively small body of evidence, especially for medica-
tion studies
� Brief follow-up of most studies
� Use of different symptom rating scales across studies to
assess improvement
� Lacking, sparse, or unstratified descriptions of potentially
mediating and moderating variables (eg, intervention
components, participant demographics, comorbidities,
symptom severity)
� Poor representation across studies of both very young
children and young adults
� Poor representation across studies of multiracial youths
� Paucity or lack of medication studies addressing selective
mutism, specific phobias, panic, or agoraphobia as the
primary disorder
� Variable methods for reporting treatment-emergent
adverse events and serious adverse events
� Insufficient data to assess risk of suicidal behavior
The limitations of the Assessment and Implementation
sections of this guideline reflect the derivation of the
narrative from a single time-limited review by the CQI
Guideline Writing Group of published expert opinion and
consensus. When expert opinions differed, judgment was
exercised by the CQI Guideline Writing Group to select
among equally supported opinions. Although differences in
professional judgment are possible, any differences are
deemed unlikely to affect the overall conclusions of the
guideline.
CONCLUSIONS
Congruent with previous national and international guide-
lines,62-65 in this guideline both cognitive-behavioral
therapy (CBT) and selective serotonin reuptake inhibitor
(SSRI) medication have considerable empirical support as
safe and effective short-term treatments for anxiety in
children and adolescents. Serotonin norepinephrine reup-
take inhibitor (SNRI) medication has some empirical sup-
port as an additional treatment option. CBT may be
considered to be the first-line treatment for anxiety in
children and adolescents, particularly for mild to moderate
presentations, with SSRI (and possibly SNRI) medication
an alternative treatment consideration, particularly for more
severe presentations or when quality CBT is unavailable.
Combination treatment (CBT and SSRI) may be a more
effective short-term treatment for anxiety in children and
adolescents than either treatment alone. Because effective
treatment outcomes are predicated in part upon accuracy of
the diagnosis, depth of the clinical formulation, and breadth
of the treatment plan, comprehensive, evidence-based
assessment may enhance evidence-based treatment.
www.jaacap.org 1121
http://www.jaacap.org
AACAP OFFICIAL ACTION
In the context of a protracted severe shortage of child
and adolescent�trained behavioral health specialists,
research demonstrating convenient, efficient, cost-effective,
and user-friendly delivery mechanisms for safe and effec-
tive treatments for child and adolescent anxiety disorders is
an urgent priority. Pharmacotherapeutic task-sharing with
pediatric practitioners, particularly for moderate anxiety
presentations, can greatly expand access to safe and effective
care while conserving child and adolescent psychiatrists for
the management of more severe and complex presentations.
The comparative effectiveness of anxiety treatments, delin-
eation of mediators and moderators of effective anxiety
treatments, long-term effects of SSRI and SNRI use in
children and adolescents, and additional evaluation of the
degree of suicide risk associated with SSRIs and SNRIs,
remain other key research needs.
The AACAP Clinical Practice Guidelines critically assess and synthesize scien-
tific and clinical information as an educational service to AACAP members and
other interested parties. The treatment statements in the guidelines are based
upon information available on the date of publication of the corresponding
AHRQ/Mayo systematic review. The guidelines are not continually updated
and may not reflect the most recent evidence. The guidelines should not be
considered to be a statement of the standard of care nor exclusive of all proper
treatments or methods of care. The guidelines do not account for individual
variation among patients. As such, it is not possible to draw conclusions about
the effects of not implementing a particular recommendation, either in general
or for a specific patient. The ultimate decision regarding a particular assess-
ment, clinical procedure, or treatment plan must be made by the clinician in
light of the psychiatric evaluation, other clinical data, the patient’s and family’s
personal preferences and values, and the diagnostic and treatment options
available. Use of these guidelines is voluntary. AACAP provides the guidelines
on an “as is” basis, and makes no warranty, expressed or implied, regarding
them. AACAP assumes no responsibility for any injury or damage to persons or
property arising out of or related to any use of the guidelines or for any errors
or omissions.
The primary intended audience for the AACAP Clinical Practice Guidelines is
child and adolescent psychiatrists; however, the information presented also
could be useful for other medical or behavioral health clinicians.
Author Contributions:
Conceptualization: Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-
Suhler, Rockhill
Data curation: Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-Suhler,
Rockhill
1122 www.jaacap.org
Formal analysis: Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-
Suhler, Rockhill
Investigation: Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-Suhler,
Rockhill
Methodology: Walter, Bukstein, Abright, Keable, Ramtekkar, Ripperger-Suhler,
Rockhill
Project administration: Walter
Supervision: Walter
Writing e original draft: Walter, Bukstein, Abright, Keable, Ramtekkar,
Ripperger-Suhler, Rockhill
Writing e review and editing: Walter, Bukstein, Abright, Keable, Ramtekkar,
Ripperger-Suhler, Rockhill
Karen Ferguson and Ron Szabat, JD, LLM served as the AACAP staff liaisons
for the CQI.
ORCIDs:
Heather Walter: 0000-0002-1594-6638
Oscar Bukstein: 0000-0002-6324-1392
A. Reese Abright: 0000-0002-3467-3807
Helene Keable: 0000-0002-7358-1227
Ujjwal Ramtekkar: 0000-0001-5988-7994
Jane Ripperger-Suhler: 0000-0001-6149-4022
Carol Rockhill: 0000-0001-5799-9706
The authors acknowledge the following topic experts for their contributions to
this guideline: Boris Birmaher, MD, John Piacentini, PhD, Moira Rynn, MD,
Jeffrey Strawn, MD, John Walkup, MD, V. Robin Weersing, PhD.
The guideline underwent peer review from February 1, 2019, to March 11, 2020;
peer reviewers were as follows: Christopher Bellonci, MD, John Diamond, MD,
Laurence Greenhill, MD, Roma Vasa, MD (AACAP Committee on Quality Is-
sues); Debra Koss, MD, Karen Pierce, MD, Laura Willing, MD (AACAP Advocacy
Committee); Cathryn A. Galanter, MD, Alice Mao, MD (AACAP Consumer Is-
sues Committee); Andrew Harper, MD, Lindsay Moskowitz, MD (AACAP
Continuing Medical Education Committee); Adelaide Robb, MD, Tim Wilens,
MD, Mina Dulcan, MD (AACAP Psychopharmacology Committee); Daniel
Dickstein, MD, Manpreet Singh, MD (AACAP Research Committee); Debra
Koss, MD, Marian Swope, MD (Executive Committee, AACAP Assembly of
Regional Organizations); Victor Fornari, MD, Richard Martini, MD (Presidents,
American Association of Directors of Child and Adolescent Psychiatry); AACAP
Members; AACAP Council.
This Clinical Practice Guideline was approved by AACAP Council on March
11, 2020.
This Clinical Practice Guideline is available at www.aacap.org.
During the preparation of this guideline, none of the authors had any financial
conflicts of interest to disclose.
Correspondence to the AACAP Communications Department, 3615 Wisconsin
Avenue NW, Washington, DC 20016.
0890-8567/$36.00/ª2020 Published by Elsevier Inc. on behalf of the American
Academy of Child and Adolescent Psychiatry.
https://doi.org/10.1016/j.jaac.2020.05.005
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Dis-
orders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
2. Polanczyk GV, Salum GA, Sugaya LS, et al. Annual research review: a meta-analysis of
the worldwide prevalence of mental disorders in children and adolescents. J Psychol
Psychiatry. 2015;56:345-365.
3. Merikangas KR, He J, Burstein M, et al. Lifetime prevalence of mental disorders in U.S.
adolescents: results from the National Comorbidity Survey Replication�Adolescent
Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980-989.
4. Copeland W, Shanahan L, Costello EJ, et al. Cumulative prevalence of psychiatric
disorders by young adulthood: a prospective cohort analysis from the Great Smoky
Mountains Study. J Am Acad Child Adolesc Psychiatry. 2011;50:252-261.
5. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distri-
butions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen
Psychiatry. 2005;62:593-602.
6. Beesdo-Baum K, Knappe S. Developmental epidemiology of anxiety disorders. Child
Adolesc Psychiatry Clin N Am. 2012;21:457-478.
7. Clauss JA, Blackford JU. Behavioral inhibition and risk for developing social anxiety
disorder: a meta-analytic study. J Am Acad Child Adolesc Psychiatry. 2012;51:
1066-1075.
8. Feder A, Coplan JD, Goetz RR, et al. Twenty-four-hour cortisol secretion patterns in
prepubertal children with anxiety or depressive disorders. Biol Psychiatry. 2004;56:
198-204.
9. Watson D, Clark LA, Carey G. Positive and negative affectivity and their relation to
anxiety and depressive disorders. J Abnorm Psychol. 1988;97:346-353.
10. Suarez L, Barlow D, Bennett S, et al. Understanding anxiety disorders from a “triple
vulnerabilities” framework. In: Anthony M, Stein M, eds. Handbook of Anxiety and
the Anxiety Disorders. New York, NY: Oxford University Press; 2008.
11. Green JG, McLaughlin KA, Berglund PA, et al. Childhood adversities and adult psy-
chiatric disorders in the National Comorbidity Survey Replication I: associations with
first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67:113-123.
12. Colonnesi C, Draijer EM, Jan JM, et al. The relation between insecure attachment and
child anxiety: a meta-analytic review. J Clin Child Adolesc Psychol. 2011;40:630-645.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
http://www.aacap.org/
https://doi.org/10.1016/j.jaac.2020.05.005
http://www.jaacap.org
AACAP OFFICIAL ACTION
13. Verduin TL, Kendall PC. Differential occurrence of comorbidity within childhood
anxiety disorders. J Clin Child Adolesc Psychol. 2003;32:290-295.
14. Costello EJ, Egger HL, Copeland W, et al. The developmental epidemiology of anxiety
disorders: phenomenology, prevalence, and comorbidity. Anxiety Disord Child Adolesc
Res Assess Intervent. 2011;2:56-75.
15. Cummings CM, Caporino NE, Kendall PC. Comorbidity of anxiety and depression in
children and adolescents: 20 years after. Psychol Bull. 2014;140:816-845.
16. Manassis K, Monga S. A therapeutic approach to children and adolescents with anxiety
disorders and associated comorbid conditions. J Am Acad Child Adolesc Psychiatry.
2001;40:115-117.
17. Kessler RC, Avenevoli S, Costello EJ, et al. Prevalence, persistence, and sociodemo-
graphic correlates of DSM-IV disorders in the National Comorbidity Survey Replica-
tion Adolescent Supplement. Arch Gen Psychiatry. 2012;69:372-380.
18. Costello EF, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric
disorders in children and adolescence. Arch Gen Psychiatry. 2003;60:837-844.
19. National Institute of Mental Health. Research Domain Criteria Matrix. Available at:
https://www.nimh.nih.gov/research-priorities/rdoc/index.shtml. Accessed July 29, 2020.
20. Bittner A, Egger HL, Erkanli A, et al. What do childhood anxiety disorders predict?
J Child Psychol Psychiatry. 2007;48:1174-1183.
21. Copeland WE, Shanahan L, Costello EJ, et al. Childhood and adolescent psychiatric
disorders as predictors of young adult disorders. Arch Gen Psychiatry. 2009;66:764-772.
22. Copeland WE, Angold A, Shanahan L, et al. Longitudinal patterns of anxiety from
childhood to adulthood: the Great Smoky Mountains Study. J Am Acad Child Adolesc
Psychiatry. 2014;53:21-33.
23. Husky MM, Olfson M, He J, et al. Twelve-month suicidal symptoms and use of
services among adolescents: results from the National Comorbidity Survey. Psychiatr
Serv. 2012;63:989-996.
24. Lepine JP, Chignon JM, Teherani M. Suicide attempts in patients with panic disorder.
Arch Gen Psychiatry. 1993;50:144-149.
25. Foley DL, Goldston DB, Costello EJ, et al. Proximal psychiatric risk factors for suicidality
in youth: the Great Smoky Mountains Study. Arch Gen Psychiatry. 2006;63:1017-1024.
26. Bennett K, Manassis K, Duda S, et al. Treating child and adolescent anxiety effectively:
overview of systematic reviews. Clin Psychol Rev. 2016;50:80-94.
27. Ford T. Practitioner review: how can epidemiology help us plan and deliver effective child
and adolescent mental health services? J Child Psychol Psychiatry. 2008;49:900-914.
28. Saloner B, Carson N, Cook BL. Episodes of mental health treatment among a na-
tionally representative sample of children and adolescents. Med Care Res Rev. 2014;71:
261-279.
29. Kazak AE, Hoagwood K, Weisz JR, et al. A meta-systems approach to evidence-based
practice for children and adolescents. Am Psychol. 2010;65:85-97.
30. Novins DK, Green AE, Legha RK, et al. Dissemination and implementation of
evidence-based practices for child and adolescent mental health: a systematic review.
J Am Acad Child Adolesc Psychiatry. 2013;52:1009-1025.
31. American Academy of Child and Adolescent Psychiatry, Guidelines, Updates, and
Parameters. Available at: https://www.aacap.org/AACAP/Resources_for_Primary_Care/
Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx. Accessed July
29, 2020.
32. Institute of Medicine of the National Academies. Clinical Practice Guidelines We Can
Trust. Washington, DC: National Academies Press; 2011.
33. AGREE Next Steps Consortium. AGREE-II User’s Manual. 2013. Available at: https://
www.agreetrust.org. Accessed July 29, 2020.
34. Wang Z, Whiteside S, Sim L, et al. Anxiety in Children. Comparative Effectiveness
Review No. 192. (Prepared by the Mayo Clinic Evidence-based Practice Center under
Contract No. 290-2015-00013-I.) AHRQ Publication No. 17-EHC023-EF. Rockville,
MD: Agency for Healthcare Research and Quality; August 2017.
35. Wang Z, Whiteside SPH, Sim L, et al. Comparative effectiveness and safety of cognitive
behavioral therapy and pharmacotherapy for childhood anxiety disorders. A systematic
review and meta-analysis. JAMA Pediatr. 2017;17:1049-1056.
36. Wang Z, Whiteside S, Sim L, et al. Anxiety in Children. Comparative Effectiveness
Review No. 192. (Prepared by the Mayo Clinic Evidence-based Practice Center under
Contract No. 290-2015-00013-I.) AHRQ Publication No. 17-EHC023- EF. Rockville,
MD: Agency for Healthcare Research and Quality; August 2017. Erratum July 2018.
37. Locher C, Koechlin H, Zion SR, et al. Efficacy and safety of selective serotonin reuptake
inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common
psychiatric disorders among children and adolescents—a systematic review and meta-
analysis. JAMA Psychiatry. 2017;74:1011-1020.
38. Strawn JR, Mills JA, Sauley BA, et al. The impact of antidepressant dose and class on
treatment response in pediatric anxiety disorders: a meta-analysis. J Am Acad Child
Adolesc Psychiatry. 2018;57:235-244.
39. Dobson ET, Bloch MH, Strawn JR. Efficacy and tolerability of pharmacotherapy for
pediatric anxiety disorders: a network meta-analysis. J Clin Psychiatry. 2019;80:
17r12064.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
40. Crowe K, McKay D. Efficacy of cognitive-behavioral therapy for childhood anxiety and
depression. J Anxiety Disord. 2017;49:76-87.
41. Wiesz JR, Kuppens S, Ng MY, et al. What five decades of research tells us about the
effects of youth psychological therapy: a multilevel meta-analysis and implications for
science and practice. Am Psychol. 2017;72:79-117.
42. Warwick H, Reardon T, Cooper P, et al. Complete recovery from anxiety disorders
following cognitive behavior therapy in children and adolescents: a meta-analysis. Clin
Psychol Rev. 2017;52:77-91.
43. Zhou X, Zhang Y, Furukawa TA, et al. Different types and acceptability of psycho-
therapies for acute anxiety disorders in children and adolescents—a network meta-
analysis. JAMA Psychiatry. 2019;76:41-50.
44. Connolly SD, Suarez LM, Victor AM, et al. Anxiety disorders. In: Dulcan MK, ed.
Dulcan’s Textbook of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA:
American Psychiatry Association Publishing; 2016:305-343.
45. O’Brien JD. The process of assessment and diagnosis. In: Dulcan MK, ed. Dulcan’s
Textbook of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA: American Psy-
chiatry Association Publishing; 2016:3-16.
46. Jha P. Assessing the elementary school-age child. In: Dulcan MK, ed. Dulcan’s Text-
book of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA: American Psychiatry
Association Publishing; 2016:57-71.
47. Cuffe SP, Desai CV. Assessing adolescents. In: Dulcan MK, ed. Dulcan’s Textbook of
Child and Adolescent Psychiatry. 2nd ed. Arlington, VA: American Psychiatry Associ-
ation Publishing; 2016:73-87.
48. Lee ES, Findling RL. Principles of psychopharmacology. In: Dulcan MK, ed. Dulcan’s
Textbook of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA: American Psy-
chiatry Association Publishing; 2016:691-708.
49. Emslie GJ, Croarkin P, Chapman MR, et al. Antidepressants. In: Dulcan MK, ed.
Dulcan’s Textbook of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA:
American Psychiatry Association Publishing; 2016:737-768.
50. Beidel DC, Reinecke MA. Cognitive-behavioral treatment for anxiety and depression.
In: Dulcan MK, ed. Dulcan’s Textbook of Child and Adolescent Psychiatry. 2nd ed.
Arlington, VA: American Psychiatry Association Publishing; 2016:973-991.
51. Taylor JH, Lebowitz ER, Silverman WK. Anxiety disorders. In: Martin A, Bloch MH,
Volkmar FR, eds. Lewis’s Child and Adolescent Psychiatry, A Comprehensive Text-
book. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018:509-518.
52. Bostic JQ, Potter MP, King RA. Clinical assessment of children and adolescents:
content and structure. In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s Child and
Adolescent Psychiatry, A Comprehensive Textbook. Philadelphia, PA: Wolters Kluwer;
2018:299-320.
53. Angold A, Costello EJ, Egger H. Structured interviewing. In: Martin A, Bloch MH,
Volkmar FR, eds. Lewis’s Child and Adolescent Psychiatry, A Comprehensive Text-
book. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018:342-354.
54. Volkmar FR, Sukhodolsky DG, Schwab-Stone, et al. Diagnostic classification. In:
Martin A, Bloch MH, Volkmar FR, eds. Lewis’s Child and Adolescent Psychiatry, A
Comprehensive Textbook. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018:354-362.
55. Martin A, Oesterheld JR, Bloch MH, et al. Pediatric psychopharmacology. General
principles and clinical practice. In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s
Child and Adolescent Psychiatry, A Comprehensive Textbook. 5th ed. Philadelphia, PA:
Wolters Kluwer; 2018:715-718.
56. Bloch MH, Beyer C, Martin A, et al. Specific medication treatments. Antidepressants.
In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s Child and Adolescent Psychiatry, A
Comprehensive Textbook. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018:724-732.
57. Weersing VR, Goger P, Conover KL. Psychotherapies. Psychotherapy for children and
adolescents: a critical overview. In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s
Child and Adolescent Psychiatry, A Comprehensive Textbook. 5th ed. Philadelphia, PA:
Wolters Kluwer; 2018:749-757.
58. Minjarez MB, Montague RA, Fox EA, et al. Psychotherapies: cognitive and behavioral
therapies. In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s Child and Adolescent
Psychiatry, A Comprehensive Textbook. 5th ed. Philadelphia, PA: Wolters Kluwer;
2018:757-787.
59. Guite JW, Kazak AE. Anxiety symptoms and disorders. In: Shaw RJ, DeMaso DR, eds.
Textbook of Pediatric Psychosomatic Medicine. Washington, DC: American Psychi-
atric Publishing; 2010:101-119.
60. Klykylo W, Bowers RT, Weston CD, et al. Green’s Child & Adolescent Clinical
Psychopharmacology. 5th ed. Philadelphia, PA: Wolters Kluwer; 2019.
61. Klykylo WM, Kay J, eds. Clinical Child Psychiatry. 3rd ed. Chichester, UK: John
Wiley & Sons; 2012.
62. Connolly SD, Bernstein GA, Bernet W, et al. Practice parameter for the assessment and
treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc
Psychiatry. 2007;46:267-283.
63. British Columbia Ministry of Health Services Guidelines & Protocols Advisory
Committee. Anxiety and Depression in Children and Youth—Diagnosis and
www.jaacap.org 1123
https://www.nimh.nih.gov/research-priorities/rdoc/index.shtml
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
https://www.aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and_Resource_Centers/Practice_Parameters.aspx
http://www.jaacap.org
AACAP OFFICIAL ACTION
Treatment, 2010. Available at: https://www2.gov.bc.ca/assets/gov/health/practitioner-
pro/bc-guidelines/depressyouth . Accessed July 29, 2020.
64. National Institute for Health and Care Excellence, NICE Guideline. Social Anxiety
Disorder: Recognition, Assessment, and Treatment, 2013. Available at: https://www.
nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-
treatment-pdf-35109639699397. Accessed July 29, 2020.
65. National Institute for Health and Care Excellence, Nice Quality Standard. Anxiety
Disorders, 2014. Available at: https://www.nice.org.uk/guidance/qs53/resources/
anxiety-disorders-pdf-2098725496261. Accessed July 29, 2020.
66. National Institutes of Health, U.S. National Library of Medicine. Available at:
https://dailymed.nlm.nih.gov/dailymed/. Accessed July 29, 2020.
67. U.S. Food & Drug Administration. Available at: https://www.fda.gov/Drugs. Accessed
July 29, 2020.
68. Massachusetts General Hospital, Pediatric Symptom Checklist. Available at: https://
www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist/.
Accessed July 29, 2020.
69. Youth in Mind, Strengths and Difficulties Questionnaire. Available at: https://sdqinfo.
org. Accessed July 29, 2020.
70. American Psychiatric Association. Online Assessment Measures. Available at:
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-
measures. Accessed July 29, 2020.
71. Narrow WE, Clarke DE, Kuramoto SJ, et al. DSM-5 field trials in the United States
and Canada, part III: development and reliability testing of a cross-cutting symptom
assessment for DSM-5. Am J Psychiatry. 2013;170:71-82.
72. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in
child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;
52:1101-1115.
73. Jensen-Doss A, Youngstrom EA, Youngstrom JK, et al. Predictors and moderators of
agreement between clinical and research diagnoses for children and adolescents.
J Consult Clin Psychol. 2014;82:1151-1162.
74. Kobak K, Townsend L, Birmaher B, et al. Computer-assisted psychiatric diagnosis.
J Am Acad Child Adolesc Psychiatry. 2020;59:213-215.
75. Silverman WK, Albano AM. Anxiety Disorders Interview Schedule for DSM-IV: Child
Version. Child and Parent Interview Schedules. San Antonio, TX: Psychological Cor-
poration; 1996.
76. University of Pittsburgh. Kiddie Schedule for Affective Disorders and Schizophrenia,
Present and Lifetime Version, DSM-5. Available at: https://www.pediatricbipolar.pitt.
edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final . Accessed July
29, 2020.
77. Ford-Paz RE, Gouze KR, Kerns CE, et al. Evidence-based assessment in clinical set-
tings: reducing assessment burden for a structured measure of child and adolescent
anxiety. Psychol Serv. 2019 Jun 13. Advance online publication. Available at: https://
doi.org/10.1037/ser0000367. Accessed July 29, 2020.
78. University of Pittsburgh. Screen for Child Anxiety Related Disorders (SCARED).
Available at: https://www.pediatricbipolar.pitt.edu/resources/instruments. Accessed July
29, 2020.
79. Spence Children’s Anxiety Scale. Available at: https://www.scaswebsite.com. Accessed
July 29, 2020.
80. Patient Health Questionnaire Screeners; https://www.phqscreeners.com. Accessed July
29, 2020.
81. Silverman WK, Ollendick TH. Evidence-based assessment of anxiety and its disorders
in children and adolescents. J Clin Child Adolesc Psychol. 2005;34:380-411.
82. Choudhury MS, Pimentel SS, Kendall PC. Childhood anxiety disorders: parent-child
(dis)agreement using a structured interview for the DSM-IV. J Am Acad Child Ado-
lesc Psychiatry. 2003;42:957-964.
83. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and
emotional problems: implications of cross-informant correlations for situational speci-
ficity. Psychol Bull. 1987;101:213-232.
84. De Los Reyes A, Augenstein TM, Wang M, et al. The validity of the multi-informant
approach in assessing child and adolescent mental health. Psychol Bull. 2015;141:
858-900.
85. Havighurst SS, Downey L. Clinical reasoning for child and adolescent mental health
practitioners: the mindful formulation. Clin Child Psychol Psychiatry. 2009;14:251-271.
1124 www.jaacap.org
86. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academies Press; 2001.
87. Hall DE, Prochazka AV, Fink AS. Informed consent for clinical treatment. CMAJ.
2012;184:533-540.
88. AHRQ. Methods Guide for Effectiveness and Comparative Effectiveness Reviews.
AHRQ Publication No. 10(14)-EHC063-EF. Rockville, MD: Agency for Healthcare
Research and Quality; January 2014.
89. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of In-
terventions, Version 5.1.0. Cochrane Collaboration; 2011.
90. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing
the quality of nonrandomized studies in meta-analyses. Ottawa, ON, Canada: Ottawa
Hospital Research Institute; 2000.
91. Guyatt GH, Oxman AD, Sultan S, et al. GRADE guidelines: 9. Rating the quality of
evidence. J Clin Epidemiol. 2011;64:1311-1316.
92. McGuire JF, Caporino NE, Palitz SA, et al. Integrating evidence-based assessment
into clinical practice for pediatric anxiety disorders. Depress Anxiety. 2019;36:
744-752.
93. Peris TS, Caporino NE, O’Rourke S, et al. Therapist-reported features of exposure tasks
that predict differential treatment outcomes for youth with anxiety. J Am Acad Child
Adolesc Psychiatry. 2017;56:1043-1052.
94. Ressler KJ, Nemeroff CB. Role of serotonergic and noradrenergic systems in the
pathophysiology of depression and anxiety disorders. Depress Anxiety. 2000;12(Suppl
1):2-19.
95. Aldrich SL, Poweleit EA, Prows CA, et al. Influence of CYP2C19 metabolizer status on
escitalopram/citalopram tolerability and response in youth with anxiety and depressive
disorders. Front Pharmacol. 2019;10:99.
96. Axelson DA, Perel JM, Birmaher B, et al. Sertraline pharmacokinetics and dynamics in
adolescents. J Am Acad Child Adolesc Psychiatry. 2002;41:1037-1044.
97. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal
ideation and suicide attempts in pediatric antidepressant treatment. A meta-analysis of
randomized controlled trials. JAMA. 2007;297:1683-1696.
98. Luft MJ, Lamy M, DelBello MP, et al. Antidepressant-induced activation in children
and adolescents: risk, recognition and management. Curr Probl Pediatr Adolesc Health
Care. 2018;48:50-62.
99. Foong AL, Patel T, Kellar J, et al. The scoop on serotonin syndrome. Can Pharm J.
2018;151:233-239.
100. Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor
discontinuation syndrome: a randomized clinical trial. Biol Psychiatry. 1998;
44:77-87.
101. Hemeryck A, Belpaire FM. Selective serotonin reuptake inhibitors and cytochrome
P-450 mediated drug-drug interactions: an update. Curr Drug Metab. 2002;3:13-37.
102. Costa E, Giardini A, Savin M, et al. Intervention tools to improve medication adher-
ence: review of literature. Patient Prefer Adherence. 2015;9:1303-1314.
103. Haddad PM. Antidepressant discontinuation syndromes—clinical relevance, preven-
tion, and management. Drug Safety. 2001;24:183-197.
104. Keks N, Hope J, Keogh S. Switching and stopping antidepressants. Aust Prescr. 2016;
39:76-83.
105. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a
combination in childhood anxiety. N Engl J Med. 2008;359:2753-2766.
106. Ginsburg GS, Sakolsky D, Piacentini J, et al. Remission after acute treatment in chil-
dren and adolescents with anxiety disorders: findings from the CAMS. J Consult Clin
Psychol. 2011;79:806-813.
107. Ginsburg GS, Becker EM, Keeton CP, et al. Naturalistic follow-up of youths treated for
pediatric anxiety disorders. JAMA Psychiatry. 2014;71:310-318.
108. Brent DA, Emslie GJ, Clarke GN, et al. Predictors of spontaneous and systematically
assessed suicidal adverse events in the Treatment of SSRI-Resistant Depression in
Adolescents (TORDIA) study. Am J Psychiatry. 2009;166:418-426.
109. Cipriani A, Zhou X, Del Giovane C, et al. Comparative efficacy and tolerability of
antidepressants for major depressive disorder in children and adolescents: a network
meta-analysis. Lancet. 2016;1263-1271.
110. Owen JR, Nemeroff CB. New antidepressants and the cytochrome P450 system:
focus on venlafaxine, nefazodone, and mirtazapine. Depress Anxiety. 1998;7(Suppl
1):24-32.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 59 / Number 10 / October 2020
https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depressyouth
https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depressyouth
https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
https://www.nice.org.uk/guidance/qs53/resources/anxiety-disorders-pdf-2098725496261
https://www.nice.org.uk/guidance/qs53/resources/anxiety-disorders-pdf-2098725496261
https://dailymed.nlm.nih.gov/dailymed/
https://www.fda.gov/Drugs
https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist/
https://www.massgeneral.org/psychiatry/treatments-and-services/pediatric-symptom-checklist/
https://sdqinfo.org
https://sdqinfo.org
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures
https://www.pediatricbipolar.pitt.edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final
https://www.pediatricbipolar.pitt.edu/sites/default/files/KSADS_DSM_5_Supp3_AnxietyDO_Final
https://doi.org/10.1037/ser0000367
https://doi.org/10.1037/ser0000367
https://www.pediatricbipolar.pitt.edu/resources/instruments
https://www.phqscreeners.com
http://www.jaacap.org
- Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders
Overview of the Guideline Development Process
Authorship, Source, and Scientific Review
Assessment of Anxiety
Identification
Evaluation
Evaluation Structure
Differential Diagnosis
Psychiatric Comorbidities
Medical Comorbidities
Structured Interview Guides
Symptom Rating Scales
Mental Status Examination
Clinical Formulation
Safety
Treatment Planning
Treatment of Anxiety
Development of Treatment Statements From the AHRQ/Mayo Systematic Review
AHRQ/Mayo Systematic Review Rating Procedure
CQI Treatment Statement Rating/Grading Procedure
Applicability of Treatment Findings From the AHRQ/Mayo Review
Treatment StatementsccThe treatment statements below are intended to apply to the named anxiety disorders for which all dia …
Benefits and Harms
Additional Support
Differences of Opinion
Quality Measurement Considerations
Implementation
Benefits and Harms
Additional Support
Differences of Opinion
Quality Measurement Considerations
Implementation
Benefits and Harms
Additional Support
Differences of Opinion
Quality Measurement Considerations
Implementation
Benefits and Harms
Additional Support
Differences of Opinion
Quality Measurement Considerations
Implementation
Areas for Additional Treatment Research
Limitations
Conclusions
References
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
