Pharmacotherapy for separation anxiety disorder in children

Psychosocial interventions are first line for separation anxiety disorder in children.

If a child with separation anxiety disorder has severe symptoms, consider pharmacotherapy. Pharmacotherapy is ideally started by a clinician with expertise in using psychotropics in children (eg child psychiatrist, paediatrician). If a drug is required, use this concurrently with psychosocial interventions if possible.

Selective serotonin reuptake inhibitors (SSRIs) are first-line drugs; however, paroxetine is not recommended in children because it has been associated with an increased risk of suicidal thoughts and behaviours, and other serious adverse events.

There is limited evidence to guide dosing of SSRIs in children. The dosage regimens in these guidelines are predominantly based on expert opinion and are included as a guide to suitable dosing. If the dosage regimens in these guidelines prove inadequate (eg higher doses are needed), expert advice should be sought because alternative regimens may be appropriate.

Starting patients on a low dose may help to decrease initial adverse effects (eg nausea, restlessness, agitation). However, the use of a lower starting dose prolongs the time taken to achieve therapeutic effect. See here for information on managing adverse effects.

Note: Psychosocial interventions are first line for separation anxiety disorder in children; if pharmacotherapy is used, it is ideally started by a clinician with expertise in using psychotropics in children.

Do not use pharmacotherapy for separation anxiety in children 6 years or younger.

In children older than 6 years and younger than 12 years, if pharmacotherapy is considered necessary for separation anxiety disorder, use:

1 citalopram 5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing separation anxiety disorder citalopram

OR

1 escitalopram 2.5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 2.5 to 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 10 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing separation anxiety disorder escitalopram

OR

1 fluoxetine 5 mg orally, in the morning¹. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 30 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing separation anxiety disorder fluoxetine

OR

1 fluvoxamine 12.5 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 100 mg is reached. Doses above 50 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing separation anxiety disorder fluvoxamine

OR

1 sertraline 12.5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 100 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. separation anxiety disorder sertraline

When deciding upon a suitable dosing regimen in children 12 years and older, consider the child’s developmental (physical) maturity—developmental maturity can vary between individuals of the same age (eg some 12-year-olds might be metabolically similar to young children, whereas others are similar to adults). At the lower end of the dose range, the recommended doses approximate those used in younger children, whereas the maximum doses approximate those used in adults and young people. In children 12 years and older, if pharmacotherapy is considered necessary for separation anxiety disorder, use:

1 citalopram 5 to 10 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 40 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing citalopram

OR

1 escitalopram 2.5 to 5 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 2.5 to 5 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 20 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing escitalopram

OR

1 fluoxetine 5 to 10 mg orally, in the morning². Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 5 to 10 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 60 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing fluoxetine

OR

1 fluvoxamine 12.5 to 25 mg orally, at night. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. Doses above 50 mg daily may be given in 2 divided doses for better tolerability. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing fluvoxamine

OR

1 sertraline 12.5 to 25 mg orally, in the morning. Assess the patient’s response to therapy after 2 to 4 weeks to determine whether dose adjustment is needed. If it is, increase the daily dose by 12.5 to 25 mg no more often than every 2 weeks until an acceptable response is achieved or a daily dose of 200 mg is reached. If there is an acceptable response, continue at the same dose for 6 months, then consider deprescribing. sertraline

¹ To obtain 5 mg of fluoxetine, the 20 mg dispersible tablets can be halved, dispersed in water and half of the solution consumed. For information on palatability, see the Don’t Rush to Crush Handbook , published by the Society of Hospital Pharmacists of Australia. Return

² To obtain 5 mg of fluoxetine, the 20 mg dispersible tablets can be halved, dispersed in water and half of the solution consumed. For information on palatability, see the Don't Rush to Crush Handbook , published by the Society of Hospital Pharmacists of Australia.Return