Max is a 13-year-old with severe social and generalized anxiety disorder (GAD) who is not improving after six months of cognitive behavioral therapy (CBT). You recommend a selective serotonin reuptake inhibitor (SSRI), but his parents have read online that SSRIs are dangerous. They ask if Max can take lorazepam every day instead.

Pediatric anxiety is the most common psychiatric condition in childhood, affecting about 10% of kids (Kowalchuk A et al, Am Fam Physician 2022;106(6):657–664). Parents often recall positive experiences taking benzodiazepines (BZDs) for their own anxiety and wonder if these medicines would be helpful for their children. You’ll encounter these requests regularly, and they present an opportunity to educate families about effective and safe approaches for pediatric anxiety.

GAD, separation anxiety disorder, and social anxiety disorder each occur in about 1%–3% of kids annually (Bitsko RH et al, MMWR 2020;71(2):1–42). Many patients show anxious symptoms in early childhood but develop clinical impairment during middle childhood or adolescence. While parents of young anxious children may ask about prevention strategies, we don’t yet have established preventive interventions for subclinical anxiety levels (Rapee RM et al, J Consult Clin Psychology 2010;78(6):863–870).

How to sequence treatmentThe landmark Child/Adolescent Anxiety Multimodal Study (CAMS) established that SSRIs and CBT are equally effective for pediatric anxiety, and combining medicine and CBT is superior to either treatment alone (Piacentini J et al, J Am Acad Child Adolesc Psychiatry 2014;53(3):297–310).

For mild to moderate anxiety
We usually recommend CBT first. Families often have concerns about medication side effects and prefer to start with therapy. Clinical trials show that CBT groups have fewer dropouts compared to medication groups (Wang Z et al, JAMA Pediatr 2017;171(11):1049–1056). However, it is important to reassure families that SSRIs are generally safe and well tolerated.

For severe anxiety
When symptoms are causing substantial impairment, we recommend a combination treatment to minimize developmental disruption. Don’t wait if the anxiety is significantly interfering with school, relationships, or daily functioning.

When specialized therapy isn’t available
Not every child has access to well-trained CBT providers, even through telehealth. In these instances, medication alone is a good option. A recent ­meta-analysis found that compared with all other medicines (serotonin/norepinephrine reuptake inhibitors, tricyclics, BZDs, buspirone, and guanfacine), SSRIs were the most effective medication class for pediatric anxiety (Dobson ET et al, J Clin Psychiatry 2019;80(1):17r12064).

Poor efficacy, problematic side effects
You might assume that BZDs, which work well for adult anxiety, would also help kids. However, several double-blind studies of BZDs in children with anxiety showed no difference from placebo. Worse, BZDs caused more negative side effects, including drowsiness, irritability, and oppositional behavior. In addition, BZDs interfered with learning and impeded therapy (Nicotra CM and Strawn JR, Child Adolesc Psychiatr Clin N Am 2023;32(3):573–587). The 2020 American Academy of Child and Adolescent Psychiatry guidelines for treating pediatric anxiety don’t even mention using BZDs (Walter HJ et al, J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124).

You explain to Max’s parents that not only would daily lorazepam be ineffective for his anxiety, it carries significant risks of dependence and might interfere with therapy and learning. The evidence clearly shows that SSRIs are both safer and more effective for his condition. 

What about BZDs and pediatric sleep?
Parents also ask about BZDs for sleep problems. One US study of 18.6 million pediatric visits for sleep issues found that while only 22% of kids were referred for behavioral therapy, 81% received medication prescriptions. About 33% got antihistamines, 25% got clonidine, and 15% received BZD prescriptions (Stojanovski SD et al, Sleep 2007;30(8):1013–1017).

Because of safety concerns, there are no clinical trials of BZDs for pediatric sleep problems. Studies of zolpidem and eszopiclone showed no benefit in children with insomnia. Instead, 20 placebo-controlled trials of melatonin in children have shown significant improvements in sleep latency, sleep duration, and wake time after sleep. Melatonin remains effective for years with typical doses of 1–3 mg given about 90 minutes before bedtime (McDonagh MS et al, J Child Neurol 2019;34(5):237–247).

Growing concerns about BZD misuse
From 2000 to 2015, there was a 54% increase in reports of BZD exposure to poison control centers, with about half from intentional misuse. Most pediatric exposures came from adult prescriptions in the household. In 2019, 92 million BZD prescriptions were filled, mostly by adults, creating widespread household availability.

About 4% of high school students report nonmedical BZD use (Hirschtritt ME et al, JAMA 2021;325(4):347–348). Nonmedical BZD use is linked to higher risks of opioid overdose and substance use disorder in adulthood (Sun EC et al, BMJ 2017;356:j760; Blanco C et al, J Clin Psychiatry 2018;79(6):18m12174).

When BZDs are appropriate for kids
Despite these concerns, there are specific situations in which you should consider BZDs for pediatric patients.

Medical procedures
Children who are extremely anxious and undergoing medical procedures benefit from single doses of oral midazolam, given 15–30 minutes before the procedure. Used this way, there’s no increased risk of paradoxical agitation (Kuang H et al, Depress Anxiety 2017;34:888–896). You could prescribe midazolam 0.25–0.5 mg/kg (maximum 15 mg) given 15–30 minutes before procedures for children with severe procedural anxiety.

Catatonia
BZDs play a critical role in diagnosing and treating catatonia in children and adolescents. About 5% of pediatric outpatients exhibit catatonia symptoms, but prevalence reaches 17% in patients with psychotic disorders or autism. You can use a BZD challenge test with 2–4 mg lorazepam to verify the diagnosis. If symptoms improve, continue lorazepam at regular intervals (Luccarelli J et al, Schizophrenia Research 2024;270:410–415). Patients often require high doses, up to 24 mg/day. 

Acute agitation
Lorazepam is commonly used to manage severe agitation in pediatric emergency departments. Its benefits include rapid onset and reversible effects. Typical doses are 0.05–0.1 mg/kg (maximum 2 mg) given intramuscularly or intravenously (Sonnier L and Barzman D, Pediatr Drugs 2011;13(1):1–10).

Epilepsy
Neurologists use BZDs for acute seizure management and combination therapy, though this use may be decreasing due to side effect concerns.

Since Max’s symptoms are severe and he has already had six months of CBT with limited improvement, combination therapy is the logical next step. You reassure his parents about SSRI safety and recommend starting sertraline at 25 mg/day, then increasing to 50–100 mg based on response, while continuing his therapy sessions. This gives him the best chance for meaningful improvement of his anxiety symptoms.