Although there are only minimal data, consider prazosin for PTSD in kids, especially for PTSD-associated sleep disturbances and nightmares, but monitor BP.

Benzodiazepines are generally only appropriate for use before procedures. Lorazepam probably has less risk of misuse than others. Lorazepam is also the first-line, but off-label, treatment for catatonia.

Due to the lack of large randomized controlled data to support its use and the potential for side effects, clonazepam should be avoided. If you decide to use it, keep it very short term and deploy it adjunctively in kids who exhibit only partial response to first-line therapies (SSRI, SNRI) or have severe anxiety.

Despite the lack of large randomized controlled data to support first-line use, buspirone may be used adjunctively in kids who exhibit partial response to first-line therapies for anxiety (SSRI, SNRI), without the sedation and abuse potential burden of benzodiazepines.

Antihistamines can be effective sleepers for some kids and are the most prescribed by pediatricians, although some patients may experience too much grogginess (“hangover”) in the morning or a paradoxical excitation.

Anxiety treatment algorithm for children and adolescents

Anxiety is perhaps the most frequent symptom for which child psychiatrists are consulted.

Like the first norepinephrine reuptake inhibitor for ADHD, atomoxetine, viloxazine has no misuse potential and is less likely than stimulants to cause insomnia, anxiety, or tics.

Adderall is effective but is probably the most misused and diverted of all stimulants, and it tends to have more side effects, all of which is why we recommend starting most patients on methylphenidate instead.

Daytrana is helpful for kids who, for whatever reason, cannot use any of the wide variety of oral stimulant preparations.