MARA GOVERMAN: A parent sits across from you and asks, “Why can't my child just take the same anxiety medicine that helps me?” Sounds reasonable, but the evidence tells a very different story.

JOSH FEDER: I'm Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the Child Medication Fact Book for Psychiatric Practice, second edition 2023, and our other book, Prescribing Psychotropics.

MARA GOVERMAN: And I’m Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of the Carlat Psychiatry Reports. Today, we are going to look at how benzodiazepines fit into care for children and adolescents. So picture this: a teenager whose anxiety is still disrupting their life despite a solid trial of therapy, they've stayed engaged in CBT for months, yet worries and avoidance continue to affect school performance, social life, and day-to-day functioning in the family.

JOSH FEDER: That's when families often start asking about medication. If you suggest an SSRI, some parents push back because they've seen alarming headlines online, or they draw on their own experiences using benzodiazepines and assume those medications might work the same way for their child. And that question opens the door to a bigger discussion of what actually works for anxiety in kids and teens and what the evidence tells us to avoid.

MARA GOVERMAN: Okay, to understand these questions, we need to zoom out. Pediatric anxiety affects 10% of children (Kowalchuk A et al, Am Fam Physician 2022;106(6):657–664), and these disorders include generalized anxiety, separation anxiety, and social anxiety, often starting early, but real functional impairment usually shows later in childhood or adolescence.

JOSH FEDER: We'd love to see more families coming to us early on to ask whether there's a way to step in and keep the anxiety from escalating. At that point, we don't really have a lot of proven strategies for children whose symptoms haven't reached a clinical level, but most families come to us when things have already gotten very complicated.

MARA GOVERMAN: When anxiety causes impairment, we start with treatment sequencing. Research shows that CBT and SSRIs each reduce anxiety symptoms in children and adolescents.

JOSH FEDER: Combining cognitive behavioral therapy, CBT, and medication leads to better outcomes than either approach alone, especially when symptoms interfere with development or with daily functioning.

MARA GOVERMAN: From mild to moderate anxiety, CBT often comes first. Families generally prefer therapy, and engagement tends to stay higher compared with medication-only approaches.

JOSH FEDER: And the hard part throughout our careers has been finding people who are actually pretty good at doing cognitive behavioral therapy with kids, right? It's simple when you think about what the different aspects are, right? I mean, how you think about stuff affects how you feel about stuff, and how you use your body or don't, especially if you're moving and exercising, affects mood and anxiety, stuff like that; and they all kind of fit together. And in cognitive behavioral therapy, we try to figure out what are the thoughts that the person's having, those automatic thoughts. What are the ideas underlying those automatic thoughts? How do you change those? And also, what other behaviors could you engage in, in addition to relaxation, debriefing, all that stuff, that can change just how the anxiety feels, very effective, but actually, a lot of people don't execute it very well, not very organized, and so finding somebody who's pretty good at it is a challenge. And we do have some people who want medication first, partly because they can't find anyone.

MARA GOVERMAN: In my experience, underneath CBT, effective treatment is the relational, social-emotional piece, because it requires a working relationship that has trust and support, because it takes patients to tolerate distress, to have a game plan, and continue to make adjustments during the treatment process.

JOSH FEDER: Well, that's true. I mean, we're big proponents of relationship-based approaches, and we've had concerns about the utilization of behavioral approaches more with autism than the CBT here. But in any case, if you're being very prescriptive and you don't have a good therapeutic relationship, it might not go very well. In fact, there are so many adult studies and fewer child studies that show that the relationship is actually what helps kids get better, more than the specific technique. That said, if you're trying to be organized and efficient, good CBT is still a good idea for most kinds of anxiety. And anxiety can be really crippling. I mean, it can truly change a person's life, and oftentimes what we see are parents who don't want their kids to be anxious, and so they do things to help their kids not be anxious, as if that's the goal, when anxiety care, and everybody needs to remember this, anxiety care is not about not feeling anxious, it's about tolerating anxiety, because we all feel anxious a bunch of the time. I was just talking with an adult patient yesterday about this because they're very stuck in their anxiety, and their thought, their automatic thought, is, “Oh, I don't want to feel anxious, and I can't do these things because I might feel anxious.” And my response is, and working with a therapist, actually, the goal is to experience the anxiety but do stuff anyway. Again, not easy for families to do when their kids are raising the roof about this stuff, but we all have to figure out how to learn to take little bits of anxiety and then grow that, so that we can tolerate everyday life.

MARA GOVERMAN: I just have one other thing to add: sometimes, if you have an extremely anxious child or teen, you have to calm the nervous system down first for them to be calm and regulated enough and available to attempt something new.

JOSH FEDER: Well, that's a great segue, because when anxiety stays intense or interferes with daily life, delaying medication doesn't improve outcomes. Adding medication at that point helps kids engage more fully in school, social activities, and in therapy.

MARA GOVERMAN: Access also shapes decisions around anxiety management. Some patients don't have access to trained CBT providers, even though telehealth exists. In those cases, medication alone still reduces symptoms.

JOSH FEDER: They're on a medication, and they're doing well, kids and adults, who have done just fine on an SSRI. So it can certainly be fine to use an SSRI. I mean, my general hope is that people will feel better and then get tools, or at least a clarity of understanding that they don't have to feel that way, and then eventually be able to move away from medication, but that's not always the case, and there are some people who are chronically on SSRIs, and it's kind of okay. So across medication options, SSRIs show the strongest evidence for treating pediatric anxiety; other medication classes just don't perform as well (Dobson ET et al, J Clin Psychiatry 2019;80(1):17r12064).

MARA GOVERMAN: That includes benzodiazepines. While they reduce anxiety in adults, studies in children show there's no advantage over placebo.

JOSH FEDER: And that's the big thing here, right? They don't really work. And they have more side effects, they have sedation, irritability, and oppositional behavior, they interfere with learning, they interfere with motor function, they limit progress in therapy (Nicotra CM and Strawn JR, Child Adolesc Psychiatr Clin N Am 2023;32(3):573–587). I've seen way too many people who are essentially being medicated with something that makes it impossible to do the therapy that they need to be able to not have to be on medication. It's a real problem. It's a problem with benzos. It's a problem with weed. It's a problem with alcohol. It's a problem with a lot of things, and we see kids and teens who are using some of these other substances. But for me, benzos aren't a whole lot different, except maybe fewer long-term problematic side effects, such as cirrhosis or lung damage. I mean, I guess you're not getting that with benzos, but it isn't much better, as far as I'm concerned.

MARA GOVERMAN: From a therapeutic standpoint, the challenges are making changes in lifestyle and family habits and routines, and that's a struggle for some families.

JOSH FEDER: Yeah, and so another way that these are used is kind of on a PRN basis, right? Where somebody gives someone literally a chill pill, as a way of trying to not have them upset. And plenty of prescribers prescribe benzos to kids for the same reason, right? They feel like, “Oh, well, the kid's anxious, so let's fill those receptors, and maybe they'll do better.” But it doesn't make the anxiety better. It makes the kid generally more sensitized to, “Oh, now I'm feeling a little anxious,” and they go sooner to the medication, just like later on in life, perhaps, or maybe the same age, they go sooner to weed or sooner to alcohol.

MARA GOVERMAN: Because of this, our algorithm and other clinical guidelines don't include benzodiazepines as a treatment for pediatric anxiety disorders.

JOSH FEDER: So when parents ask about benzodiazepine use, you might want to focus your response on the evidence. These medications don't treat anxiety in children and carry real risk.

MARA GOVERMAN: As well as they do not teach self-care and coping strategies.

JOSH FEDER: Meaning if you give somebody a fish, they eat for a day. And if you teach a person to fish, they eat for a lifetime.

MARA GOVERMAN: Questions about sleep come up as well. Many children with anxiety struggle at bedtime, and families may ask about sedating medications.

JOSH FEDER: We don't have trials supporting benzodiazepines for pediatric insomnia. Studies of other hypnotics also fail to show decent benefit. And again, we've got an algorithm for everything, our algorithm for sleep has a lot to do with relaxation and maybe short-term use of diphenhydramine, which a lot of people want off the market, or hydroxyzine, or something like that. Melatonin, if you take it 90 minutes before you're planning to go to bed, because it takes some time to kick in, and never more than about 3 milligrams of melatonin (McDonagh MS et al, J Child Neurol 2019;34(5):237–247).

MARA GOVERMAN: I also think that melatonin doesn't work for everyone. And sometimes magnesium citrate or magnesium creams, especially for kids, can be useful as well.

JOSH FEDER: Yeah, we like those herbals too, right? Chamomile tea works well for a lot of people. Passionflower and valerian root it comes in capsules, and it's kind of stinky, but some people take that as well. But nothing is better than cognitive behavioral therapy for insomnia. So while research shows that melatonin can help some kids fall asleep and stay asleep longer, et cetera, especially the long-acting stuff, we really like cognitive behavioral therapy for insomnia, which breaks down sleep hygiene stuff.

MARA GOVERMAN: Thank you.

JOSH FEDER: The usual sleep hygiene stuff. Getting up at the same time every day, even weekends, and not trying to go to bed extra early for an extra good night's sleep, not lying awake in bed, avoiding caffeine and screen use at night.

MARA GOVERMAN: Quiet activities, a hot shower, a bath, and reading, just things to not stimulate the body and the brain.

JOSH FEDER: Right. So this is great advice, but most people have heard it a bunch of times, but they don't use it. What cognitive behavioral therapy for insomnia does is it takes those ideas, breaks them down, and helps you fit them to your life, your problems, your way of actually implementing it so that it happens. So it's not just advice that goes out the window. A potential concern for clinicians to think about is benzodiazepine availability in the home. Benzo prescriptions for adults are common, and many pediatric exposures come from shared household access.

MARA GOVERMAN: And adolescents who use benzodiazepines without a prescription face risks later on, including substance-related problems (Sun EC et al, BMJ2017;356:j760; Blanco C et al, J Clin Psychiatry 2018;79(6):18m12174).

JOSH FEDER: Yeah, so substance abuse often starts at home, whether it's benzos or opiates. And so we really need to be cleaning our cabinets and locking up medications. It's not going to always stop everybody from getting them, but it certainly reduces the risk. And it's not just at your house. It's the kids who come over to your house and are looking for stuff, or your kid going to another house and maybe poking through the cabinets while they're in the bathroom. So benzodiazepines do have some specific roles in pediatric care.

MARA GOVERMAN: Research shows that single doses of midazolam can help children with severe anxiety perform medical procedures. Benzodiazepines can also play a central role in diagnosing and treating catatonia.

JOSH FEDER: And that's another piece of our clinic work over the years. As kids with malignant catatonia, I mean, it's a life-threatening condition, and high-dose lorazepam is kind of the way to go, and you titrate it fairly rapidly if you can. I've had families who resist that because they're worried about benzo use. Here's the place where I don't worry about it, because it's literally saving a life. Also, intractable seizures is another place where you're going to use benzodiazepines in pediatric emergency settings. Clinicians are going to use it for those seizures. They're going to use it for acute agitation because the effects are rapid and reversible. But even for acute agitation, we've got a separate algorithm in our Child Medication Fact Book for Psychiatric Practice that has a whole way of thinking about this, starting with the surround. Why is somebody agitated? It might be because they have sensory differences, and they're freaking out about what's going on around them. I was just reading another description of a kid in a grocery store who, the yogurt wasn't the right yogurt, and so the kid is flailing about and really causing a ruckus, and people want them to go spank the kid or people want to call the paramedics. And the mom is saying, “Sure, I'll call them. Sure, go call the paramedics.” What do you think that's going to look like when all these people come, lights and everything? How do you think that's going to help this kid calm down? In the end, a great bystander comes up and is able to really calmly be with the mom, help the mom feel calmer, and then the kid calms down, and they're actually able to distract the child. So, I mean, there are other ways to address these kinds of problems, even in an agitated acute setting. We've got protocols for that, and there are other medications that can be used. Again, hydroxyzine, occasionally, this is one of the places where we might use a D2 blocker, an antipsychotic. Not that we like to use those either, but better that than starting to get into the whole benzo thing.

MARA GOVERMAN: So outside these situations, benzodiazepines don't fit routine anxiety treatment very well.

JOSH FEDER: Not in kids. So when therapy alone doesn't go far enough, the next step involves combining CBT with an SSRI.

MARA GOVERMAN: You explain the rationale, address safety concerns, and start at a low dose and adjust gradually while therapy continues.

JOSH FEDER: That approach aligns with the evidence and supports steady improvement without interfering with learning or development.

MARA GOVERMAN: The larger lesson is this: therapy anchors treatment for pediatric anxiety when medication helps. SSRIs offer the best balance of benefit and tolerability.

JOSH FEDER: And it's not that they don't have any side effects, right? I mean, you can have behavioral activation. There's that 1% suicidality with SSRIs. Some people gain some weight, I mean, so they're not perfect, but they're sure the best thing we got. Anticholinergics stay reserved for short-term targeted situations, not daily management of childhood anxiety in most situations.

JOSH FEDER: Today's podcast isinspired by our article with Dr. Anthony Charuvastra and Tal Tetzeli in our October/November/December 2025 newsletter.

MARA GOVERMAN: We'll link it in the show notes. And if you found this episode valuable, which we really hope that you did, please share it with others who need to hear this message.

JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry.

MARA GOVERMAN: The newsletters and books we produce depend entirely on reader support. There are no ads, and our authors don't receive industry funding, which helps us bring you unbiased information that you can trust.

JOSH FEDER: Thanks to all of you for tuning into this episode. Again, like Mara said, if you found this discussion helpful, subscribe to more episodes on mental health and psychiatric care and tell your friends. Until next time, take care, and if you look for good things, more good can happen.