Between 2002 and 2007, the landmark Child/Adolescent Multimodal Study (CAMS) compared four treatment arms in the management of pediatric anxiety:
The study found that at 12 weeks, 50-60% of participants in both the CBT and the SSRI groups showed significant improvement in anxiety symptoms, with no statistically significant difference between the two arms; the CBT arm showed slightly more improvement than the SSRI arm alone. Moreover, the study found that 80% of children treated with a combination of both CBT and SSRIs showed improvement in anxiety symptoms (27). Although this study guides management of anxiety in youth, it does not necessarily address acute anxiolysis. Current recommendations for long term anxiety management do include combination treatment using SSRI’s plus CBT.
Below, we review different pharmacologic options for acute anxiety management:
Hydroxyzine (Atarax)
A 1st generation antihistamine (21) that is FDA approved for short-term symptomatic management of acute anxiety in pediatric populations (3). This drug takes effect within 15-30 minutes of oral intake, with the anxiolytic effects lasting for 4-6 hours (3). Hydroxyzine carries no addictive potential (3). Dosing for youth older than 6 ranges from 12.5 to 25 mg up to 4 times daily (7). However, doses as much as 50 mg may sometimes be needed in youth with an adult habitus. Hydroxyzine is often well-tolerated with a limited side effect profile. The most common side effect is sedation, which sometimes can be helpful in youth who have sleep difficulties. Less common side effects include QT prolongation at doses greater than 50 mg, as well as dry mouth and increased appetite with sustained use (20).
Propranolol
A non-selective beta blocker used off-label for situational anxiety (i.e., performance anxiety, dental phobia, etc…) in adults and adolescents (23-26). There is limited evidence for propranolol in pediatric anxiety (18; 22; 24-25). For adolescents, the initial dose is often 10 mg and titrated to effect up to 20 mg per dose. Total daily dose can range from 10 mgto as high as 40 mg, and doses can be divided up to 2-3 times per day (20). Common side effects include dizziness, fatigue, bradycardia, and hypotension. Initial vital signs, a personal cardiac history, and family cardiac history should be obtained prior to starting and monitored longitudinally. If there are any concerns of cardiac history, family cardiac history, or abnormal heart rate or blood pressure prior to initiation, consultation with Pediatric Cardiology should be sought. Use of propranolol is contraindicated in asthma, sick sinus syndrome, >1st degree heart block, and sinus bradycardia (20). Caution should be taken in the use of beta blockers with youth experiencing concurrent depressive symptoms, as beta blocker use may worsen depression.
Benzodiazepine
A class of medications that binds to GABA receptors in the central nervous system, leading to inhibition of neuronal activity (5). Although research in pediatric populations is limited, existing data suggest benzodiazepines are effective acute anxiolytics in youth and are generally well-tolerated (14). Due to the potential for dependence and withdrawal as a schedule IV controlled substance, the American Academy of Child & Adolescent Psychiatrists recommends short-term (<2 weeks) benzodiazepine use in limited circumstances with close monitoring (1). Benzodiazepines should be reserved for more severe cases of anxiety where psychotherapy and other pharmacologic management have been limited in promoting functioning, or the severity warrants a brief bridge of benzodiazepine for anxiolysis until more sustained therapies and pharmacologic treatments are able to take effect. Additionally, rare use prior to a highly anxiety-provoking activity can be considered when other non-pharmacologic and pharmacologic strategies have been limited in addressing acute anxiety (e.g. prior to procedure or diagnostic study, such as MRI).
Benzodiazepines can have short, moderate, or long-acting half-lives. Avoid benzodiazepines with short-half lives, like alprazolam, that have an increased risk of dependence. Consider moderate to longer acting benzodiazepines, like lorazepam, clonazepam, and diazepam, when needed. Short-term use of lorazepam in adolescents involves starting at doses of 0.25 mg 2-3 times daily, titrating to a dosing range of 0.02 mg/kg/dose to 0.1 mg/kg/dose with a maximum dose of 2 mg per dose (9; 13). However, caution should be taken with the dosing, frequency, and duration of use of lorazepam. If you consider dosing of other benzodiazepines or have questions about considering a benzodiazepine, please contact MC3 for further guidance. The most common side effects of benzodiazepine use are sedation and fatigue. Less common side effects include weakness, respiratory depression, paradoxical agitation, and disinhibition (16; 2).
Gabapentinoids
Gabapentinoids, like gabapentin and pregabalin, are GABA analogs that cause inhibition of neuronal activity (6). A number of studies suggest that gabapentin may be helpful for anxiety in adults (4; 10; 15; 17). Little to no data exists for youth with notable risk with the use of this medication class. Patients can develop dependence and withdrawal (6), and long-term daily use in adults may increase the risks of cognitive impairment and dementia later in life (8; 11; 12; 19). Gabapentinoids are also classified as a Schedule V controlled substance in some states. Use of this medication class should be limited in youth, unless there is another indication for use (such as neuropathic pain) with comorbid anxiety. Common side effects include drowsiness, dizziness, fatigue, respiratory depression, and weight gain (6). There also may be an indication for gabapentin in adolescents with anxiety and co-occurring substance use disorders, although close monitoring is required in this population and gabapentin would serve as an adjunctive therapeutic. If there are questions about gabapentinoids, please feel free to contact MC3 for further guidance.
Abrams G, Malas N. Acute Anxiety Management. Michigan Clinical Consultation & Care. January 14, 2026. https://mc3michigan.org/clinical-pearls-faqs-acute-anxiety-management/.