TABLE 1

Summary of Medications for the Treatment of Anxiety in Youth With ASD

SymptomsaMedicationbDose RangebReferences
Starting DoseMaximum Dose
Core anxiety symptomsSertralinec12.5 mg daily200 mg dailyReviews in typically developing youth: Mohatt et al (2013), Strawn et al (2014)
Fluoxetinec2.5–5 mg daily60 mg daily
Citalopramc2.5–5 mg daily40 mg daily
Escitalopramc1.25–2.5 mg daily20 mg daily
Specific anxiety symptomsd
 Sleep disturbanceMelatonin2 mg hs10 mg hsGuenoe et al (2011)
Clonidine0.05 mg hs0.2 mg hsNguyen et al (2014)
Trazodonee12.5–25 mg hs100 mg hs
 Physiologic symptomsfClonidinef0.05 mg hs for 1 week then bid-qid0.1 mg tid-qidNo data in TD or ASD youth; recommendations based on clinical consensus
Guanfacinef0.05 mg hs for 1 week then bid-qid1 mg tid
Clonidine ERf0.1 mg hs or qam0.2 mg hs or qamg
Guanfacine ERf1 mg hs or qam4 mg hs or qamg
Propanolol10 mg bid-tid or prn30 mg tid
 Behavioral dysregulationfClonidine0.05 mg hs for 1 week then bid-qid0.1 mg tid-qidReviews by: Mahajan et al (2012), Ji and Findling (2014)
Clonidine ER0.1 mg daily0.2–0.3 mg daily
Guanfacine0.5 mg hs for 1 week then bid tid1 mg tid
Guanfacine ER1 mg hsg4 mg hs or qam
 Situational anxietygLorazepam0.25–0.5 mg prn2 mg prnNo data in TD or ASD youth; recommendation based on clinical consensus
Propanolol5–10 mg prn20 mg prn
  • bid, twice daily; ER, extended-release; hs, bedtime; prn, as needed; qam, each morning; qid, 4 times per day; tid, 3 times per day.

  • a Specific anxiety symptoms refer to individual or limited symptoms of anxiety, whereas core anxiety symptoms refer to the entire syndrome of cognitive, affective, and physiologic changes associated with anxiety.

  • b Maximum doses are based on data in TD children and adolescents. Higher doses in this table should only be used in consultation with a specialist versed in their use, such as a child psychiatrist or developmental-behavioral pediatrician

  • c Discuss side effects including risk of behavioral activation. Higher doses may be needed for fast metabolizers. Slow metabolizers may need lower doses.

  • d Behavioral dysregulation refers to symptoms of irritability, aggression, property destruction, and self-injury. For severe behavioral dysregulation, refer to a mental health specialist or follow the ATN pathway for treatment of irritability and problem behaviors.

  • e There are no data to support the use of trazodone. It is only recommended in children aged >8 years. The risk of priapism should be discussed with the family.

  • f For short and ER clonidine and guanfacine preparations, monitor blood pressure and heart rate at each visit. Check for orthostatic hypotension if dizziness, light-headedness, or falls are reported. Guanfacine ER can be started in the evening initially due to the possibility of sedation and then switched to morning, if needed. Alternatively, it can be started directly in the morning if tolerated by the patient. Guanfacine is preferred over clonidine during daytime hours because of its longer half-life and lower potential for sedation.

  • g Lorazepam is a short-acting benzodiazepine (6–8 hours). For situational anxiety, it should be given 30 min before the event. There are no data on the use of propranolol in children and adolescents, but it is used by some experts for the treatment of situational anxiety.