Ten years old and frightened, my patient sat huddled in the chair, tears streaming down her face, knees drawn to her chest, avoiding school for the third consecutive week. Her parents appeared worn out. “We’ve attempted everything. We don’t want to medicate her… but we can’t continue like this.”

As a child and adolescent psychiatrist, I’ve had this dialogue many times. Some families enter asking for medication. Others come in firmly believing that psychiatric drugs are off the table. I grasp both perspectives.

I’m a careful prescriber, especially with children and adolescents. I fully recognize that I’m dealing with a developing brain. Yet, after many years of experience, I’ve arrived at a tough-earned truth: at times, excessive caution is the real risk.

Recognizing when anxiety becomes an issue

Anxiety exists on a spectrum, and since most of us feel it to some extent, individuals often underestimate just how consuming clinical anxiety can be. We tend to think it’s something one can just push through, as many of us have done. However, clinical anxiety doesn’t merely rise and fall—it dominates.

In its usual form, anxiety is beneficial. In medical school, it drove me to stay in and study when it was tempting to socialize with friends. The anxiety served a purpose: It kept my focus. After the test, it dimmed.

But clinical anxiety differs. It isn’t motivating—it’s immobilizing. It doesn’t dissipate—it remains persistent and relentless. The hyperaware brain gets stuck in a mode of threat, continually searching for danger, heightening uncertainty, and diminishing safety and personal agency. This type of anxiety doesn’t encourage a child to develop. It confines their world.

Certain children are biologically more susceptible due to their fear response: quicker to trigger, slower to calm. This is not due to weakness or willfulness—it’s how their system operates. This is why reassurance and sheer willpower often fall short. Biological aids such as proper sleep, nutrition, exercise, and in some cases, medication, can assist in shifting that internal state and fostering room for transformation.

As Drs. Ross Greene and Stuart Ablon state, “Kids do well if they can.” When they possess the right tools and support, they engage. They strive. They develop.

When should we think about medication?

As physicians, our duty is to be safe, considerate, and evidence-based while ensuring our patients receive the treatment necessary for the progress they deserve.

Instead of questioning, “Is this child anxious?” I inquire, “Is anxiety dominating the situation?” And if it is, then “What will it take to help this child counteract it?”

When anxiety escalates and consumes a child’s world—interrupting school, friendships, and family life—medication should be explored. Medication is not a cure-all. It doesn’t impart new skills. But it can create space for the child to learn and practice those skills through other means, such as cognitive behavioral therapy (CBT). In other words, medication cannot substitute therapy, but it can enhance the likelihood of its success.

For this reason, I never prescribe medication in a vacuum. I either provide therapy myself or ensure that the family is actively involved with a provider who can address the psychological and social aspects of anxiety, paving the way for lasting change.

Data indicates that this combined approach is effective. A landmark RCT demonstrated that cognitive behavioral therapy (CBT) paired with medication (SSRI) achieved a response rate exceeding 80 percent, more than 20 percent higher than therapy or medication alone.

Steering clear of common pitfalls

Here’s a typical scenario: A child begins with a low dosage of an SSRI. Side effects are minimal, as are improvements. After several weeks, the family concludes, “I suppose meds don’t work.”

A trial was commenced but not completed. If we’re going to attempt medication, let’s genuinely attempt it. A proper trial necessitates adequate duration (roughly 12–28 weeks) of a therapeutic dose with confirmed adherence (and don’t underestimate how often this is the missing element). Equally important is setting realistic expectations. Medication is not intended to eradicate all anxiety; understand that some anxiety is normal, and some may even be beneficial.

Our goal is to lower the intensity of the anxiety. When anxiety is blaring, it’s difficult (and exhausting) to pay attention to anything else. But when the intensity decreases even slightly, there’s room to disengage from the anxiety and respond differently. When that change occurs, it shifts the momentum. Therapy becomes more effective, school feels more manageable, and hope is rekindled.

Medication is not a permanent solution.

Naturally, families inquire, “Will my child have to be on this forever?”

In most instances, the answer is no. The pediatric brain is flexible, molded by experiences. And