An aspect of the Center for
written by: Lindsay Thom
I attest that the following
report is a product of my own original work.
disorder is a common psychiatric disorder that is characterized by
and unexpected panic attacks. Until
recently, this disorder was thought to only affect adolescents and
adults. Now in accordance with the
panic disorder has also been found to be present among youths. Within this website, the prevalence, clinical
characteristics, risk factors, comorbid states, and treatment of panic
are reviewed. Classroom issues and
recommendations for treatment within the classroom are also presented.
disorder is a common psychiatric disorder that is characterized by
and unexpected panic attacks. According
to the Diagnostic and Statistical of Mental Disorders- 4th ed.
panic attack is described as a distinct period of intense fear or
that develops abruptly and reaches a peak in ten minutes or less. This unexpected attack must be accompanied by
at least 4 of the 13 somatic or cognitive symptoms.
The somatic symptoms include accelerated
heart rate, shortness of breath, chest pain, dizziness, choking
tingling or numbing sensations, sweating, trembling, hot and cold
nausea. Cognitive symptoms include a
fear of dying, going crazy, or losing control.
In order for a person to be diagnosed as having
panic disorder, he or
she must experience these panic attacks repeatedly for at least one
month. These panic attacks must also cause
relentless concern about having another panic attack and worry about
consequences of a panic attack (American Psychiatric Association, 1994).
of Panic Disorder>
recently, panic disorder was thought to be a disorder that only
adults. This assumption began to change
many retrospective studies in adults reported that up to 40% of the
with panic disorder recalled that the onset of their disorder occurred
age 20 (Diler, Birmaher, Brent, Axelson, Firinciogullari, Chiapetta,
Bridge, 2004). Since then many studies
have been conducted to examine this possibility. Research
has shown that panic attacks and
panic disorder are less common in children, but they are nonetheless
(Ollendick, 1998). According to several
the prevalence of panic disorder in community samples ranges between
5.0% and in pediatric psychiatric clinics from 0.2% to 10% (Diler et
and Ethnicity Differences
attacks have been reported to be equally common among males and females
2003). However, females reported more
panic attacks in comparison to males (Ollendick, 1998).
Studies have also shown that girls had more
dizziness/faintness and nausea than boys (Diler, 2003).
In regards to anxiety disorders in general,
it is interesting to note that significant gender differences were seen
the age of 14, with higher rates found in females than in males (Essau,
Conradt, & Peterman, 2000). Perhaps,
this higher prevalence of anxiety disorders is associated with females’
physical maturity; however, this does not explain the gender
panic attacks during childhood. Further
research is needed in order to have a thorough understanding of gender
differences in panic disorder.
for ethnicity differences, previous research has not shown any
in panic disorder among various ethnicities.
Although, studies have shown that the majority of
receiving treatment for panic disorder at clinics are Caucasian (Diler,
2003). However, this finding should be
caution. The high frequency of
Caucasians may be due to the ethnic origin distribution of the places
such studies were conducted. Therefore,
to assertively make the claim that Caucasian children are affected more
panic disorder, further research is still needed.
of Childhood Panic Disorder
symptomology of panic disorder expressed in childhood may vary slightly
the clinical features seen in adolescence and adulthood.
More specifically, panic attacks in childhood
may be associated with particular events and are not unexpected
1998). This is different from
adolescents and adults for they tend to attribute their panic attacks
internal causes. Children are not
capable of making attributions to internal causality due to their
immaturity. Children and younger
adolescents tend to relate panic attacks to cues that are immediately
in the external environment, thus creating a concrete cause-effect
relationship. The development of abstract
adolescence allows the change from external to internal causes. This shift permits adolescents to make
internal attributions which are more typical of panic disorder (Masi,
2000). All of the other somatic and
symptoms associated with panic disorder seem to be similar for
adolescents, and adults.
has shown that panic disorder has a high comorbidity rate with many
disorders. According to Diler (2003),
the majority of children and adolescents with panic disorder show
with other anxiety disorders, such as generalized anxiety
disorder, separation anxiety disorder, social phobia, and agoraphobia. He also reported that up to 50% of children
with panic disorder have been reported to have other co-occurring
including substance use disorders, conduct disorder, oppositional
attention deficit disorder, and bipolar disorder. In
comparison to all other disorders, panic
disorder has shown the highest comorbidity rate with depressive
(Essau et al., 2000). It is interesting
to note that after analyzing the sequential occurrence of panic
disorder and depressive
disorders, panic disorder generally began first. This
finding may be explained by Klien’s
(1981) model called the “symptom progression model” (as cited by Essau
2000). He proposed that the presence of
an unexpected panic attack could result in the development of
anxiety (generalized anxiety disorder) and demoralization (major
depression). Although research has shown
that panic disorder co-occurs with a variety of other disorders, the
behind this comorbidity is still very much unknown.
are several risk factors that could help identify children who are at
for developing panic disorder. One risk
factor is familial predisposition, meaning the children of parents with
disorder are at high risk for developing panic disorder and other
disorders (Biederman, Hirshfeld, Rosenbaum, Herot, Friedman, Snidman,
& Faraone, 2001). However, because
most of these children will not become ill, another strategy is needed
identify at risk children, in addition to family history.
One example is behavioral disinhibition,
which is the consistent tendency to display fear and withdrawal in
situations (Ollendick, 1998). Children
with behavioral disinhibition tend to be shy around strangers and
unfamiliar situations. Research has
shown a direct association between behavioral disinhibition and social
among children whose parents had panic disorder (Biederman et al.,
risk factor for panic disorder is children who are anxious-ambivalent
insecurely attached. Children who have
an ambivalent/resistant insecure attachment style have difficulty
from the caregiver to explore the environment.
They tend to seek contact prior to separation and
often display cautiousness
in response to novel environmental stimuli, including people. After separation these children exhibit severe
distress and tend to display resistant behavior upon return of the
1998). These children thus experience
distress reactions in response to the stress of separation. The association between separation and
heightened anxiety could condition these children to relate the
attributions of the distress to the negative outcomes of such
experiences. Over time, this association
could cause these
children to become anxious over the possibility that these experiences
reoccur (Ollendick, 1998). Children with
this high anxiety reactivity may be vulnerable to the onset of panic
and eventual panic disorder (Diler, 2003).
By using parental panic disorder, child behavioral
child anxious-ambivalent insecure attachment to identify children at
panic disorder, preventive therapy and early intervention strategies
this stage, there are promising psychosocial and psychopharmacological
treatments available for adolescents and adults. As
for children, empirically supported
psychosocial and psychopharmacological treatments have not been fully
or tested. However, there are
therapies and pharmacologic treatments that appear to be promising
1998). One example is a psychosocial
model that is based on cognitive-behavioral theories and consists of
cognitive therapy and behavioral assessments.
It is designed to alter the faulty
misrepresentations of the somatic
sensations. This so-called panic control
treatment can aid in the elimination of panic attacks and the reduction
avoidant behavior (Diler, 2003). As for
pharmacologic treatments, case reports have shown that tricyclic
antidepressants, such as imipramine or despramine, are effective in
panic disorder in children (Diler, 2003).
Research has also indicated that SSRIs are a safe
treatment for children with panic disorder (Diler, 2003).
Although studies have shown both
cognitive-behavioral therapies and pharmacologic treatments can be
the treatment of panic disorder in children, further research is needed.
or situations, in which escape may appear to be blocked or at least
can create great anxiety for children with panic disorder. For many children with panic disorder, the
school environment tends to be one of those places.
According to Masi, Favilla, Mucci, &
Millepiedi (2000), children may actually refuse to go to school due to
cognitive anticipation and avoidant behaviors which are associated with
disorder. Since these children attribute
their panic attacks to specific external situations, they do not allow
themselves the opportunity to learn that school is, in fact, harmless
(Muris, 2003). This has become the major
obstacle of parents and educators. They
must gradually introduce the school setting as a non-threatening
environment. Perhaps, with the aid of
exposure with response prevention, which would of course be facilitated
school psychologist, children with panic disorder could eventually
the classroom is a safe environment to learn.
The rationale for this exposure is that if the
children remain long
enough in a situation without escaping or avoiding it, they would find
anxiety would disappear (Ollendick, 1998).
once the children are inside the classroom, they are again met with
obstacles. According to Essau et al.
(2000), teachers reported that children experiencing panic disorder
impairment in both their social activities and school activities. They found that these children were more
likely to have poor relationships with their peers and they had a low
perception of self-competence. These
findings were also supported by a study conducted by Ialongo et al.
(1996). Their study found that boys who
reported high levels of anxiety (including those with panic disorder)
times more likely to be in the top quartile of concentration problems
teacher-related shyness than boys who were classified as not anxious. These findings encourage educators to provide
the least anxiety provoking environment possible to maximize the amount
learning for children with panic disorder.
By doing so, the academic and social impairments of
these children can
be addressed more effectively.
Within the Classroom
panic disorder is considered a disabling condition that is accompanied
psychosocial, family, peer, and academic difficulties, the classroom
environment could be utilized in helping children cope with this
disorder. There are several ways in which
setting could facilitate the academic growth of children with panic
disorder. First, teachers could
implement several techniques that are commonly used in psychotherapy to
regulate panic attacks, such as breathing techniques, applied
cue-controlled relaxation (Ollendick, 1998).
These techniques could be easily applied to the
whole classroom. For example, at times
when students are
exhibiting anxiety or frustration, teachers could lead them in one of
relaxation techniques. This way all
students could benefit by taking a moment to calm down.
As for children with panic disorder, these
techniques could assist them in coping with their panic attacks and
self-efficacy for dealing with future attacks (Ollendick, 1998). Second, teachers could capitalize on
encouragement by providing profuse praise to children in times of
difficulty. This may be very important
for children with panic disorder, since they do tend to avoid or
withdraw from situations that present obstacles (Ollendick, 1998). Third, the teacher could emphasize the
importance of collaboration between educators and parents.
By getting the parents involved, teachers could
ensure that the techniques and behaviors learned in the classroom would
utilized in the home. This joint effort
permit the children to generalize these techniques by using them not
the classroom and in the home, but also in life’s everyday situations.
childhood panic disorder has only received recent attention, much
been dedicated to this disorder.
However, psychology professionals and researchers
have merely scraped
the surface in understanding this disorder.
For instance, very little is still known about the
differences, comorbid states, and treatment of childhood panic disorder. With further research and a more thorough
understanding of this disorder, professionals, parents, and educators
more capable of helping children cope with panic disorder.
(1994). Diagnostic and
statistical manual of mental disorders
Rosenbaum, J.F., Herot, C., Friedman, D., Snidman, N., Kagan,
J., & Faraone,
S.V. (2001). Further evidence of
association between behavioral inhibition
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Journal of Psychiatry, 158, 1673-1679.
(2003). Panic disorder
in children and adolescents. Yonsei
Medical Journal, 44(1),
Birmaher, B., Brent,
D.A., Axelson, D.A., Firinciogullari, S., Chiapetta, B.S., & Bridge, J.
of panic disorder in youth. Depression
and Anxiety, 20, 39-43.
Conradt, J., & Petermann, F. (2000).
Frequency, comorbidity, and psychosocial
anxiety disorders in German adolescents. Journal
of Anxiety Disorders, 14(3),
Werthamer-Larson, L., Crockett, L., & Kellam, S. (1996). Social
cognitive impairment in first-grade children with
anxious and depressive symptoms.
Child Psychology, 25(1), 15-24.
Favilla, L., Mucci, M.,
& Millepiedi, S. (2000). Panic
in clinically referred
adolescents. Child Psychiatry
and Human Development, 31(2), 139-151.
Muris, P. (2003). Information processing abnormalities in
childhood anxiety. Behavior Change,
(1998). Panic disorder in children and
New developments, new
directions. Journal of Clinical Child Psychology, 27(3), 234-245.
This website is a
service learning project by the students of "Psychology of the
Exceptional Child" at Frostburg State University. Manager of web
page and project:
Dr. Megan E. Bradley