Topic: Childhood Panic Disorder
Researched and written by: Lindsay Thom
                                                I attest that the following report is a product of my own original work.

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Summary
 

Overview of Disorder             Panic disorder is a common psychiatric disorder that is characterized by recurrent and unexpected panic attacks.  According to the Diagnostic and Statistical of Mental Disorders- 4th ed. (DSM-IV), a panic attack is described as a distinct period of intense fear or discomfort 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 sensations, tingling or numbing sensations, sweating, trembling, hot and cold flashes, and 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 the consequences of a panic attack (American Psychiatric Association, 1994).  <>           <>Prevalence of Panic Disorder             Until recently, panic disorder was thought to be a disorder that only affected adults.  This assumption began to change when many retrospective studies in adults reported that up to 40% of the patients with panic disorder recalled that the onset of their disorder occurred before 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 present (Ollendick, 1998).  According to several studies, the prevalence of panic disorder in community samples ranges between 0.5% and 5.0% and in pediatric psychiatric clinics from 0.2% to 10% (Diler et al., 2004).     Gender and Ethnicity Differences             Panic attacks have been reported to be equally common among males and females (Diler, 2003).  However, females reported more severe 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 after 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 differences in panic attacks during childhood.  Further research is needed in order to have a thorough understanding of gender differences in panic disorder.             As for ethnicity differences, previous research has not shown any significant differences in panic disorder among various ethnicities.  Although, studies have shown that the majority of pediatric patients receiving treatment for panic disorder at clinics are Caucasian (Diler, 2003).  However, this finding should be addressed with caution.  The high frequency of Caucasians may be due to the ethnic origin distribution of the places where such studies were conducted.  Therefore, to assertively make the claim that Caucasian children are affected more by panic disorder, further research is still needed. Characteristics of Childhood Panic Disorder             The symptomology of panic disorder expressed in childhood may vary slightly from the clinical features seen in adolescence and adulthood.  More specifically, panic attacks in childhood may be associated with particular events and are not unexpected (Ollendick, 1998).  This is different from adolescents and adults for they tend to attribute their panic attacks to unexpected internal causes.  Children are not capable of making attributions to internal causality due to their cognitive immaturity.  Children and younger adolescents tend to relate panic attacks to cues that are immediately present in the external environment, thus creating a concrete cause-effect relationship.  The development of abstract thinking during 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 cognitive symptoms associated with panic disorder seem to be similar for children, adolescents, and adults.   Comorbidity             Research has shown that panic disorder has a high comorbidity rate with many other disorders.  According to Diler (2003), the majority of children and adolescents with panic disorder show comorbidity with other anxiety disorders, such as generalized anxiety disorder/overanxious 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 disorders, including substance use disorders, conduct disorder, oppositional defiant disorder, attention deficit disorder, and bipolar disorder.  In comparison to all other disorders, panic disorder has shown the highest comorbidity rate with depressive disorders (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 et al., 2000).  He proposed that the presence of an unexpected panic attack could result in the development of expectation anxiety (generalized anxiety disorder) and demoralization (major depression).  Although research has shown that panic disorder co-occurs with a variety of other disorders, the reason behind this comorbidity is still very much unknown. Risk Factors             There are several risk factors that could help identify children who are at high risk for developing panic disorder.  One risk factor is familial predisposition, meaning the children of parents with panic disorder are at high risk for developing panic disorder and other anxiety disorders (Biederman, Hirshfeld, Rosenbaum, Herot, Friedman, Snidman, Kagan, & Faraone, 2001).  However, because most of these children will not become ill, another strategy is needed to help 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 unfamiliar situations (Ollendick, 1998).  Children with behavioral disinhibition tend to be shy around strangers and hesitant in unfamiliar situations.  Research has shown a direct association between behavioral disinhibition and social anxiety among children whose parents had panic disorder (Biederman et al., 2001).              Another risk factor for panic disorder is children who are anxious-ambivalent insecurely attached.  Children who have an ambivalent/resistant insecure attachment style have difficulty separating 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 caregiver (Ollendick, 1998).  These children thus experience heightened distress reactions in response to the stress of separation.  The association between separation and heightened anxiety could condition these children to relate the internal 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 could reoccur (Ollendick, 1998).  Children with this high anxiety reactivity may be vulnerable to the onset of panic attacks and eventual panic disorder (Diler, 2003).  By using parental panic disorder, child behavioral disinhibition, and child anxious-ambivalent insecure attachment to identify children at risk for panic disorder, preventive therapy and early intervention strategies could be implemented.     Psychotherapeutic Treatment             At 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 developed or tested.  However, there are cognitive-behavioral therapies and pharmacologic treatments that appear to be promising (Ollendick, 1998).  One example is a psychosocial model that is based on cognitive-behavioral theories and consists of both 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 of avoidant behavior (Diler, 2003).  As for pharmacologic treatments, case reports have shown that tricyclic antidepressants, such as imipramine or despramine, are effective in controlling panic disorder in children (Diler, 2003).  Research has also indicated that SSRIs are a safe and effective treatment for children with panic disorder (Diler, 2003).  Although studies have shown both cognitive-behavioral therapies and pharmacologic treatments can be effective in the treatment of panic disorder in children, further research is needed.      Classroom Issues             Places or situations, in which escape may appear to be blocked or at least difficult, 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 their cognitive anticipation and avoidant behaviors which are associated with their 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 and safe (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 by a school psychologist, children with panic disorder could eventually realize that 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 that the anxiety would disappear (Ollendick, 1998).                       Unfortunately, once the children are inside the classroom, they are again met with many obstacles.  According to Essau et al. (2000), teachers reported that children experiencing panic disorder exhibited 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) were two times more likely to be in the top quartile of concentration problems and 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 of learning for children with panic disorder.  By doing so, the academic and social impairments of these children can be addressed more effectively. Treatment Within the Classroom             Although panic disorder is considered a disabling condition that is accompanied by 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 the school 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 relaxation, and 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 these 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 encouraging 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 completely 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 also be utilized in the home.  This joint effort could permit the children to generalize these techniques by using them not only in the classroom and in the home, but also in life’s everyday situations.                  Although childhood panic disorder has only received recent attention, much research has 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 ethnicity differences, comorbid states, and treatment of childhood panic disorder.  With further research and a more thorough understanding of this disorder, professionals, parents, and educators will be more capable of helping children cope with panic disorder.

American Psychiatric Association. (1994).  Diagnostic and statistical manual of mental disorders             (4th ed.).  Washington, DC: American Psychiatric Association.

Biederman, J., Hirshfeld, D.R., Rosenbaum, J.F., Herot, C., Friedman, D., Snidman, N., Kagan, J., &             Faraone, S.V. (2001).  Further evidence of association between behavioral inhibition and                     social anxiety in children.  American Journal of Psychiatry, 158, 1673-1679. 

Diler, R.S. (2003). Panic disorder in children and adolescents.  Yonsei Medical Journal, 44(1),                     174-179.

Diler, R.S., Birmaher, B., Brent, D.A., Axelson, D.A., Firinciogullari, S., Chiapetta, B.S., & Bridge, J.             (2004). Penomenology of panic disorder in youth.  Depression and  Anxiety, 20, 39-43.  

Essau, C.A., Conradt, J., & Petermann, F. (2000).  Frequency, comorbidity, and psychosocial                         impairment of anxiety disorders in German adolescents.  Journal of Anxiety Disorders, 14(3),             263-279.   

Ialongo, N., Edelsohn, G., Werthamer-Larson, L., Crockett, L., & Kellam, S. (1996).  Social and                 cognitive impairment in first-grade children with anxious and depressive symptoms.  Journal of             Clinical Child Psychology, 25(1), 15-24.  

Masi, G., Favilla, L., Mucci, M., & Millepiedi, S. (2000).  Panic disorder in clinically referred children             and adolescents.  Child Psychiatry and Human Development, 31(2), 139-151. 

Muris, P. (2003).  Information processing abnormalities in childhood anxiety.  Behavior Change,                     20(3), 129-130.

Ollendick, T.H. (1998).  Panic disorder in children and adolescents: New developments, new                         directions.  Journal of Clinical Child Psychology, 27(3), 234-245.