Treating pediatric panic disorder

Clinical Psychiatry News, August, 2008 by Diana Mahoney

Monsters in the closet. Bogeymen under the bed. Flying shadow creatures cast by bedroom curtains blowing in the breeze. These are the stuff of childhood fears--all of which are readily dismissed as products of overactive imaginations and emotional immaturity.

Less easy to dismiss, however, are fullblown panic attacks--random bouts of unexplained terror accompanied by heart palpitations, shortness of breath, faintness, sweating, and a pervasive sense of dread--that can wreak emotional havoc on children and adolescents.

Although panic disorder is often thought of as an adult condition, mounting evidence suggests that for many people, the seeds of the disorder are planted in childhood, with first symptoms often emerging during the teen years. In one retrospective study of adults with panic disorder, 40% of the study participants reported experiencing their first panic attacks during adolescence (Child Adolesc. Psychiatr. Clin. North Am. 1993;2:581-602). Estimates of the prevalence of panic disorder in children and adolescents vary, but the available data from community samples suggest the disorder that is present in about 2% of children and up to 5% of adolescents, according to Thomas H. Ollendick, Ph.D., director of the Child Study Center at Virginia Polytechnic Institute, Blacksburg.

As with adults, panic disorder in children and adolescents can be a chronic and disabling anxiety disorder leading to social, emotional, academic, and familial problems. Unlike in adults, however, pediatric panic disorder is a tricky diagnosis. For example, children who experience panic attacks often describe primarily somatic symptoms, which can lead families and care providers down a path of mostly nonproductive medical investigations, while the absence of obvious psychiatric symptoms delays referral to child psychiatric services, according to Leonard A. Doerfler, Ph.D, director of the counseling psychology program at Assumption College, Worcester, Mass.

Even when psychiatric or behavioral symptoms do present and children are referred for treatment, panic disorder (PD) often is not detected. In both children and adults, "panic disorder is associated with high levels of comorbidity with other anxiety disorders, as well as depression and behavioral problems," Dr. Doerfler said. "The high levels of comorbidity may mask or obscure the presence of PD in children and adolescents."

In fact, in a recent study by Dr. Doerfler and his colleagues examining the frequency and characteristics of panic disorder in 280 children and adolescents who had been referred to a pediatric psychopharmacology clinic, the prevalence of panic disorder was 13%, yet none of the children diagnosed with panic disorder had been referred to the clinic for evaluation or treatment of the condition. Rather, "the most common presenting problem reflected parents' concerns about ADHD or mood disorders," the authors wrote. Because panic disorder tends to occur with other disorders, "it may be overlooked because parents tend to identify other problems as the most distressing problem," they said (Child Psychiatry Hum. Dev. 2007;38:57-71).

The diagnosis of pediatric panic disorder also is complicated because diagnostic criteria for the condition in children are the same as those used for adults. "How absurd to think an 8-year-old or a 12-year-old or even a 16-year-old should be judged by adult criteria," Dr. Ollendick said. "Unfortunately, the [Diagnostic and Statistical Manual of Mental Disorders] is very silent on most developmental issues," and that silence can contribute to missed or incorrect diagnoses, he noted.

Unrecognized and untreated panic disorder can have devastating consequences. During childhood and adolescence, it can lead to social impairment as a result of avoiding school, independent activities, and involvement with friends and an increased risk of substance use and abuse (J. Subst. Abuse 2000;11:7-15). The need to avoid potential panic triggers and the anticipatory anxiety associated with panic attacks can and often does lead to a related anxiety disorder: agoraphobia. In Dr. Doerfler's study, for example, 45% of the adolescents with panic disorder also met the diagnostic criteria for agoraphobia.

The psychosocial sequelae of untreated panic disorder in childhood and adolescence can persist into adulthood, according to the findings of a series of studies by Renee D. Goodwin, Ph.D., of Columbia University's School of Public Health, New York, and colleagues.

In one investigation using data drawn from the 5-year longitudinal Early Developmental Stages of Psychopathology Study comprising more than 3,000 adolescents from the community, panic attacks were associated with significantly increased odds of mental disorders across the diagnostic spectrum among young people and appeared to be a risk factor for the onset of specific anxiety and substance use disorders, the authors wrote (Am. J. Psychiatry 2004;161:2207-14).

In a separate report based on data from a longitudinal epidemiological study of psychopathology across the life spans of about 700 people, Dr. Goodwin and colleagues provided initial evidence "that panic attacks early in life are a marker or risk factor for the development of personality disorders in young adulthood" (Psychol. Med. 2005;35:227-35).