Panic disorder, Separation Anxiety disorder, and Agoraphobia in Children and Adolescents

by Jim Chandler, MD

Part 1.

What are panic attacks?

How can you be sure that what happened was a panic attack and not some other medical problem?

Part 2.

Agoraphobia and school

Separation Anxiety Disorder

Co-morbidity

Prognosis Ė will they get better?

What Can be Done?

Non-medical treatments

Part 3.

Medical treatments

In summary  


Introduction

[ Table Of Contents ]

Up to 12% of ninth graders have had a panic attack. About 1-2% of all adults have multiple panic attacks. If you look at adults with panic disorder, 20% had their first panic attack before age 10. The first question is, What is a panic attack? Here are the official criteria:

Panic Attack


A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reach a peak within 10 minutes:

In children and teenagers, panic attacks can take on many different disguises. Here are a few of the presentations.

The Classic - At age 10 Ted walked into the school and felt his heart race, skip, and all of a sudden he could not breathe well. His chest hurt and he called out to his friend to get the principal. By the time the principal came Ted was sitting on a chair and his face was very red. He was breathing very fast. He said everything was spinning. He told the principal he was afraid he was dying, and to call an ambulance. By the time the ambulance arrived and brought Ted to outpatients, Ted was scared, but all of the other symptoms were gone. Routine medical tests showed nothing.

The Nausea disguise - Sheryl is 14. Even though the bus goes right by her house, her Dad takes her to school. The reason is that every time she gets on the bus she feels very, very nauseated. She is afraid she will vomit right on the bus. If she stays on the bus, she gets more and more restless, her heart races and she starts shaking. She had this for one entire bus ride, and she told her mother she would never risk that again in her life.

The anger disguise - Jean, age 12, was sitting in math class. All of a sudden he felt like he had to run out of there or he was going to go nuts or hurt someone. He felt a rush of adrenaline surge through his body. He started breathing hard, felt his heart race and was trembling. He raised his hand to tell Mr. D'entremont he had to leave. Mr. D'entremont said no. Jean started screaming that he was going anyway and knocked over his desk and then slammed the door so hard they could hear it upstairs. By the time he ended up in the vice-principal's office, it was over and he was sorry, but he ended up with a lot of detention.

The family doctor's new child - Cody, age 9, has been to the family doctor six times in the last two weeks. He has insisted that his mother take him ever since he had a spell when he was dizzy, felt like his stomach was turning inside out, and couldn't breathe. He thought he was going to die. The family doctor couldn't find anything. But Cody wonders every time he feels a little bit wrong if maybe the family doctor missed something and maybe if he went now they could find out what it is. On the way home from doctor visit number 7, Cody told his mom that sometimes he wishes that he could just live at his family doctor's house in case there ever was another spell.

What causes Panic attacks?


Most researchers have found that they are caused by an abnormality in the part of the brain which tells the brain how much Carbon Dioxide (CO2) is in the blood. If your brain finds there is getting to be too much CO2, it usually means that you are not breathing fast enough, or there is too much CO2 in the air (for example, in a room with no ventilation or a cave). So your body sends all sorts of signals to increase breathing and a rush of adrenaline to help you get out of wherever you are in a hurry. This is a great thing if you are in a fire, for example.

It is thought that in Panic attacks this Carbon Dioxide sensor is too sensitive, and tells the brain there is not enough Carbon Dioxide when there is just plenty. So a person could be just sitting quietly and then BOOM, this rush of adrenaline and fast breathing appears out of nowhere. Since there is no reason outside the body to be worried, most people will start thinking there is something horribly wrong with their own body.

Beyond this brain problem, Panic Attacks are inherited. If a parent has an anxiety disorder, their children are much more likely to have an anxiety disorder, too. Part of this heredity is expressed through something called Behavioral Inhibition.

Behavioral Inhibition is a tendency to react negatively to new situations or things. Some infants and children will be very happy and curious about new people and things. However, roughly 15% of children will be shy, withdrawn, and irritable when they are in a new situation or with new people or things. Often these children and irritable as infants, shy and fearful as toddlers, and cautious, quiet, and introverted at school age. Children who are consistently this way are much more likely to have biological parents with anxiety disorders. The children themselves are much more likely to develop anxiety disorders. On the other hand 5-10 percent of children with Behavioral inhibition will never develop anxiety disorders. At the moment it is thought that the majority of the genetic predisposition to anxiety disorders is expressed through behavioral inhibition. Often there is a combination of an inherited predisposition plus a stress In the environment. Deaths in the family, divorce, and abuse will make panic attacks much more likely.

How can you be sure that what happened was a Panic Attack and not some other medical problem?


Panic attacks in children can be confused with many things. Common imitators are ulcers, irritable bowel syndrome, thyroid disease, some prescription drugs, migraines, epilepsy, diabetes, drug abuse, and other psychiatric disorders. There are some research tests which look at the brain which will show certain abnormalities in panic attacks. However, for a variety of reasons these are not in regular clinical use. The main principle is to rule out other problems using a careful medical history, a physical exam, and often certain lab or x-ray examinations. If the history and exam looks like panic attacks and no other cause is found, then a physician assumes it is a panic attack.

In females, stomach aches and headaches together are very, very common. In fact, recent studies have shown that when these two are found together in the same child, 69% had an anxiety disorder. (4)

You have been talking about panic attacks as if it only happens once. My son has them all the time.

One Panic attack is bad enough, but recurrent panic attacks can be devastating. If a child or adolescent has recurrent panic attacks and the following, it is called Panic Disorder.

Panic disorder in children is a very disabling condition. It will often affect a child's school performance. It almost always impairs them socially, and can lead to a lot of other problems. It is not a common illness in children. While perhaps 10% of children will have a panic attack, about 1-2% will develop Panic disorder. Of those that do develop Panic disorder, 10-35% will recover and remain well the rest of their lives. At least 50% will be mildly affected years later, and the rest will have chronic Panic disorder for years. If you follow-up children with panic disorder, about 25% will still have it years later. Of those who continue to have Panic disorder as they go into adulthood, many will develop other psychiatric difficulties. About 50% will develop agoraphobia, 20% will make suicide attempts, 27% will develop alcohol abuse, 60% will develop depression, 35% will believe they are unhealthy, 27% will not be financially independent, 28% will make frequent outpatients visits, and 50% will be show significant social impairment.

With my daughter, the panic attacks are nothing compared to her fears of having one. She is terrified she will panic when she goes out with us to the mall.

The most common fear or phobia in the context of Panic disorder is Agoraphobia. Here is the official definition of Agoraphobia.

The usual pattern I find with children is not that different than with adults. Panic attacks will set in process a slow restricting of peoples lives. Slowly the stop doing all sorts of things they used to and stop going all sorts of places. Lots of times, especially with children, they have some excuse (other than fear of panic) for not going which seems fairly reasonable at first. Often they play at their home without problems, but if they have to go there is always a reason they aren't going. Sometimes it is because the child says he doesn't want to (even though you know he would love to do this before) other times it is because all of a sudden her stomach is hurting, she feels weak and tired, her eyes hurt, or she needs to go use the bathroom.

[ Next: Agoraphobia and school ]

[ Table Of Contents ]

 


Agoraphobia and school

[ Table Of Contents ]

This is of only minor concern compared with agoraphobia that revolves around school. There are many parts of school which are the cause of problems in agoraphobics. I have never seen a child or adolescent who did not have problems with school. I will start from the beginning.

Wake up - Many children with agoraphobia will awaken on school days with horrible abdominal pain, diarrhea, nausea, headache, or many other signs of physical illness which all disappear as soon as there is no chance they are going to school. This is real, not made up. The anxiety is making their body react this way. This results in a battle between parent and child and sometimes involves the school.

Bus rides - It is common that children with agoraphobia will be afraid that something horrible or embarrassing will happen on the bus such as diarrhea, vomiting, going crazy, and getting sick with no one to help. Often this results in parents driving the child to school.

Going in the school - Other children are fine until they see the school and they know they have to go in. The idea of going and sitting in their classrooms leads to all sorts of anxiety about what could go wrong (as in the bus ride). Some children will just refuse to go to school.

Leaving class - For some agoraphobic children, they get into school, but they can not stay the whole day. Their physical signs of anxiety are enough to get most teachers to call home and have a parent come and get the child. As a result, the parent is basically "on-call" throughout the school day.

Special events - some agoraphobic children can handle the usual school day but not field trips (without their mother), performances, and changes in teachers.

All of these can lead to school refusal. There are other reasons besides Agoraphobia that children will refuse to go to school. However, it is usually what will bring a child to my attention. Any of the other anxiety disorders of children can lead to school refusal. The most important thing is to get them back in school as soon as possible and find out what the problem(s) is.

My son says he is fine as long as we don't do anything to make him worse.

Many children with agoraphobia and panic disorder will have come up with their own "treatment". This consists of getting everyone else on the planet to live their lives such that it minimizes the anxiety for this child. When people (usually family members) forget or refuse to follow one of these many rules, then the child with the anxiety disorder blames the family member for his or her anxiety. Common rules are:

This "treatment" drives caregivers nuts. Any worsening of anxiety is now the parents fault. Obviously, this is not the way to go. However, most children prefer this as they have no responsibility and the focus is not on them.

Separation Anxiety Disorder

Agoraphobia and Panic attacks often go together. More recently it has been discovered that Panic attacks and agoraphobia are much more common in children who currently have Separation Anxiety Disorder or had it in the past. What is Separation Anxiety Disorder?

It is a worry about being away from home or about being away from parents which is way out of line for that child's age, culture, and life.

So if a child worries about being away from his mother while at preschool at age 4 for a few weeks, that isn't Separation Anxiety Disorder.

If a child is very concerned about their mother and is calling her at home. That is unusual, but if the mother just got out of cancer treatment the week before, that is not Separation Anxiety Disorder.

Signs of Separation Anxiety Disorder

Examples would be a young child having a tantrum when the mother starts to get her work clothes on or an older child noticing that in two hours the mother is leaving and starting to have panic symptoms.

For example, a young child goes in at night to make sure parents are still breathing in their beds. A child calls all relatives in the area because the mom is 10 minutes late. A teenager has to stay home from school to watch mom because the mother is slightly ill.

A teenager must have eye contact with parents in a mall. A child will not go and check and make sure parents are still in the house every 10 minutes.

Examples are being afraid to go to school, having to call home many times a day from school. Unable to stay overnight at friends or camps, afraid to ride on bus as there is no way to contact parents.

Examples are a small child who can not play in a room without parent visible in the next room. Going to check on parent if the child doesn't hear the parent every few minutes. Being unable to play in the yard even though the parent is in the house. A teenager unable to tolerate the mother going for a short 10 minute walk.

An older child still sleeping with parents. A child wants to sleep with sibling or will not sleep at all. A teenager wanting room right next to parents.

Common ones are dreams of parents getting in car accidents, of houses burning down. Of being lost in malls, schools, and stores. Of getting lost on camping trips.

Common ones are Severe headaches, nausea, vomiting, shortness of breath and diarrhea right before school or before parent goes to work.

Examples

Pre-School

Tina is 4 years old. She is a pleasant child and no problem for the mother at all at home. No one would guess there is any difficulty to visit the family at their home. But Tina's mom is about ready to throw her out the window. Why? Her mom says it is because she has had an "overdose" of Tina. She wakes up in the morning to find Tina in bed. She sneaks in during the night. Tina waits outside the bathroom door while her mother gets ready for the day. Every few minutes Tina calls out "Mom?" to check and make sure her mother hasn't somehow disappeared. Then it is off to breakfast and time for the big question, "Is there pre-school today?" If the answer is no Tina is happy, sits down to eat her cereal and sings to herself. If the answer is yes, she starts screaming, won't eat a thing because her stomach hurts and grabs on to her mother's leg. Then the fun really begins. It takes about 45 minutes to dress her and then drag her out the door. All the way out she is grabbing for anything she can hold on to and screaming "noooooo". Once wrestled into the car seat it is a noisy trip until the stop the car at the pre-school. Then the two women who run the place come out and drag her into the preschool. It takes Tina an hour to calm down but the second hour now goes all right. She has been going for almost a year now. Once her mother appears she grabs on like velcro for the rest of the day. Outside of pre-school, there is nothing that separates the two. When her father comes home Tina puts on her shoes and walks as fast as she can with the walkman in an attempt to regain her sanity before the bedtime ritual. That is not easy. Tina does not want to go to bed without her mother for fear her mother will leave in the night. After about 2 hours of stories, threats, screaming and calling out, she is asleep. Tina's mother is always sleep deprived because she tries to live a whole life between 9 pm and bedtime.

Elementary School

Terry is 9 years old. He always looks sleepy and looks like something is bothering him. Well, something is bothering him. Every night he has to make sure that his mom is alright. A year ago is great-grandfather died in his sleep. Terry wasnít that close to him but it did make him think. His mom is not that young (35 years old) and could she die in her sleep? Terry wakes up in the night and wonders, is mom alive or not? So he goes in and checks on her. He can't tell in the dark if she is sleeping or dead so he just wakes her up to make sure she is in fact okay. "Mom, are you okay" is what she hears. She has learned that if she speaks her mind and says, " I am not okay! I was sound asleep and now I am awake!" then Terry just worries more and more and doesnít go back to sleep. But usually he does and doesnít wake her up again until near 5:00 when the fishing boats are going by. As a result, the mother and son are always tired and they fight a lot. So at breakfast Terry asks her (never his Dad, for some reason he doesnít worry much about him) exactly what she is doing that day. Terry wants to know where his mother will be at every moment of the day just in case he needs her. Of course she doesnít plan her schedule down to the minute which leads to the usual arguments. "What do you mean, you might go down to Yarmouth in the afternoon? Are you going or not?" Terry used to use his lunch money to call home and check on her but now she does not answer the phone if the school is calling after getting twenty phone calls one day when she had the flu. After school all goes well unless she is a little late getting home. He isn't alone those days. Usually his Dad is working in the shed when he comes home. Of course he isn't once Terry comes home. Terry wants to know why she isnt home, where she has gone and gets all worked up over a 5-10 minute delay. His Dad jokes with his friends that he would never have to worry about his wife having an affair, as Terry keeps one close eye on his mom. His mom tells his father that the danger isn't an affair, but murder. She has had it with this and sometimes would like to send Terry to visit his Uncle in BC. Permanently.

 High School

Laura is no 16. She is no stranger to anxiety. When she was 12 she started having panic attacks. When she was 14 she got depressed. Last year, when she was 15, things seemed to really turn around. She liked all her teachers and got involved playing drums in a small group. They played for some parties and weddings. She also had a really nice boyfriend who took her out even though she would have rather stayed home. But this year her luck has changed. The band broke up and her boyfriend moved to Dartmouth with his family. Her Dad's boat had engine trouble and he had to be towed in by the Coast Guard as a storm was coming up. Everyone kept telling her that her dad was lucky to have gotten out of that with his life. Her mom had a scare with breast cancer after a mammogram was positive, but the biopsy was okay. Laura has basically stopped hanging around with her friends. Now she likes to help around the house. At first her mom was delighted to have some extra help but not anymore. She overheard her daughter tell a friend that she was not allowed to go the show. Not allowed? Well, she didnít want to tell her friend that she just didnít want to go out. Why not? Well, you just never know if you or mom are going to need something and she had a stomach ache. When her Dad comes home he often takes a walk with Laura's mom after dinner. Laura used to be satisfied with just knowing when they are going to be coming home. Now she is pleading with them that they go along the beach and not through the woods. Why would she care? Because she can see them the whole way on the beach but not in the woods. Laura has quit basketball because of away games. She won't go to youth group and quit choir. Her life is slowly slipping away.

Separation Anxiety Disorder can persist into adulthood. As mentioned above, it is very common for a child to start with this and later develop Panic Disorder or Agoraphobia or all three! As far as causes go, the same things cause Separation Anxiety Disorder that cause Panic and agoraphobia. (see above). However, some research now suggests that having a parent with alcoholism significantly increases a child's risk of having Separation Anxiety Disorder. About 14% of children of alcoholic parents will have Separation Anxiety Disorder. (3) The treatments are basically the same and will be covered in the treatment section.

 

Prognosis- Will my Child Get Better?

The good news is that about 80% of children with Separation Anxiety Disorder will be markedly better in 18 months. Boys are even more likely to improve. The same is true for other anxiety disorders, that is about 75% are better over the next year or two. However, it is not uncommon that a child will move from one anxiety disorder to another.

Can you predict which children will not improve?

Having ODD (Oppositional Defiant Disorder), ADHD, and a mother who is unhappy in her marriage are associated with Separation Anxiety Disorder not improving.

Those children who still have Separation Anxiety Disorder as adolescents are at a high risk for depression. (12)

Comorbidity


My daughter has panic attacks, but it is her other nervous problems which are causing her the most trouble. What is going on?

Panic Disorder with agoraphobia often does not exist alone. Many children will also have another anxiety disorder. Here is a thumbnail sketch of the other common childhood anxiety disorders.

Separation Anxiety disorder - This is a fear of being separated from your parents which is far more than one would expect for the child's developmental stage. See above for details.

Obsessive-Compulsive Disorder - Obsessions are foolish thoughts which go through a person's head over and over. Compulsions are actions people do over and over, usually related to obsessions. Children will obsess about colors, numbers, songs, germs, and other worries. The compulsions are usually checking, repeating things, having to do things a very exact way, and hoarding. These are present in most people to some extent. In this disorder, people spend hours of their days thinking or doing these things.

Generalized Anxiety disorder - These are people who worry all the time over nothing - themselves, others safety, their health, the world, and everything else you can imagine to a far great extent than the average. They often have many physical signs of anxiety - headache, abdominal pain, cramps diarrhea, vomiting, dizziness, and many others.

Social phobia - This starts out with severe shyness and can progress so that children are afraid of doing anything in public.

Selective Mutism - A severe version of the above where children will not speak to anyone but their closest friends and family.

Post-Traumatic Stress Disorder - After something horrible happens to a child, sometimes they will keep thinking of it over and over, avoid things that remind them of that horrible thing, and being very nervous.

Tic disorders - Tics are sudden rapid movements or sounds. They are more common in nervous children.

Specific Phobias- An unreasonable fear of all sorts of things. Being in crowds, the dark, dying, and heights are common ones.

Many children have multiple anxiety disorders. Sadly, many children I see have multiple anxiety disorders plus one of the problems listed below.

Attention Deficit Hyperactivity Disorder (ADHD) - This is the most common pediatric psychiatry disorder. It occurs in 3-6 % of all children. However, if a child has an anxiety disorder, she has a 20% chance of having ADHD.

Depression - Most children who have multiple anxiety disorders and many who have just one will develop clinically significant depression later in childhood or adolescence. Some will be chronically depressed for years. Anxiety disorders plus depression greatly increases the risk of suicide and suicide attempts.

Bipolar Disorder - Adolescents with Panic Disorder are 4-5 times more likely to get Bipolar disorder. That means that almost 20% of adolescents with panic disorder will develop bipolar disorder.(7) Those who do end up having both disorders are more likely to be psychotic (hearing voices, having bizarre ideas) that patients that just have bipolar disorder without panic. This is especially important as the medical treatment of panic attacks can cause mania. Click here to go to Bipolar Pamphlet

Example - Tanya is 14. She went to see a psychiatrist because she couldnít breathe and was almost passing out in school. Her family doctor thought these were panic attacks, but the family wasnít so sure so she went to see a psychiatrist. As a result she didnít want to go to school anymore. When these attacks came she was terrified that she was going to die and would scream at her mother to "do something", run around, and pant. It was quite dramatic. It took quite a bit of time to explain to her and her mother that these were panic attacks. They had a lot of questions, and so the psychiatrist didnít have time to ask about manic symptoms. She put Tanya on Paxil. It helped the panic. Three days later Tanya had no panic and felt great. Six days later she decided to write a play about the history of her town. Ten days later she was controlling the videos on Much Music, never slept, and spoke so fast that no one could understand her.

They forgot to ask her and her mom about manic symptoms, which she had been having in the last 6 months, and family history of bipolar illness. It turns out her aunt had been very manic and hospitalized.

The lesson? If you have some bipolar symptoms, donít take medicine for Panic unless you treat the bipolar disorder first.

Panic attacks as a sign of things to come

Less than half of children and adolescents who have panic disorder will be well as young adults. In other words, while most children and adolescents recover from Panic disorder, more than half of them relapse by adulthood. Some relapse back into panic disorder, but often they develop new disorders

Panic attacks are bad enough themselves. However, recent research is suggesting that sometimes the appearance of panic attacks in the beginning of some other psychiatric disorder. If a child has panic attacks at age 14 they are much more likely than other children to develop these problems:

        2-3 times more likely to develop Social anxiety disorder

        10 times more likely to develop Generalized Anxiety Disorder

        2-3 times more likely to develop substance abuse

        2-3 times more likely to develop some type of depression

By percentages, this means that if you look at a group of children and adolescents who had panic attacks at age 14, by the time they are 24

        33% will still have an anxiety disorder

        24% will have a mood disorder

        18% will have substance abuse disorder

Even more worrisome, teenagers with panic attacks are 3-4 more likely to develop more than one anxiety disorder later in life(13)

The bottom line is panic disorder is very chronic, comes back more often than not, and can change into other psychiatric problems


What can be done?


If Panic disorder with or without agoraphobia persists into adolescence, Often the teenager will have become depressed, become involved with drugs and alcohol, fail or drop out of school, become socially isolated and almost house bound, or all of the above. The same is true for Separation Anxiety Disorder

The treatment of these conditions revolves around two things, Medications and Psychological treatments. I will start with Psychological treatments. There are three elements to the psychological treatment of anxiety disorders.

Behavioral

1. Graduated Exposure - It has been found that children, like adults, will be able to overcome phobias with this technique. What you do is gradually expose yourself to the thing that makes you so panicky. Let's take entering the school as an example. If a child is unable to go to school because of agoraphobia, the first thing to do is break it down into little pieces. I would sit down with the family and the child and decide what the first step is. It should be something the child can probably do. For example, Go into the school yard and stand inside the door way for a certain amount of time. Then with time you slowly increase the time and the task until they are in class all day. In Separation Anxiety Disorder, it might mean going outside alone for a certain amount of time. Lots of times this is paired with "carrots and sticks". That is, if you can do your task for today, then you can stay up later. If you can not, I will take away your compact disc player for one day.

Response Prevention - The key to this technique is to keep yourself from doing the thing you want to when you get panicky. For example, if a child is in class and wants desperately to raise his hand so that he can go home and call his mother to come and get him, You might try to teach the child to wait 5 minutes before calling.

There is a lot more to this type of therapy. There are many books available on how to do it.

The good

When this works, the child feels a great sense of personal accomplishment

No side effects

Has been found effective in children.

The bad

You need to work with someone who has experience with this in kids as it is fairly easy to screw this up by being too harsh or too soft.

Relaxation techniques

When people start having panic symptoms, or if they are having to tolerate separation in Separation Anxiety Disorder, if they have learned some specific techniques they can often ride out the panic much easier. These involve:

The good
The bad
Some children are just too anxious to do it

So much time and energy can go into relaxing that there is little time for anything else.

Cognitive Therapy

This is a technique which was first used in adults with depression but has been used with teenagers and adults with anxiety disorders. This consists of learning about how certain thought patterns are leading to worsening of the anxiety disorder. Each person with anxiety has these. Some common ones are, if I have another panic attack, I will die. If I get nauseated, I will vomit. If my stomach gurgles, I will have diarrhea. When my eyes blur, it means I have a brain tumor. Through homework assignments, reading, writing, and talking with a professional in this technique, you can help to control or eliminate these automatic bad thoughts.

The good

Best for teenagers who want to talk

Can help with many areas outside of panic attacks and agoraphobia

The bad

A child or teenager needs to be motivated, at ease with reading and writing, and able to identify their own thoughts or feelings.

You need to see someone regularly for about 4 months to make this work

It requires waiting quite awhile or paying quite a bit, as it is not cheap or that readily available.

It doesn't work quickly.

There are many other psychological treatments, but they have not been found to be effective. For example, just talking about what your are scared about, discussing your dreams, and getting in touch with yourself and others have not found to be helpful.

[ Previous: What Are Panic Attacks? ] [ Next: Medical Treatments ]

[ Table Of Contents ]

 


Medical Treatments

[ Table Of Contents ]


Often the idea of taking medicines for anxiety disorders makes either one of the parents very nervous or the child. Before discussing the individual drugs, I will discuss the general approach to pediatric psychopharmacology that I use.

Why would anyone want to give drugs that affect the brain to children?

The main reason would be if the non-medical interventions are not working. No one would suggest trying medical treatments before the non-medical interventions are used. It is similar to diabetes in that way. If you have diabetes which is not severe, your doctor will first suggest you try diet control. If that doesn't work, only then will the doctor consider medical treatment. In some situations, a child is very ill, has numerous disorders or there is some urgency. For example, a child has multiple anxiety disorders and depression and is either in the hospital or unable to go to school. Then I consider medications as a first line approach along with other interventions.

If the drug works, how will my child be different?

In cases where the drugs work very well, a child will be able to face situations in which they usually panic with little or no anxiety. Panic attacks should be basically eliminated. Children are usually more carefree, enthusiastic, and less depressed. Each drug works in a different way on the chemical transmitters in the brain.

What if it doesn't work?

Sometimes a medication won't work because the dose is too high or too low. Some people will not respond to one medication for the treatment of this problem but they will respond to another. If the drug doesn't work, of course, it is discontinued, and then you and I decide what do next. Try something else? Abandon medical treatment? Both are sometimes reasonable options.

I have heard that these drugs can do a lot of bad things. Is this true?

Yes, it is. Like all medical treatments, there are side effects and sometimes people can have pretty bad side effects. There are two types of side effects. One type are the kind that disappear when you stop the drug. The other kind can last long after the drug is discontinued. I do not use any of the drugs which can cause permanent side effects after the drug is stopped.

Are they that dangerous??

Yes, when used improperly they can be quite dangerous. However, when used carefully they can be almost 100% safe.

How can that be?

Each drug has certain problems which need to be watched for. The current medical literature suggests three basic principles when using psychiatric drugs in children. 1) Start low, 2) Go slow, and 3) Monitor carefully

What do you mean by Start low?

This means that you do not start any of these drugs at the usual dose, or the maximum dose. When you have pneumonia, it can be a real emergency. You want to give people plenty of medicine right away, and if there is problems, then you reduce it. Unfortunately, many people use this same strategy in the medical treatment of anxiety. The problem is that big doses can cause big problems, and when the problems affect your mind and personality, this usually means trouble for the person taking the medicines. So I start with the lowest dose possible. For example, if I use a drug called rivotril, for a boy about 60 lb., I know that the dose that will probably work for most boys that size is 2-3mg a day. If I gave him that to start out with, I might win and it would work. But if he happens to be sensitive to that drug, he could have big problems. Although they would be reversible problems, it would probably make most kids and or parents never want to take the drug again. So what do I do? I start with .5 mg a day, about 25% of the usual dose. That way if the child is sensitive to the drug, it causes little problems. I also find that some children respond to drugs at very low doses, far below the usual recommendations.

What do you mean, go slow?

Anxiety disorders are usually not acute illnesses. Less than 10% of the people I see with this need to be treated very quickly. Most people who I see with this problem have had it for months to years. As a result, there is no need to increase the dose quickly. By going slowly, it is a lot easier to manage any side effects because things don't happen suddenly. Also, it is easier to find the lowest effective dose.

What do you mean, monitor?

For each of the medical treatments for anxiety, there are specific side effects which need to be checked regularly. Some common ones (see individual drugs below) are monitoring weight so that people are gaining weight, watch for tics, watch for depression, checking blood pressure and pulse, checking blood tests and EKGs, and making sure parents know what the side effects are of the different medications. In this way, if there is a problem, we can pick it up early and avoid the horror stories, some of which are true, about the medical treatment of this problem.

Here are the specific drugs.

Serotonin Reuptake Inhibitors (SRIs)

In most cases, these are the first choice drugs for all anxiety disorders in pediatrics. These drugs all increase the activity of the serotonin nervous system in the brain. These neurons are involved in the regulation of mood, appetite, sexuality, sleep, aggression, obsessions, and compulsions. The side effects are usually fairly minor, but of course some people will react strongly to them. These drugs can cause restlessness, insomnia, and sometimes stomach upset, nausea vomiting, or diarrhea. They even can make kids more anxious and some can even become suicidal. They can also cause behavioral disinhibition. This can be things like acting silly, saying things that should not be said, increased aggressiveness and irritability. This is always reversible upon discontinuing the medicine. In extremely rare cases, less than 1 in 10,000, these drugs can make people stiff and sometimes have unusual movements. In all the cases I have seen reported, this disappeared within a few months at most. When used for anxiety, the dose needs to be very slowly increased so to avoid worsening anxiety.

Are there studies in children that show that these drugs work?

The best studies are those that compare a drug to placebo and the drug works better than placebo. This includes Luvox (9). These drugs are outlined in green font. The next level of evidence is studies where the drug has been tested in children, but a placebo was not used. These drugs are in yellow font. This includes Paxil (10) and Prozac (11). Drugs that haven't been tested in either way are in red. They are not good drugs to start with. The following drugs are in this family:

 

Drug

Brand Name

Usual Dosage

Sizes

comments

Fluoxetine

Prozac

About 1mg/kg

10, 20, liquid

Long acting

Paroxetine

Paxil

20-60mg a day

10, 20, 30

Worse withdrawal symptoms

Citalopram

Celexa

20-40mg a day

20

New in 1999

Sertraline

Zoloft

3mg/kg max

25, 50

capsules

Fluvoxamine

Luvox

3mg/kg max

50, 100

Pills are scored

 

The effect can take 6-8 weeks to become apparent, and sometimes up to three months before the full effect is seen. It is impossible to tell which drug in this class might be tolerated best by a child. It is also impossible to know which drug will work. That means if one is not tolerated or not working, it is reasonable to try another. When used carefully, it is unusual not to find a drug in this family that is moderately effective and well tolerated. When they are used for anxiety they need to be started at very low doses, as sometimes they can make children more anxious at first.

Drug Interactions

The drugs in this family can change how much of other medicines get into your blood stream. Other drugs can also change the amount of these SRI medications in your blood stream. What can happen? Here are the possibilities:

If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go up enough to give you more severe side effects.

If you start taking a drug that interacts with the SRI, the amount of the SRI in your blood could go down and you could become more psychiatrically ill again.

The SRI can result in another medication going up in your system, too. If you were taking other drugs while you were on an SRI, those other drugs might give you more side effects.

Unfortunately, the SRIs are not similar in this regard. Each one has different medications which it interacts with.

Example: Tina has a cough

Tina is 11. She has been taking Prozac now for about a month and she is a lot better. But she has the flu which is going around and so her mom went to the drug store and got some cough syrup. Tina took the cough syrup and got very, very confused. Her mom (already nervous) was worried that Tina was getting meningitis. She took her to the hospital and was glad to find out that it was a drug interaction between dextromethopham, the main ingredient in cough syrup, and Prozac. Still, it took Tina about a week to get over this. (5)

This does not mean that these drugs are dangerous. It does mean that if you are taking an SRI, a doctor should make sure that it will not interact badly with other drugs you might be prescribed. It also means you should check with the pharmacist before you take anything. (6)

 


The Good

The bad

Tricyclics

This category of medication has been around since the 1960s. They are used for depression and anxiety in adults, but do not work for depression alone in children. One of them, imipramine, has been carefully tested for Separation Anxiety disorder. They are very cheap. Double blind studies have shown that, if used at an adequate dosage, it is better than placebo. (8)

Here are the drugs in this group

All are generic now.

So why aren't they used more?

Approximately 5-10 children have died suddenly while taking one of these drugs, desipramine. This turns out to be a rate of about 8 per million. Children die of unknown causes at a rate of 8 per million. To put this in perspective, the childhood suicide rate is about 8 per million. The risk of dying in an auto accident are about 70 per million. So, although there is a very slight risk, compared to the risks of the disorder, it is very small. In my practice, it would be ten times more likely that someone would die on the way to their appointment with me in a car crash than die of sudden death related to these drugs. There is still a debate as to whether this small increase in deaths is from the medication or something else. It is also unclear as to whether monitoring as below will pick out these super rare cases. It has only happened with desipramine. A much more real risk is over dose. If children or adults take too much of these drugs accidentally or on purpose, they can die. These drugs can cause rhythm problems in the heart, blood pressure problems, and fast pulse, plus constipation and dry mouth and occasionally sweating and dizziness. It is very hard to figure out the dose.

Are they safe?

Yes, they quite safe if they are used correctly. The American Heart Association studied this issue and published their recommendations in August of 1999 (21). They suggest the following.

First I get an EKG. If it is normal, we start the drug at a very small test dose amount. For Desipramine and Imipramine, this is usually 1 mg/kg. The doses for Nortryptiline are half of this. Over the next few weeks I slowly increase the dose to 3-5 mg/kg for desipramine or 2-3 mg/kg for Nortryptiline . At this point we check a blood level and another EKG. It takes a week to get the result back. Based on the results of the blood test, I adjust the dose, and occasionally a person will need another EKG and blood test, but not usually. I check the blood pressure and pulse after a few weeks. The toxicity of these drugs is mostly related to the blood level and the EKG. By following these very conservative guidelines, the drug is very safe and often very effective.. BUT, it is a fair amount of hassle. Obviously if someone is dead set against having their blood drawn, they will never get this.

 

Benzodiazepines

I have heard that these are addictive. Will my son become addicted to these?

It depends on which one was used. Can a child get addicted to high doses of Xanax? yes. There are two things that determine whether one of these drugs will be addictive and produce withdrawal. The first is how fast it gets into the bloodstream. The second is how fast it goes out. The faster it gets in and the faster it gets out of your system, the more addictive it will be. Valium, for example, goes into your system very fast. It goes out slowly. It has moderate addiction potential. Librium goes in you system slowly and goes out slowly, too. It is not at all addictive. Cocaine goes in and out very fast. It is very addictive. There are two drugs that are commonly used in children with anxiety in this group. These are Rivotril (Clonazepam) and Ativan (Lorazepam).

Rivotril (clonazepam) - This drug was first used to control seizures in children and still is. Along the way people started using it in anxiety disorders. It lasts a long time in your body after a dose, so it only needs to be given once or twice a day. It is very unlikely to produce withdrawal, and since it goes into your system slowly, it does not make people high nor is it very addictive. It is very safe in children. The dosage is usually .5 mg to 2.5 mg a day. I start with the lowest dose first and slowly increase it up to about 2 mg a day and then watch for a week or two. If it works people are able to do things that they could not before with minimal anxiety. Rarely do all the symptoms disappear, but it can make a big difference in a hurry. The side effects which have been reported are sleepiness, slurred speech, bad balance, and sometimes aggression or agitation. Most people will have one or two side effects to a mild degree, but only at the beginning. However, some people can not tolerate this, as is true with all medications.

Ativan (Lorazepam) - This drug is similar to rivotril except it does not last as long. It usually is given two or three times a day as a result. It does have the potential to produce some withdrawal symptoms if it is stopped suddenly. Because of this it is my second choice amongst these drugs. However it is very safe and has been used in children for years.

The good
The Bad

Tricyclics and SSRIs can cause mania

About 5-10% of children who take these drugs will start to get manic. That is, elevated or irritable mood, hyperactivity, non-stop talking, risky or child -like behavior, thoughts going so fast that you can't follow them, not sleeping, and thinking they can do things that they really can't. This is reversible if you stop the drug early. Everyone who is being put on these drugs should be checked for signs of bipolar disorder. Click here to go to bipolar pamphlet

Other Drugs

There are a number of other drugs which have been found to be useful in anxious adults, but have never really been tested in children with panic disorder. They are Effexor, Serzone, Buspar, Welbutrin, and remeron. I would not use those unless the drugs which have been tested in children did not work.

With this information in mind, this is how I usually approach the medical treatment of anxiety disorders in children and adolescents.

The first choice if it is not an emergency

Serotonin Reuptake Inhbitors

         The first choice if Severe anxiety plus depression

Serotonin Reuptake Inhbitors

The first choice if Severe anxiety, Depression, and an emergency

The first and second choice if there are some manic symptoms and a family history of bipolar disorder

If they have bipolar signs and psychotherapy doesnít work

         Treat the bipolar disorder first.

Did someone in the family respond real well to one of these drugs?

How long do I have to continue treatment?

There are very few studies to guide this decision. Overall, I follow the same guidelines as I do with depressed patients. That is-

How do you go off the medication?

Slowly. This is called tapering. That leads to minimal withdrawal and less chance of relapse.

What happens if the child relapses after medication is stopped or during the taper?

Then they go back on the medication for at least two years, maybe more.

What about psychotherapy?

For the first episode, it is adequate to stop psychotherapy once you are well. For treatment resistant depression and people who have relapsed after they get better, ďbooster sessionsĒ are a good idea. This is monthly to every three month psychotherapy. When medication is being tapered down, it is also a good idea to go back to psychotherapy for awhile, especially if you have relapsed

Since relapse is so common, it is key to do all that you can to make sure you get well, stay well, and pick up early relapses. Even with the best family, the best luck, and the best care, relapse is common. As a result, once I see a child with panic disorder, I will always see them back in the future if necessary.

 

In summary,


  1. Anxiety disorders can be very disabling in children and should be treated.
  2. You need to make sure it is not some other medical problem and also see if other psychiatric problems are present, too.
  3. Most studies have found the best results when medical and non-medical treatments are combined.
  4. Most children with anxiety disorder should benefit significantly from treatment. It is a crime to do nothing.

[ Previous: Agoraphobia and school ]

[ Table Of Contents ]