eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Anxiety Disorder: Panic Disorder: Follow-up

Author: David S Reitman, MD, MBA, Director of Pediatric and Adolescent Health, John L Gildner Regional Institute for Children and Adolescents; Chairman of Pediatrics, Department of Pediatrics, Suburban Hospital; University Physician, George Washington University; Clinical Assistant Professor of Pediatrics, George Washington University; Attending Staff, Children's National Medical Center
Coauthor(s): Lene Holm Larsen, PhD, Instructor, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital of Chicago; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Contributor Information and Disclosures

Updated: May 24, 2006

Follow-up

Further Outpatient Care

  • Outpatient psychotherapy may be required for a few weeks to a year or longer.
  • Follow-up care during medical treatment with an SSRI (eg, fluoxetine) includes monitoring pulse and paying particular attention to symptoms of hepatic dysfunction, seizures, and movement disorder. Anorexia, gastrointestinal dysfunction, and headache tend to be possible transient adverse effects of SSRIs. Rashes may not be reported until they already have passed and tend to be coincidental with viral illness; thus, they should be assessed by a primary care physician familiar with the rash-producing illnesses currently occurring in the community.

Inpatient & Outpatient Medications

  • For patients for whom medication is prescribed, regular follow-up care with a child and adolescent psychiatrist or developmental-behavioral pediatrician is necessary for the duration of treatment.

Deterrence/Prevention

  • A consistent, stable, supportive home environment with parenting practices that promote self-confidence, self-esteem, and effective coping skills are important preventive measures. Minimize psychosocial stressors or traumatic events when possible and provide rapid psychological intervention. Parents and other significant people in the child's life should model adaptive problem-solving and coping skills.

Complications

  • Somatic symptoms may lead to excessive and invasive examinations when appropriate mental health professional assessment is delayed.
  • Reluctance to go to school or engage in other age-appropriate activities may result.
  • Comorbid depression is not uncommon, and, in severe cases, children and adolescents may become suicidal.
  • Adolescents may self-medicate, leading to substance abuse.

Prognosis

  • The prognosis may be worsened when parents are unable to assist in the child's treatment or model adaptive coping/anxiety management because of their own untreated anxiety (or other psychiatric conditions).
  • In a clinical sample, 10 of 23 children met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for panic disorder. During a 3-4-year follow-up period, the recovery rate was 70%, but 30% of the children had developed new psychiatric disorders (Last, 1996). This constitutes the worst prognosis for an anxiety disorder with onset in childhood or adolescence, but the prognosis with ongoing treatment is unknown and may be more favorable with recent developments in psychopharmacology and psychotherapy.

Patient Education

  • Psychoeducation should be part of the treatment process. Patient and parents should have a good understanding of the contributing and maintaining factors of anxiety. Also, they should be clear on the treatment goals, process, and expectations.
  • For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation.

Miscellaneous

Medicolegal Pitfalls

  • Because literature describes the risk of suicide in patients with comorbid depression and because risks are associated with unwarranted diagnostic procedures, consideration of this diagnosis is important when a child presents with the symptoms described earlier.
  • In the event that further nonpsychiatric medical evaluation is warranted, early mental health professional consultation is important to obtain assistance in excluding this diagnosis.
  • The FDA has not approved the use of antidepressants for treating panic disorder in children and adolescents. Physicians considering this off-label option must document that the child and parents received sufficient informed consent regarding the use of these medications.
 


More on Anxiety Disorder: Panic Disorder

Overview: Anxiety Disorder: Panic Disorder
Differential Diagnoses & Workup: Anxiety Disorder: Panic Disorder
Treatment & Medication: Anxiety Disorder: Panic Disorder
Follow-up: Anxiety Disorder: Panic Disorder
References
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References

  1. Barrett PM, Rapee RM, Dadds MM, Ryan SM. Family enhancement of cognitive style in anxious and aggressive children. J Abnorm Child Psychol. Apr 1996;24(2):187-203. [Medline].

  2. Birmaher B, Brent DA, Chiappetta L, et al. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. Oct 1999;38(10):1230-6. [Medline].

  3. Green WH. Child and Adolescent Clinical Psychopharmacology. 3rd ed. Philadelphia:. Lippincott Williams & Wilkins;2001.

  4. Hayward C, Killen JD, Kraemer HC. Predictors of panic attacks in adolescents. J Am Acad Child Adolesc Psychiatry. Feb 2000;39(2):207-14. [Medline].

  5. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. Feb 1994;62(1):100-10. [Medline].

  6. Kendall PC, Sugarman A. Attrition in the treatment of childhood anxiety disorders. J Consult Clin Psychol. Oct 1997;65(5):883-8. [Medline].

  7. Last CG, Perrin S, Hersen M, Kazdin AE. A prospective study of childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry. Nov 1996;35(11):1502-10. [Medline].

  8. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. Apr 1997;36(4):554-65. [Medline].

  9. Ost L, Treffers PD. Onset, course, and outcome for anxiety disorders in children. In: Silverman W, Treffers PD, eds. Anxiety Disorders in Children & Adolescent. 2001:293-312.

  10. Reynolds CR, Richmond BO. What I think and feel: a revised measure of children''s manifest anxiety. J Abnorm Child Psychol. Jun 1978;6(2):271-80. [Medline].

  11. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for Children (DSM-IV). San Antonio, TX:. Psychological Corporation;1997.

  12. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

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Further Reading

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Keywords

panic disorder, hyperventilation syndrome, agoraphobia, panic attacks, unexpected panic attacks, situationally bound panic attacks, situationally predisposed panic attacks, recurrent panic attacks

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Contributor Information and Disclosures

Author

David S Reitman, MD, MBA, Director of Pediatric and Adolescent Health, John L Gildner Regional Institute for Children and Adolescents; Chairman of Pediatrics, Department of Pediatrics, Suburban Hospital; University Physician, George Washington University; Clinical Assistant Professor of Pediatrics, George Washington University; Attending Staff, Children's National Medical Center
David S Reitman, MD, MBA is a member of the following medical societies: American Academy of Pediatrics, American College Health Association, American College of Physician Executives, American College of Sports Medicine, American Medical Association, Phi Beta Kappa, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Lene Holm Larsen, PhD, Instructor, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital of Chicago
Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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