Case Study Diagnosis of Panic Disorder in Prepubertal Children BENEDETTO VITIELLO, M.D., DAVID BEHAR, M.D., SAUL WOLFSON, M.D., SUSAN V. McLEER, M.D.
AND
Abstract. Few reports on panic disorder in children are available, despite the retrospectively documented onset in childhood of about 20% of the cases of adult panic disorder. The authors report on six prepubertal children, aged 8 to 13 years, who met DSM-IlI-R criteria for adult-type panic disorder. Hyperthyroidism, cardiologic, and respiratory problems were excluded as well as abuse of caffeine or other drugs. The first panic attack occurred between 5 to 11 years of age, with an average interval of 3 years between onset of the disorder and diagnosis. Mitral valve prolapse was documented in two cases. Family history was always positive for panic disorder. Although not common, panic disorder should be considered in children with school phobia and positive family history. As it is in adults, mitral valve prolapse may be associated with panic disorder in children. J. Am. Acad. Child Adolesc. Psychiatry, 1990,29,5:782-784. Key Words: panic disorders, children, mitral valve prolapse.
dearth of reports of panic symptoms in prepubertal children. Clinical descriptions of panic attacks in children are available (van Winter and Stickler, 1984; Biederman, 1987). Vitiello et al. (1987) reported on two cases of DSM -III panic disorder in prepubertal children, followed by Alessi and Magen (1987), who found that 5% of 136 child psychiatric inpatients had this diagnosis. Last and Strauss (1989) reported a 9.6% prevalence of panic disorder in postpubertal child psychiatric outpatients. Recently, other clinical reports of this disorder in children and adolescents have been published (Moreau et al. 1989; Hayward et al. 1989). Mitral valve prolapse has been reported to be more frequent in adult patients with panic disorder (Crowe, 1985a). Singlecase reports of association of mitral valve prolapse with separation anxiety (Casat et al., 1987) and with panic disorder in children (Vitiello et al., 1987) are available. The purposes of the present clinical report are: (1) to provide additional evidence of the presence of adult-type panic disorder in children; (2) to describe the clinical features of this disorder in childhood and its relationship with school phobia and separation anxiety; (3) to document the presence of mitral valve prolapse in some of these children.
Anxiety disorders in children are usually classified apart from the anxiety disorders in adults. DSM-III and DSM-III-R (American Psychiatric Association, 1980, 1987) maintain this tradition with "Anxiety Disorders in Childhood and Adolescence," namely, separation anxiety, avoidant disorder, and overanxious disorder. A similar split in classification existed for depression before the use of adult criteria for affective disorders became accepted in children. The present classification of anxiety disorders in children tantalizes by paralleling adult agoraphobia, social phobia, and generalized anxiety disorder. There are suggestions of a continuity between childhood and adult anxiety disorders. For instance, adult agoraphobics often reported having suffered from separation anxiety as children (Gittelman and Klein, 1984). A better understanding of anxiety disorders in these different age groups could ultimately lead to a more satisfactory classification of childhood anxiety disorders, given also the fact that the interrater reliability of current childhood anxiety disorders is disappointing (kappa coefficients from 0.25 to 0.44 versus 0.63 to 0.72 for adult anxiety disorders) (American Psychiatric Association, 1980). Panic disorder, which has a lifetime prevalence of about 1.4% (Robins etal., 1984), often has an early onset. The peak of onset has been found to be between 15 and 19 years, with 18% of adult patients indicating onset before 10 years of age (von Korff et al., 1985). This retrospectively documented presence of panic disorder in childhood contrasts with the
Cases The authors report on six children, five boys and one girl, all white, aged 8 to 13 years, suffering from DSM-III-R panic disorder. Patients were prepubertal (Tanner stage I or II) at the time of diagnosis. Five were outpatients and one an inpatient. They were among approximately 320 inpatients and 840 outpatients, aged 5 to 13 years, who were referred to the authors' academic child psychiatry services during the past 4 years. All the referred children received a complete psychiatric evaluation by child psychiatry fellows, supervised by trained child psychiatrists. Children who presented with symptoms suggestive of discrete episodes of anxiety were referred to the authors for additional evaluation. Diagnosis of panic disorder (DSM-III-R) was obtained by two independent child psychiatrists. In addition to an unstructured psychiatric interview, the Diagnostic Interview for Children and
AcceptedNovember 2, i989. Drs. Vitiello, Behar, and McLeer are with the Medical College of Pennsylvania at the Eastern Pennsylvania Psychiatric institute, Philadelphia, PA. Dr. Wolfson is with the Eastern State School and Hospital, Trevose,PA. Presented at the 8th World Congress ofPsychiatry, Athens, Greece, October, i989. The authors gratefully acknowledge the help ofM. A. Delaney, M.D. Reprint requests to Dr. Vitiello, ClinicaiNeuropharmacology, Lab. of Clinical Sciences, NiMH, NiH Clinical Center, iOI3D-4i, Bethesda, MD 20892. 0890-8567/90/2905-0782$02.0010© 1990 by the American Academy of Child and Adolescent Psychiatry.
782
PANIC DISORDER IN PREPUBERTAL CHILDREN TABLE I. Children with DSM-IIl-R Panic Disorder
Case
Sex
I 2 3
M M M
4 5
M M F
6
Tanner
Age at Diagnosis (yrs)
Age at 1st Attack (yrs)
8 10
5 5
9
6
II I
13
7
11
II
12
11 11
School Phobia
+ +
Separation anxiety Separation anxiety Separation anxiety
+
Separation anxiety Overanxious Oppositional
Adolescents (DlCA), child and parent versions (Herjanic and Campbell, 1977), and the panic disorder section of the adult Diagnostic Interview Schedule (DIS) (Robins et al., 1981), were administered by one of the two child psychiatrists . The DIS was used because the DICA lacked a specific section on adult-type panic disorder. The diagnosis of panic disorder was accepted when both the unstructured and structured interviews were consistent with the disorder. None of these children had a history of significant medical problems. In particular, none suffered from asthma, hyperthyroidism, neurological, or heart diseases. They were not on medications. Caffeine abuse was excluded. Cardiologic examination and bidimensional echocardiogram were obtained in these six children. Cardiologists were blind to the psychiatric diagnosis. The parents were interviewed on the DIS. Family history was obtained from the patients' parents. Family members, who were reported to suffer from psychiatric disturbances, were interviewed over the telephone using the DIS. However, for some of them, direct interview was not possible and the information had to be collected from the closest family member. Clinical vignettes of cases 1 and 2 are provided.
Casel An 8-year-old white boy was referred to the inpatient unit for severe separation anxiety with school avoidance since first grade. At 5 years of age, while at home with his parents, he suffered a sudden anxiety attack lasting about 15 minutes, with palpitations, dyspnea, trembling, and sweating. Three years later, child and parents were still able to remember the exact day and time of this first episode. The attack did not occur in the context of separation from family members , and there was no evident trigger. He later presented with similar episodes, both at home and in school, and refused to attend school. At cardiologic examination, he had a midsystolic click . The echocardiogram was positive for mitral valve prolapse. His father reported that his paternal grandmother had suffered from panic attacks.
Case 2 A lO-year-old white boy was referred to outpatient services for separation anxiety with school avoidance. At 5.5 years of age, he developed panic attacks while at home. He presented with more than five attacks per month. He later became school phobic, requiring a private tutor at home. No relevant J. Am .Acad. Child Adolesc. Psychiatry , 29:5, September 1990
Other Diagnoses
Mitral Valve Prolapse
+
+
Family History of Panic Disorder Paternal grandmother Brother, father Mother, maternal aunt, and grandmother Mother, maternal grandmother Father, paternal grandfather Maternal aunt
TABLE 2. Symptoms Presented during Panic Attacks in Six
Prepubertal Children Symptom Heart pounding Weakness Trembling or shaking Feeling of dying or going crazy Shortness of breath Feeling light-headed, dizzy Chest tightness or pain Tingling of fingers or face Choking or smothering Sweating Hot or cold flashes Blurred vision
No . of Patients Reporting
6 6 6 6
5 5 5 4 4 4
o o
medical disorders were found. He had an innocent heart murmur and his echocardiogram was normal. His father and older brother had suffered from panic disorder since early adolescence, and his brother had been school phobic. A paternal cousin had had panic disorder with agoraphobia as a child and had committed suicide at 19 years. Demographics, clinical, and echocardiographic findings of the six cases are summarized in Table 1. The age of onset ranged from 5 to 11 years. The two patients whose onset occurred at 5 years were the most severely disabled of the group. The occurrence of the first panic attack was always remembered in detail by the patients and their families, who were usually able to provide exact date and circumstances under which the disorder started. The onset of the disorder was characterized by anxiety attacks which were unexpected and nonsituationally related. The symptoms presented during the panic attacks are summarized in Table 2. Despite the fact that school was never the place of the first attack, three children displayed school avoidance a few months after the onset of the panic attacks . In addition to the panic disorder, four patients met criteria for separation anxiety, two for oppositional disorder, and one for overanxious disorder. Reasons for referral to the authors' clinic were the symptoms of panic attacks for three children and the school avoidance for the remaining three. Mitral valve prolapse was documented in two cases. Family history was invariably positive for panic disorder and was often reported in several generations. As shown in 783
VITIELLO ET AL .
Table I, only one side of the family, maternal (in four cases) or paternal (in the other two) , was affected . Discussion DSM-IIl-R criteria for adult-like panic disorder can be used in prepubertal children. This disorder is not common in the authors' experience, having been identified in six children over 4 years in a clinic that received more than 1,000 referrals during the same period. However, the prevalence might have been underestimated, given that only the patients with severe separation anxiety/school phobia were referred for structured interviewing. No systematic screening of a population was carried out. Epidemiological data in adults showed a higher prevalence of panic disorder in females and an equal racial distribution in whites and blacks (Robins et al., 1984) . By contrast, the cases in this study were white and predominantly male. The small sample size, referral biases, or a combination of these , may account for the discrepancy. There are clear links between panic disorder and separation anxiety (Gittelman and Klein , 1984), with 24% of the children of depressed agoraphobic and panic patients presenting with separation anxiety (Weissman et al., 1984). In this sample, separation anxiety accompanied the panic disorder in four cases and school avoidance was present in three. Separation anxiety and school phobia were , however, independent of panic disorder, since two children did not have a history of separation anxiety or school phobia. It is worth noting that the average interval between first panic attack and diagnosis ofpanic disorder was 3 years . This means that these children remained without appropriate diagnosis and specific treatment for several years. Mitral valve prolapse is reported to be more common in panic disorder patients (prevalence 38% to 50%) than in the general population (Crowe , 1985a). Two of the six cases had echocardiographically documented mitral valve prolapse. The family history of these patients (Table 1) shows the presence of panic disorder on one side of their families . This is consistent with an autosomal dominant transmission, as suggested elsewhere (Crowe, 1985b) . Panic disorder, even if not common in childhood, should be suspected when there is a family history of this disorder. The benefits of this approach are: (1) a nosographically "stronger" diagnosis , with better reliability and higher prognostic value than separation anxiety or overanxious disorder; (2) indications for more specific, validated treatments , including the use of tricyclic antidepressants and benzodiaze-
784
pines. In addition , children with panic disorder, as adults , may have a higher rate of mitral valve prolapse. A higher prevalence of diagnosed panic disorder in children may encourage attempts to additionally unify (Le. , to see as a continuum) the adult and child anxiety disorders , as has been done with the affective and schizophrenic disorders . References Alessi, N. & Magen , J . (1987), Panic disorder in psychiatrically hospitalized children. Am.J. Psychiatry, 145:1450-1452. American Psychiatric Association (1987), Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, DC:APA,pp.58-64. - - American Psychiatric Association (1980), Diagnostic and Statistical Manual ofMental Disorders, Third Edition. Washington , DC: APA. Biederman, J. (1987), Clonazepam in the treatment of prepubertal children with panic-like symptoms. J . Clin. Psychiatry, 48 (Suppl):3841.
Casat, C. , Ross, B. A. , Scardina , R. , Sarno , C. & Smith, K. E. (1987) , Separation anxiety and mitral valve prolapse in a 12-year-old girl. J . Am.Acad . Child Adolesc. Psychiatry, 26:444-446. Crowe, R. R. (l985a), Mitral valve prolapse and panic disorder . Psychiatr. Clin.NorthAm ., 8:63-71. - - (l985b), The genetics of panic disorder and agoraphobia. Psychiatr.Dev. 2:171-185. Gittelman, R. & Klein, D. F. (1984), Relationship between separation anxiety and panic and agoraphobic disorders . Psychopatholo gy, 17(Suppl. 1): 56-65. Hayward, C., Killen, J. D. &Taylor,C. B. (1989), Panic attacks in young adolescents.Am .J. Psychiatry, 146:1061-1062. Herjanic , B. & Campbell , W. (1977) , Differentiating psychiatrically disturbed children on the basis of a structured interview . J .Abnorm . ChildP sychol., 5:127-134. Last, C. G. & Strauss , C . C. (1989) , Panic disorder in children and adolescents. Journal of Anxiety Disorders, 3:87-95. Moreau, D. L., Weissman, M. & Warner, V. (1989), Panic disorder in children at high risk for depression . Am. J. Psychiatry , 146:10591060. Robins, L. N. , Helzer, J . E. , Weissman M. M. , Orvaschel H. , Gruenberg E., Burke J. D., Regier D. ( 19 84 ) , Lifetime prevalence of sp ecific
psychiatric disorders in three sites . Arch. Gen. Psychiatry, 41:949958. ----Croughan,J., Williams ,J. B. W. &Spitzer,R. L. (1981),The NIMH Diagnostic Interview Schedule: Version //1 . (Publication ADM-T-42-3 ) Washington , DC: Public Health Service . Van Winter , J. T. & Stickler, G. B. (1984), Panic attack syndrome. J. Pediatr. , 105:661-665. Vitiello, B. , Behar, D. , Wolfson , S . & Delaney , M. A. (1987), Panic disorder in prepubertal children . Am .J.Psychiatry, 144:525-526 . VonKorff,M. R. ,Eaton ,W .W.&Keyl,P. M. (1985), The epidemiology of panic attacks and panic disorder. Am .J. Epidemiol, 122:970-981. Weissman , M. M. , Leckrnan, J. F. , Merikangas, K. R. Gammon , G. B. & Prusoff, B. A. (1984) , Depression and anxiety disorders in parents and children . Arch .Gen . Psychiatry, 41:845-852.
J. Am .Acad. Child Ado/esc . Psychiatry, 29:5, September J990
AND
Abstract. Few reports on panic disorder in children are available, despite the retrospectively documented onset in childhood of about 20% of the cases of adult panic disorder. The authors report on six prepubertal children, aged 8 to 13 years, who met DSM-IlI-R criteria for adult-type panic disorder. Hyperthyroidism, cardiologic, and respiratory problems were excluded as well as abuse of caffeine or other drugs. The first panic attack occurred between 5 to 11 years of age, with an average interval of 3 years between onset of the disorder and diagnosis. Mitral valve prolapse was documented in two cases. Family history was always positive for panic disorder. Although not common, panic disorder should be considered in children with school phobia and positive family history. As it is in adults, mitral valve prolapse may be associated with panic disorder in children. J. Am. Acad. Child Adolesc. Psychiatry, 1990,29,5:782-784. Key Words: panic disorders, children, mitral valve prolapse.
dearth of reports of panic symptoms in prepubertal children. Clinical descriptions of panic attacks in children are available (van Winter and Stickler, 1984; Biederman, 1987). Vitiello et al. (1987) reported on two cases of DSM -III panic disorder in prepubertal children, followed by Alessi and Magen (1987), who found that 5% of 136 child psychiatric inpatients had this diagnosis. Last and Strauss (1989) reported a 9.6% prevalence of panic disorder in postpubertal child psychiatric outpatients. Recently, other clinical reports of this disorder in children and adolescents have been published (Moreau et al. 1989; Hayward et al. 1989). Mitral valve prolapse has been reported to be more frequent in adult patients with panic disorder (Crowe, 1985a). Singlecase reports of association of mitral valve prolapse with separation anxiety (Casat et al., 1987) and with panic disorder in children (Vitiello et al., 1987) are available. The purposes of the present clinical report are: (1) to provide additional evidence of the presence of adult-type panic disorder in children; (2) to describe the clinical features of this disorder in childhood and its relationship with school phobia and separation anxiety; (3) to document the presence of mitral valve prolapse in some of these children.
Anxiety disorders in children are usually classified apart from the anxiety disorders in adults. DSM-III and DSM-III-R (American Psychiatric Association, 1980, 1987) maintain this tradition with "Anxiety Disorders in Childhood and Adolescence," namely, separation anxiety, avoidant disorder, and overanxious disorder. A similar split in classification existed for depression before the use of adult criteria for affective disorders became accepted in children. The present classification of anxiety disorders in children tantalizes by paralleling adult agoraphobia, social phobia, and generalized anxiety disorder. There are suggestions of a continuity between childhood and adult anxiety disorders. For instance, adult agoraphobics often reported having suffered from separation anxiety as children (Gittelman and Klein, 1984). A better understanding of anxiety disorders in these different age groups could ultimately lead to a more satisfactory classification of childhood anxiety disorders, given also the fact that the interrater reliability of current childhood anxiety disorders is disappointing (kappa coefficients from 0.25 to 0.44 versus 0.63 to 0.72 for adult anxiety disorders) (American Psychiatric Association, 1980). Panic disorder, which has a lifetime prevalence of about 1.4% (Robins etal., 1984), often has an early onset. The peak of onset has been found to be between 15 and 19 years, with 18% of adult patients indicating onset before 10 years of age (von Korff et al., 1985). This retrospectively documented presence of panic disorder in childhood contrasts with the
Cases The authors report on six children, five boys and one girl, all white, aged 8 to 13 years, suffering from DSM-III-R panic disorder. Patients were prepubertal (Tanner stage I or II) at the time of diagnosis. Five were outpatients and one an inpatient. They were among approximately 320 inpatients and 840 outpatients, aged 5 to 13 years, who were referred to the authors' academic child psychiatry services during the past 4 years. All the referred children received a complete psychiatric evaluation by child psychiatry fellows, supervised by trained child psychiatrists. Children who presented with symptoms suggestive of discrete episodes of anxiety were referred to the authors for additional evaluation. Diagnosis of panic disorder (DSM-III-R) was obtained by two independent child psychiatrists. In addition to an unstructured psychiatric interview, the Diagnostic Interview for Children and
AcceptedNovember 2, i989. Drs. Vitiello, Behar, and McLeer are with the Medical College of Pennsylvania at the Eastern Pennsylvania Psychiatric institute, Philadelphia, PA. Dr. Wolfson is with the Eastern State School and Hospital, Trevose,PA. Presented at the 8th World Congress ofPsychiatry, Athens, Greece, October, i989. The authors gratefully acknowledge the help ofM. A. Delaney, M.D. Reprint requests to Dr. Vitiello, ClinicaiNeuropharmacology, Lab. of Clinical Sciences, NiMH, NiH Clinical Center, iOI3D-4i, Bethesda, MD 20892. 0890-8567/90/2905-0782$02.0010© 1990 by the American Academy of Child and Adolescent Psychiatry.
782
PANIC DISORDER IN PREPUBERTAL CHILDREN TABLE I. Children with DSM-IIl-R Panic Disorder
Case
Sex
I 2 3
M M M
4 5
M M F
6
Tanner
Age at Diagnosis (yrs)
Age at 1st Attack (yrs)
8 10
5 5
9
6
II I
13
7
11
II
12
11 11
School Phobia
+ +
Separation anxiety Separation anxiety Separation anxiety
+
Separation anxiety Overanxious Oppositional
Adolescents (DlCA), child and parent versions (Herjanic and Campbell, 1977), and the panic disorder section of the adult Diagnostic Interview Schedule (DIS) (Robins et al., 1981), were administered by one of the two child psychiatrists . The DIS was used because the DICA lacked a specific section on adult-type panic disorder. The diagnosis of panic disorder was accepted when both the unstructured and structured interviews were consistent with the disorder. None of these children had a history of significant medical problems. In particular, none suffered from asthma, hyperthyroidism, neurological, or heart diseases. They were not on medications. Caffeine abuse was excluded. Cardiologic examination and bidimensional echocardiogram were obtained in these six children. Cardiologists were blind to the psychiatric diagnosis. The parents were interviewed on the DIS. Family history was obtained from the patients' parents. Family members, who were reported to suffer from psychiatric disturbances, were interviewed over the telephone using the DIS. However, for some of them, direct interview was not possible and the information had to be collected from the closest family member. Clinical vignettes of cases 1 and 2 are provided.
Casel An 8-year-old white boy was referred to the inpatient unit for severe separation anxiety with school avoidance since first grade. At 5 years of age, while at home with his parents, he suffered a sudden anxiety attack lasting about 15 minutes, with palpitations, dyspnea, trembling, and sweating. Three years later, child and parents were still able to remember the exact day and time of this first episode. The attack did not occur in the context of separation from family members , and there was no evident trigger. He later presented with similar episodes, both at home and in school, and refused to attend school. At cardiologic examination, he had a midsystolic click . The echocardiogram was positive for mitral valve prolapse. His father reported that his paternal grandmother had suffered from panic attacks.
Case 2 A lO-year-old white boy was referred to outpatient services for separation anxiety with school avoidance. At 5.5 years of age, he developed panic attacks while at home. He presented with more than five attacks per month. He later became school phobic, requiring a private tutor at home. No relevant J. Am .Acad. Child Adolesc. Psychiatry , 29:5, September 1990
Other Diagnoses
Mitral Valve Prolapse
+
+
Family History of Panic Disorder Paternal grandmother Brother, father Mother, maternal aunt, and grandmother Mother, maternal grandmother Father, paternal grandfather Maternal aunt
TABLE 2. Symptoms Presented during Panic Attacks in Six
Prepubertal Children Symptom Heart pounding Weakness Trembling or shaking Feeling of dying or going crazy Shortness of breath Feeling light-headed, dizzy Chest tightness or pain Tingling of fingers or face Choking or smothering Sweating Hot or cold flashes Blurred vision
No . of Patients Reporting
6 6 6 6
5 5 5 4 4 4
o o
medical disorders were found. He had an innocent heart murmur and his echocardiogram was normal. His father and older brother had suffered from panic disorder since early adolescence, and his brother had been school phobic. A paternal cousin had had panic disorder with agoraphobia as a child and had committed suicide at 19 years. Demographics, clinical, and echocardiographic findings of the six cases are summarized in Table 1. The age of onset ranged from 5 to 11 years. The two patients whose onset occurred at 5 years were the most severely disabled of the group. The occurrence of the first panic attack was always remembered in detail by the patients and their families, who were usually able to provide exact date and circumstances under which the disorder started. The onset of the disorder was characterized by anxiety attacks which were unexpected and nonsituationally related. The symptoms presented during the panic attacks are summarized in Table 2. Despite the fact that school was never the place of the first attack, three children displayed school avoidance a few months after the onset of the panic attacks . In addition to the panic disorder, four patients met criteria for separation anxiety, two for oppositional disorder, and one for overanxious disorder. Reasons for referral to the authors' clinic were the symptoms of panic attacks for three children and the school avoidance for the remaining three. Mitral valve prolapse was documented in two cases. Family history was invariably positive for panic disorder and was often reported in several generations. As shown in 783
VITIELLO ET AL .
Table I, only one side of the family, maternal (in four cases) or paternal (in the other two) , was affected . Discussion DSM-IIl-R criteria for adult-like panic disorder can be used in prepubertal children. This disorder is not common in the authors' experience, having been identified in six children over 4 years in a clinic that received more than 1,000 referrals during the same period. However, the prevalence might have been underestimated, given that only the patients with severe separation anxiety/school phobia were referred for structured interviewing. No systematic screening of a population was carried out. Epidemiological data in adults showed a higher prevalence of panic disorder in females and an equal racial distribution in whites and blacks (Robins et al., 1984) . By contrast, the cases in this study were white and predominantly male. The small sample size, referral biases, or a combination of these , may account for the discrepancy. There are clear links between panic disorder and separation anxiety (Gittelman and Klein , 1984), with 24% of the children of depressed agoraphobic and panic patients presenting with separation anxiety (Weissman et al., 1984). In this sample, separation anxiety accompanied the panic disorder in four cases and school avoidance was present in three. Separation anxiety and school phobia were , however, independent of panic disorder, since two children did not have a history of separation anxiety or school phobia. It is worth noting that the average interval between first panic attack and diagnosis ofpanic disorder was 3 years . This means that these children remained without appropriate diagnosis and specific treatment for several years. Mitral valve prolapse is reported to be more common in panic disorder patients (prevalence 38% to 50%) than in the general population (Crowe , 1985a). Two of the six cases had echocardiographically documented mitral valve prolapse. The family history of these patients (Table 1) shows the presence of panic disorder on one side of their families . This is consistent with an autosomal dominant transmission, as suggested elsewhere (Crowe, 1985b) . Panic disorder, even if not common in childhood, should be suspected when there is a family history of this disorder. The benefits of this approach are: (1) a nosographically "stronger" diagnosis , with better reliability and higher prognostic value than separation anxiety or overanxious disorder; (2) indications for more specific, validated treatments , including the use of tricyclic antidepressants and benzodiaze-
784
pines. In addition , children with panic disorder, as adults , may have a higher rate of mitral valve prolapse. A higher prevalence of diagnosed panic disorder in children may encourage attempts to additionally unify (Le. , to see as a continuum) the adult and child anxiety disorders , as has been done with the affective and schizophrenic disorders . References Alessi, N. & Magen , J . (1987), Panic disorder in psychiatrically hospitalized children. Am.J. Psychiatry, 145:1450-1452. American Psychiatric Association (1987), Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, DC:APA,pp.58-64. - - American Psychiatric Association (1980), Diagnostic and Statistical Manual ofMental Disorders, Third Edition. Washington , DC: APA. Biederman, J. (1987), Clonazepam in the treatment of prepubertal children with panic-like symptoms. J . Clin. Psychiatry, 48 (Suppl):3841.
Casat, C. , Ross, B. A. , Scardina , R. , Sarno , C. & Smith, K. E. (1987) , Separation anxiety and mitral valve prolapse in a 12-year-old girl. J . Am.Acad . Child Adolesc. Psychiatry, 26:444-446. Crowe, R. R. (l985a), Mitral valve prolapse and panic disorder . Psychiatr. Clin.NorthAm ., 8:63-71. - - (l985b), The genetics of panic disorder and agoraphobia. Psychiatr.Dev. 2:171-185. Gittelman, R. & Klein, D. F. (1984), Relationship between separation anxiety and panic and agoraphobic disorders . Psychopatholo gy, 17(Suppl. 1): 56-65. Hayward, C., Killen, J. D. &Taylor,C. B. (1989), Panic attacks in young adolescents.Am .J. Psychiatry, 146:1061-1062. Herjanic , B. & Campbell , W. (1977) , Differentiating psychiatrically disturbed children on the basis of a structured interview . J .Abnorm . ChildP sychol., 5:127-134. Last, C. G. & Strauss , C . C. (1989) , Panic disorder in children and adolescents. Journal of Anxiety Disorders, 3:87-95. Moreau, D. L., Weissman, M. & Warner, V. (1989), Panic disorder in children at high risk for depression . Am. J. Psychiatry , 146:10591060. Robins, L. N. , Helzer, J . E. , Weissman M. M. , Orvaschel H. , Gruenberg E., Burke J. D., Regier D. ( 19 84 ) , Lifetime prevalence of sp ecific
psychiatric disorders in three sites . Arch. Gen. Psychiatry, 41:949958. ----Croughan,J., Williams ,J. B. W. &Spitzer,R. L. (1981),The NIMH Diagnostic Interview Schedule: Version //1 . (Publication ADM-T-42-3 ) Washington , DC: Public Health Service . Van Winter , J. T. & Stickler, G. B. (1984), Panic attack syndrome. J. Pediatr. , 105:661-665. Vitiello, B. , Behar, D. , Wolfson , S . & Delaney , M. A. (1987), Panic disorder in prepubertal children . Am .J.Psychiatry, 144:525-526 . VonKorff,M. R. ,Eaton ,W .W.&Keyl,P. M. (1985), The epidemiology of panic attacks and panic disorder. Am .J. Epidemiol, 122:970-981. Weissman , M. M. , Leckrnan, J. F. , Merikangas, K. R. Gammon , G. B. & Prusoff, B. A. (1984) , Depression and anxiety disorders in parents and children . Arch .Gen . Psychiatry, 41:845-852.
J. Am .Acad. Child Ado/esc . Psychiatry, 29:5, September J990
