In the wake of the Covid-19 pandemic, many children are facing heightened levels of stress due to gaps in their schooling and the return to face-to-face learning. This is showing itself in increased anxiety felt by children across the board.

In this context, taking preventative measures and reducing the stress that children feel can lower the risk of panic attacks and the development of panic disorder, according to Candice Cowen, a clinical psychologist.

“We’re coming out of two incredibly difficult years, and so we will have many children who will be experiencing things like panic attacks or heightened levels of anxiety that might not necessarily go on to meet the criteria for a diagnosis, but that will certainly need support,” said Jessie-Anne Bird, an educational psychologist.

Cowen and Bird were speaking at a webinar hosted by the South African Depression and Anxiety Group on Wednesday, 13 July, titled “Pint-sized Panic: Panic Disorder and Children”. They were joined by Dr Alicia Porter, a psychiatrist, in unpacking the identification and management of panic among young people.

Read in Daily Maverick: “Experts ring the warning bells over a mental health crisis among South African’s children during the pandemic”

Panic attacks and disorder

Panic attacks and panic disorder are different conditions, explained Porter. Panic attacks are distinct periods of intense panic-related symptoms that come on quite abruptly.

“Essentially, what happens is the brain goes into fight-or-flight mode for about two to three minutes. That’s really… how long a panic attack lasts,” said Cowen.

A panic disorder involves recurrent panic attacks, to the extent that the affected person’s behaviour changes due to the fear of having another attack, according to Porter. The condition is more common among adolescents than younger children.

Panic attacks or disorder cannot be considered in isolation from the environment in which the child lives, said Bird. There is a need to establish the triggers of these “big emotional responses”.

“I don’t think we should look at the panic attacks, or if we go further, into the disorder itself, as something that exists without a context; as something that exists without risk factors that would have come before it,” she said, adding that triggers can include academic difficulties, undiagnosed learning disorders and social struggles.

“We can’t have a one-size-fits-all approach, because we want to… work with that child and have an understanding.”

Panic and anxiety can also run in families, with certain children having a genetic predisposition to such conditions, according to Porter.

Signs and symptoms

Panic and anxiety can manifest differently in adults and children, meaning that children with these conditions are often misdiagnosed as having physical ailments such as asthma, heart problems or stomach issues, said Porter.

Symptoms of panic attacks include heart palpitations, chest pains, dizziness, sweating, trembling and nausea.

“Kids at different developmental stages can verbalise emotions, and then some struggle,” said Cowen. “So, we’re finding the ‘littlies’, the smaller kiddies, might not have the words or the vocab to say, ‘I feel worried about this’, or ‘I feel overwhelmed’. Those are big vocab things, and often kids present psychosomatically.”

Some “clues” indicating panic or anxiety that parents and guardians can look out for include disrupted sleep; a change in appetite; out-of-character behaviour; increased tearfulness; and frequent headache and stomach complaints.

“There’s often kids who will present with… separation anxiety,” continued Cowen. “When mom and dad go on date night… it seems almost like the child’s having a panic attack about them leaving, and it’s this irrational fear that something bad is going to happen.”

Support and treatment

While children are small in size, they often have big and powerful feelings, said Bird. For an adult dealing with a child’s emotions or panic, this can be overwhelming.

“Something that’s so important when you’re working with a child who is becoming anxious, who is moving into that state of panic, is to regulate your own emotions first — is to take that step back, is to pause, is to breathe,” she said. 

“It’s to calm yourself first, so that you can become that containing factor that can then help bring them back down and help them re-regulate.”

When it comes to establishing whether a child is struggling with panic or anxiety, it is the parent or guardian who needs to start the conversation, said Cowen. Asking questions about their day, school or social activities can help identify the source of their stress.

“You want to start… just empathising, or normalising that sometimes it’s okay to feel scared if your teacher raises her voice, or sometimes if you don’t get the mark you want, it is okay to feel a bit worried,” she said.

“Start normalising a lot of the stuff that they are feeling. You start giving them vocab, and when they’re having symptoms like the tummy ache, you start teaching them that sometimes our brains and our bodies work together, and… that signs that we are worried about something.”

From there, it is about teaching children techniques to manage their emotions, such as deep breathing to slow down hyperventilation, explained Cowen.

“So, you want to let them pick up ‘I’m feeling something’, put a word to it, what is it, and then start to do things to reduce how they’re feeling, and be with them through what they’re going through.”

Cowen uses cognitive behavioural therapy to equip children with the tools they need to verbalise their emotions. She also teaches them strategies, such as deep breathing, to “regulate their brains out of fight or flight” when they are panicking.

“I think it empowers kids to know that, actually, a panic attack isn’t this big monster I can’t deal with — I actually have tools and I’ve got skills,” she said.

Medication for panic attacks and disorder is a method of last resort for children, according to Porter. Where possible, experts will use non-pharmacological measures to intervene.

It takes a village

Schools can play an important role in supporting not just one child that is struggling, but entire groups that need help with validating and understanding their emotions, according to Bird.

“I certainly think we’re at a point where we need to start thinking bigger and we need to start thinking broader than just helping the one child that’s overtly showing signs of distress,” she said.

There is no need to wait until a child is at the point of needing a diagnosis to intervene and implement strategies to alleviate their anxiety. One of the features of working with children is having the “power of early intervention”.

“What I like to really emphasise is having these open channels of communication between all people involved in the child’s life — the parents, the teachers, the coaches, other relatives — so that when you start to see things that are concerning, one can act early,” she said. DM/MC