What is the appropriate acute and long‑term management of a panic attack in an 11‑year‑old child?

Management of Panic Attack in an 11-Year-Old Child

For an 11-year-old experiencing a panic attack, provide immediate reassurance and environmental calming, then initiate cognitive-behavioral therapy (CBT) as first-line treatment, reserving SSRIs for severe or treatment-resistant cases. 1, 2

Acute Management (During the Panic Attack)

Immediate Interventions

• Create a calm, low-stimulation environment by moving the child to a quiet, private space away from crowds and excessive sensory input 1
• Provide continuous reassurance that the symptoms are temporary and not dangerous, as panic attacks in children often present with fears of dying or "going crazy" 3, 4
• Teach and guide simple breathing exercises (slow, deep breathing) to counteract hyperventilation, which exacerbates panic symptoms 1
• Use distraction techniques such as bubble blowers, counting exercises, or guided imagery to redirect attention away from somatic symptoms 1
• Allow parental presence during the episode, as family support reduces anxiety and helps the child feel safe 1

What NOT to Do

• Avoid benzodiazepines in pediatric panic—they lack efficacy data in children and carry dependence risk 2, 5
• Do not use "chemical restraint" approaches with anxiolytics like lorazepam or hydroxyzine for panic attacks, as these carry risk of paradoxical agitation in children 1
• Avoid dismissing symptoms as "just anxiety" without proper assessment, as panic disorder in children is often misdiagnosed as cardiac, neurologic, or gastrointestinal illness 3, 4

Long-Term Management

First-Line Treatment: Cognitive-Behavioral Therapy

CBT is the recommended first-line treatment for pediatric panic disorder, delivered over 12-20 structured sessions. 1, 2, 6

CBT components should include:

• Psychoeducation about the physiologic basis of panic (explaining that symptoms are anxiety, not medical danger) 2
• Interoceptive exposure to help the child tolerate physical sensations of anxiety without catastrophizing 2
• Cognitive restructuring to challenge catastrophic misinterpretations of bodily sensations 2
• Relaxation training including diaphragmatic breathing and progressive muscle relaxation 2
• Graduated exposure to feared situations or sensations that trigger panic 2
• Family involvement to reduce parental accommodation of avoidance behaviors 2

When to Add Pharmacotherapy

Consider SSRIs when:

• Panic disorder is severe with significant functional impairment (school refusal, social withdrawal) 1, 2
• Quality CBT is unavailable or the child has not responded to 12-20 sessions of CBT 1, 2
• Comorbid major depression is present (occurs in up to 90% of pediatric panic disorder cases) 3

Sertraline is the preferred SSRI, with evidence showing:

• Statistically significant improvement may begin by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 2
• Start low and titrate slowly to avoid exceeding optimal dose 2
• Common early side effects include nausea, diarrhea, and heartburn 2

Critical Monitoring Requirements

• Monitor closely for suicidal ideation, especially in the first months and after dose adjustments—the pooled absolute risk is 1% versus 0.2% with placebo (number needed to harm = 143) 2, 5
• Watch for behavioral activation (motor restlessness, insomnia, impulsiveness, aggression), which is more common in younger children with anxiety disorders 2
• Use standardized symptom rating scales at each visit to track treatment response systematically 2, 6

Combination Treatment for Severe Cases

For severe panic disorder with marked impairment, combine CBT plus SSRI from the outset—this approach is more effective than either treatment alone. 2

Assessment Priorities

Before initiating treatment:

• Rule out medical mimics: hyperthyroidism, cardiac arrhythmias, asthma, hypoglycemia, and seizure disorders can present with panic-like symptoms 3, 4
• Screen for comorbidities: up to 90% of children with panic disorder have other anxiety disorders (generalized anxiety, separation anxiety, social phobia) or mood disorders 3
• Assess for agoraphobia—avoidance of situations where escape might be difficult if panic occurs 1
• Evaluate family history, as panic disorder has genetic components 3

Common Pitfalls to Avoid

• Do not perform extensive medical workups in children with clear panic symptoms and normal vital signs—this reinforces the child's belief that something is medically wrong 3, 4
• Do not allow chronic avoidance behaviors to develop—early intervention prevents progression to agoraphobia 1
• Recognize that untreated panic disorder leads to significant long-term impairments in social, educational, and mental health outcomes extending into adulthood 1, 5
• Less than half of youth needing mental health treatment receive appropriate care—proactive referral to CBT is essential 1, 5