Pediatric Panic Disorder, Review of Art Therapy as Supportive and Palliative Intervention

Abstract

A panic attack is defined as an episode of intense fear and anxiety including both physical symptoms and fearful thoughts. Panic disorder (PD) is diagnosed when a child has recurring panic attacks and ongoing concern about having more attacks for longer than 1 month. Children and teens with panic disorder sometimes avoid going places or avoid engaging in activities out of fear that a panic attack might occur. Although individual panic attacks are common, panic attacks that occur repeatedly are rare. They typically happen in only one to three percent of children and teens. Panic disorder usually does not affect children before the teenage years. Palliative and supportive interventions such as art therapy and family-based interventions are approaches that can help to reduction of this disorder’s symptoms, especially in children and teens. In this chapter, these issues will be illustrated and the practical methods will be presented.

1. Introduction (definition of pediatric panic disorder)

• A panic attack is defined as an episode of intense fear, comprised of both physical symptoms (e.g. sweaty palms and heart pounding) and fearful thoughts (e.g. “I am going to die”). They usually last for about 10–15 minutes.

• Panic attacks are not caused by medical conditions or health problems and can occur any time.

• Panic attacks can occur in the context of many anxiety disorders (e.g. when someone with a needle phobia is about to get a shot); however, an individual may be diagnosed with panic disorder (PD) when they experience recurrent panic attacks that occur “out of the blue,” resulting in intense anxiety between panic attacks about experiencing another panic attack and avoidance of situations in which panic attacks may be more likely to occur. Individuals with panic disorder commonly begin to experience symptoms in adolescence; panic disorder in younger children is less common [1].

1.1 The symptoms of panic disorder in children and teens

The children and adolescents with PD can experience the symptoms such as heart palpitations, difficulty breathing, sweating, hot or cold flashes, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, feeling as if one is in a dream, fear of going crazy, and sometimes feeling like one needs to “escape” during a panic attack. Cognition of these symptoms is very important, because parents and families can inform the pediatric psychiatry emergency for primary intervention [2].

Panic symptoms often can emerge quickly (within 10 minutes). Sometimes, the symptoms will be last for minutes or hours. Also, the children or teens may avoid from being alone or participating in kindergarten, schools, parks, or other places and need their caregivers or parents for leaving home [2].

1.2 Etiology, diagnosis, assessment and treatment

According to studies and researches, panic disorder etiology can be emerged by the biological, environmental, and social factors which can lead to disorder. For example, fear of animals, sexual or physical abuse, post traumatic stress disorder (PTSD), aggressive parents, problems in schools, high schools, and preschools, parent’s divorce, and mental trauma can lead to panic disorder in children and teens [2]. For the most valid assessment in these children and teens, the Multidimensional Anxiety Scale for Children, the Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children’s Anxiety Scale (SCAS) can be applied [3, 4, 5]. Sometimes, additional assessments as projective tests such as CAT, DAP (Drawing a Person), HTP (House-Tree-Person), DAF (Drawing a Family), and DAS (Drawing a School) may be useful. Because, drawing and paintings have projective elements in which we can see fears, anxiety, and stress in the form of drawing, size, colors, etc. [6, 7].

For treatment and psychological intervention, CBT (cognitive-behavioral therapy) and family education for control of the symptoms are the most common interventions and will be useful. Sometimes, medication may be necessary, especially in the acute cases [2].

2. Psychosocial problems and art therapy as a palliative and supportive intervention (family-based art therapy)

Psychosocial problems are highly prevalent among children and adolescents with an estimated prevalence of 10–20% worldwide [8, 9]. These problems can severely interfere with everyday functioning [10, 11].

Psychosocial problems in children and adolescents are a considerable expense to society and an important reason for using health care. But, most of all psychosocial problems can have a major impact on the future of the child’s life [12]. For improvement of the psychological problems, especially anxiety, depression, and panic disorders, we can use cognition therapy, behavioral therapy, CBT, psychoanalytic intervention, and family counseling. But sometimes, one of the most important approaches in which children and teens with psychological problems can benefit is “Art Therapy” or AT [6, 7].

AT is one of the most important supportive-palliative interventions usually called family-based art therapy in which the children and adolescences can achieve their main abilities before their psychological problems, and also their families and parents participate in art therapy sessions actively [6, 13, 14]. Traditionally, AT is (among others) used to improve self-esteem and self-awareness, cultivate emotional resilience, enhance social skills, and reduce distress [15].

AT is a dynamic approach in which client and therapist create and will be created as soon as possible. In AT, the process in which changes are occurred will be more important and the art making result is less important, because all of the psychological changes will be occurred in the dynamic art process. Then, art therapist and art modalities such as painting, clay, crafts, and collage are the facilitators [16]. Also, art therapy approaches can be applied from infancy to adults, and the parents (in the most of cases “Mothers”) have an important role in the art therapy process as a dynamic process in which the relationship between child and his or her parents will be reinforced [17, 18].

2.1 Art therapy approaches and the process relieve stress in panic and anxiety

We can explain the three art therapy approaches as follows: the humanistic art therapy, cognitive-behavioral art therapy, and expressive art therapy. All of these approaches are as palliative and supportive interventions which can be applied in the treatment of anxiety and panic attacks in children and adults. In the first approach which be called as the third force psychology, the clients are seen as a human not as a patient, because they are persons who suffer from a lot of problems such as anxiety and depression and the psychotherapists and art therapists have to support and help them by self-actualization. Josef Gary, an art therapist, has performed this approach according to three factors: 1. emphasis on solving the life problems, 2. encourage to self-actualization via creative expression, and 3. emphasis on self-esteem and attachment in the private relationships and social interaction and also survey for the life goals. Cognitive-behavioral art therapy is the second approach in which the cognition of the client will be changed via art therapy process, and finally he or she can achieve to self-actualization. And finally, in the third approach, art therapist can apply a large range of art modalities such as drama, dance/movement, music, and poetry/writing for the improvement of creativity in client and self-expression. Therefore, the third approach is called creative art therapy. The client’s family and parents can involve in all of the art therapy approaches mentioned earlier. Therefore, we can call them as family-based art therapy intervention which can be applied for all the children and teens with psychological disorders such as panic, anxiety, and learning disorders and children with special needs. All of the mentioned art therapy approaches have common therapeutic objectives such as improvement of self-esteem, self-actualization, self-awareness, self-control, reinforcement of “ego,” and projection of negative thoughts and feelings in children and teens via art works and activities [6, 13, 14].

Some of the art therapy techniques which can be applied for children and teens with panic and anxiety disorders are as follows: family painting, free association painting, collage, crafts, and clay. In all of these techniques, art therapist applies art modality instead of talking with client directly. Because, the children and teens can talk about their feelings by paintings and the other visual arts better than direct talking [14, 16]. Figures 1–3 show the art works of clients who suffer from panic and anxiety. They have been referred, and both of them have participated in art therapy sessions along with their parents. Therefore, their art therapy sessions contained family-based art therapy program [6]. In all the techniques mentioned before such as family painting, free association painting, collage, crafts, and clay, the therapist has focused on the client’s changes during the art therapy sessions. They emphasize on therapeutic objectives such as improvement of self-esteem, self-actualization, self-awareness, self-control and reinforcement of “ego,” and projection of negative thoughts and feelings in children and teens via art works and activities. Also, the client’s family members and parents (especially mothers) are involved in the art therapy process actively [6, 7].

Figure 1.

Sheida, 9 years old girl, who illustrates her mother in her paintings.

Figure 2.

Maziar, 17 years old boy, who illustrates fears and anxiety in his paintings.

Figure 3.

Maziar and his fears.

Now the two case studies which have been investigated by the author are as follows:

Case study 1.

Sheida is a 9-year-old girl who suffers from panic disorder and has experienced anxiety since 2014. She had avoided from being in popular places, and withdrawal, anxiety, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, and feeling as if one is in a dream in this client could be observed. All of these symptoms caused secondary problems such as academic and family interaction problems. During art therapy sessions, creative art therapy was applied. She liked music and painting together. At first, she has been evaluated by projective psychological tests, and then family-based art therapy program was performed for her and her parents. Her mother had very important role in her tension release because she has applied family painting and free paintings and collage actively. They drew the fearful situations in their paintings and drawings and talked about their emotions together. The art therapist could facilitate the process of emotional release by talking about her paintings and help her in better cognition of ego. After five sessions, Sheida could overcome the loss of control and withdrawal. Also, she could participate in peer group activities such as painting and clay. Now, it seems that Sheida could show better self-esteem, self-control, and self-awareness and can control her anxiety by art making activities [6, 7].

Case study 2.

Maziar is a 17-year-old boy who lives with his parents, and he shows pathological phobia about animals like cat, dog, and birds. This kind of phobia leads to panic attacks, and he could not be calmed. He was resisting about attendance in park, streets, and crowded places without his parents and also showed obsession and stereotypical behaviors which disrupt his function. After necessary projective assessments, art therapy process special creative art therapy approach has been applied for him and his parents for 2 years. At first, he was illustrating fearful items like animals in his paintings, and then his parent (mother) involved in family-based art therapy program actively. He could talk about his fears and anxiety about animals step by step, and he could show better self-esteem and self-control while dealing with animals. Now, he has better self-esteem and shows interest in group plays with peers. Figures 2 and 3 show his anxiety and fears [6, 7].

2.2 Literature review about art therapy and anxiety disorder

Some researchers have focused on the effectiveness of art therapy in anxiety and panic disorders such as Albertini who explain art therapy program in the treatment of agoraphobia and applying free paintings which can help clients for emotional expression [19], or Griffith who has explained brief cognitive-behavioral art therapy for anxiety disorders in her MS thesis. She has illustrated that art therapy can be useful in insight and cognition change in clients with panic and anxiety disorder. Indeed, she has applied cognitive-behavioral art therapy approach [20]. Also, Rosal has explained cognitive-behavioral art therapy in the research which can be useful for clients with anxiety [21]. Daneshmandi et al. have emphasized the effectiveness of family-based art therapy on children with generalized anxiety disorder (GAD) in their research [22]. Kheradmand et al. have investigated the effectiveness of art therapy on mental disorders such as anxiety and panic disorders in children [23]. Also, Hinz has investigated the effectiveness of art therapy assessment and treatment planning as an expressive therapy [24].

3. Conclusion

Panic disorder is one of the psychological disorders which can be observed in children and teens. Heart palpitations, difficulty breathing, sweating, hot or cold flashes, dizziness, trembling, numbness or tingling in the limbs, fear of dying or losing control, feeling as if one is in a dream, fear of going crazy, and sometimes feeling like one needs to “escape” are the symptoms which can be observed during panic attacks in children and teens.

For the assessment of these children and teens, the Multidimensional Anxiety Scale for Children, the Screen for Child Anxiety and Related Emotional Disorders (SCARED), and the Spence Children’s Anxiety Scale (SCAS) can be applied. Not only CBT is one of the most common interventions which can be used for children and teens who suffer from panic disorder, but also art therapy as a palliative and supportive intervention can be useful for them. The common art mediums used within the art therapy process include painting, drawing, sculpture, collage, and photography. Three art therapy approaches are as follows: the humanistic art therapy, cognitive-behavioral art therapy, and expressive art therapy which all of them can be effective in panic and anxiety disorders. According to studies and researches, in art therapy process, art therapist can change the cognition, emotion, and behavior of the client by art modalities. Art therapy can be useful for children and teens too, because they can show their fears, anxiety, and emotions better than adults by paintings and other visual arts. Therefore, their paintings and drawings contain the meaningful messages which can be interpreted by the psychologist and art therapists. For the best outcomes of the art therapy, it can be followed by the children’s family and parents at home as the family-based art therapy intervention. Finally, it is suggested that for the best anxiety and panic management, art therapy interventions are applied beside the other interventions such as play therapy, cognition therapy, and psychotherapy at clinics and schools.

A.

A.1 Anxiety

Art therapy

Art therapy process

Cognitive-behavioral art therapy

Expressive art therapy

Family-based art therapy

Humanistic art therapy

Self-expression

Self-awareness

Stress

Supportive and palliative interventions

Panic disorder