Agoraphobia in Children

The stereotype most of us have of agoraphobia is someone who is afraid of stepping outside the home. In its most severe form, agoraphobia can become this limiting. But for most people it starts with anxiety triggered by a specific situation.

Some people develop a fear of open spaces, while others fear enclosed ones. The situations that most commonly cause fear with agoraphobia are:

• Public transportation (like buses, trains and planes)
• Open spaces (like bridges and parking lots)
• Enclosed places (like shops, movie theaters and elevators)
• In line or in a crowd
• Outside of home alone

What inspires dread in these situations is the potential for something upsetting to happen. Jamie Howard, PhD, a child psychologist at the Child Mind Institute, explains, “People with agoraphobia worry that something bad will happen and then they’ll be out in the world, unsafe, unable to escape, and there will be no one who can help them.”

Dr. Howard worked with a teenager with agoraphobia who was afraid of being in long lines, riding the subway, standing in Times Square, and being in the middle of an aisle at a movie theater. “She had a full-on panic attack when she went to see Wicked, which was something she was so looking forward to,” said Dr. Howard. “She said to me, ‘It’s the fear that I can’t escape. That’s what I don’t think other people understand.’”

What makes it a little confusing is that the thing people are often afraid of is having a panic attack. A person who is having a panic attack experiences an abrupt surge of disturbing physical sensations, such as a racing heart, sweating, shaking, dizziness, shortness of breath and nausea. Accompanying those sensations are intense fears that they are having a heart attack, dying, or “going crazy,” and a desperate need to escape.

Although the person having the panic attack isn’t actually experiencing a medical crisis, they feel like they are, which makes panic attacks very frightening. People may start avoiding locations where they previously had panic attacks in order to avoid experiencing another one. This can lead to agoraphobia.

While panic attacks are closely identified with agoraphobia for this reason, not everyone with agoraphobia experiences panic attacks. Others may fear a variety of incapacitating or embarrassing things that they won’t be able to escape from or get help for, such as falling or vomiting. Younger kids tend to fear being outside the home alone, without a caregiver, or becoming disoriented and lost.

Agoraphobia can develop out of nowhere and children may or may not be aware of what is happening. They know that their anxiety feels bad, but if they are able to avoid the thing that  triggers their agoraphobia, they feel okay — at least temporarily. The problem may be more noticeable to their parents. “Kids don’t usually say, ‘Help me, I don’t want to go outside,’” says Dr. Howard. “It’s more like it’s annoying because it causes a functional impairment within the family. Parents will say, ‘What do you mean we have to take an alternate route because you can’t go over a bridge?’”

When children have agoraphobia it can sometimes be mistaken for a different mental health issue, so it is important to have an evaluation to determine what is behind a child’s avoidance.

In younger kids, agoraphobia can often look like school refusal or separation anxiety, because the child may be pleading to stay home or go home or be with their mother. But while a child with separation anxiety will be fine if a caretaker agrees to stay with them on a playdate or during soccer practice, a child with agoraphobia may still be anxious.

Likewise, a child with social anxiety might avoid things like parties or talking with sales clerks, which could look like agoraphobia, but their fear is focused on embarrassing himself socially. However, Dr. Howard notes, it isn’t uncommon for a child to have agoraphobia and another anxiety disorder as well. “Social anxiety is a worry that you’ll humiliate yourself doing everyday things. For a child who has social anxiety and agoraphobia, it would be, “I’ll humiliate myself and then I won’t be able to get away.”

For children with a history of panic attacks, it is common to be diagnosed with panic disorder as well as agoraphobia.

Treatment for children with agoraphobia is a form of cognitive behavior therapy called exposure therapy. It’s based on the idea that while it’s our instinct to avoid the things that trigger anxiety, avoiding those things actually makes it stronger. Facing these triggers in a controlled setting makes anxiety diminish over time.

At the start of exposure therapy, the clinician will explain how facing anxiety actually helps it to gradually fade away. Then, the clinician and the patient will work together to face anxiety triggers in a gradual and carefully controlled way.

In the case of agoraphobia, that means visiting places the child has been avoiding. “We break the association that these places are unsafe somehow,” says Dr. Howard. “The more data they have that it’s actually fine, the less strong that association is.” So for example Dr. Howard walked to Times Square with her patient who was afraid of it, and also helped them practice standing in long lines and riding the subway, which were other big anxiety triggers.

If a child has panic attacks along with agoraphobia, then they will also need treatment specifically to help them cope with panic attacks themselves. This is called interoceptive exposure, which is a kind of exposure therapy that induces the physical symptoms associated with panic attacks, to gradually defuse the anxiety they cause.

As with any exposure therapy, the clinician starts by explaining the theory behind the treatment. In the case of interoceptive exposure, this includes explaining how panic attacks work, and how they may feel very dangerous, but actually aren’t. Then the clinician and patient start to induce individual panic attack symptoms on purpose.

“I’ll put a person in front of a space heater,” Dr. Howard says, “and we’ll have them run up and down the stairs — because a lot of times is a really fast-beating heart and sweatiness and feeling hot and flushed that make them panic. For other people it’s nausea, so I’ll have them spin around in a chair.”

Then, once the person starts feeling panicked, their clinician will help them practice deep breathing techniques designed to calm their physical symptoms down and help them feel more in control of their symptoms.

For people with more severe agoraphobia, medication may be necessary to help them deal with their anxiety. Antidepressants called selective serotonin reuptake inhibitors (SSRIs) can be very helpful in reducing worry and enabling people to participate in therapy.

While practicing facing anxiety is essential to treatment, clinicians are careful not to push people beyond what they can handle. According to Dr. Howard, “If the child is afraid to leave their house, we’d have to go to their house. And at first it might just be that we take a step out on the porch. We look out the window.” But with the right treatment and practice, their world will get bigger.