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Section 10
Childhood Agoraphobia

Question 10 | Test | Table of Contents

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As you are aware, agoraphobia is defined as "fear of being in places or situations from which escape might be difficult or in which help might be unavailable in the event of suddenly developing a symptom that could be incapacitating or embarrassing."  In simpler terms, agoraphobia is the fear of public and social situations during which a client might undergo a panic attack that could be embarrassing or leave the client unable to reach help. 

The client becomes increasingly avoidant of social situations and prefers to seclude him or herself from the rest of the world. A consensus on the origins of agoraphobia has not yet been reached. For instance, do panic attacks incite a client to avoid certain situations, or does the disorder bring on the panic attack? Of course, this question is extremely debatable, but significant links from childhood to adult agoraphobia have been found. 

In this section, we will examine three characteristics of childhood agoraphobia, which are  development of agoraphobia in childhood and adolescence; separation anxiety; and early exposure.

Three Characteristics of Childhood Agoraphobia

♦ Characteristic #1 - Development in Childhood and Adolescence
The first characteristic of childhood agoraphobia that we will discuss is the development of agoraphobia in childhood and adolescence. As you are aware, between the ages of 6 to 11, a period also known as latency, a child client focuses his or her energy on developing and continuing social connections. The introduction of grade school and the subsequent adjustment to middle school can try a child’s social self-awareness. 

Separation anxiety, which we will discuss later on in this section, becomes more prevalent at this age as the child becomes more attached to the home. This mainly comes as a result of the home being a symbol of security and privacy. While all children and early adolescents have some anxiety of adjusting to social atmospheres, those clients with separation anxiety experience a much more severe and urgent reluctance to going to school and being in a place in which safety is not necessarily guaranteed. 

The adolescent, on the other hand, deals with much more emotional and social factors than the latent child. Mainly, during adolescent years, the client must learn to balance dependence and independence. While manifesting a mature façade, the teenage client is merely imitating those adults around him or her and is in fact teetering between adulthood and childhood. 

Inwardly, the adolescent resists the shouldering of responsibility through emotional outbursts, moodiness, and signs of depression. In adolescents suffering from agoraphobia, the anxiety resulting from new responsibility is met with increased seclusion and isolation

♦ Characteristic #2 - Separation Anxiety
Secondly, we will discuss the separation anxiety experienced by an agoraphobic child client.  Interestingly enough, although agoraphobia entails fear of public places, agoraphobic clients express anxiety when faced with the possibility of losing those close to them, such as parents or older siblings. According to research, there may be a link between separation anxiety in childhood and agoraphobia in adulthood. 

Those adults with agoraphobia that includes panic attacks have an increased rate of childhood separation anxiety while those adult clients who report panic attacks alone do not report increased rates of separation anxiety in childhood. However, the severity of the attacks do not differ. Dr. G.L. Klerman lists the following three ways that separation anxiety is linked to panic and agoraphobia in adults:

  1. "Agoraphobic adults report a greater than expected frequency of school phobia and separation anxiety as children."
  2. "School phobia and separation anxiety respond to tricyclic antidepressants as do panic and agoraphobia."
  3. "Family studies indicate that children of parents with panic/agoraphobia have a higher incidence of school phobia and separation anxiety than the children of a matched control group."

Dr. Klerman also states that "Separation anxiety may be the childhood antecedent of adult panic attacks."  Think of your agoraphobic client.  Could he or she have had a history of separation anxiety in his or her childhood?  Could he or she still have a minor case of separation anxiety?

♦ Case Study
Sam, a seven year old female client of mine, had been brought to me by her parents, Dave and Eve, who reported that Sam had developed a phobia of school and social situations. Sam had been placed in a large public school and had trouble feeling secure in classes whose numbers ranged from 30 to 40 children per class. Because both parents needed to keep their careers to support the entire family, home schooling was out of the question. 

However, I asked if it would be financially possible to put Sam in a smaller, private school.  Dave and Eve researched small schools in the city and found a small, Christian school whose average class number was around 11 children per grade. Not only were the social demands of the school lessened, but also the teachers were much more attentive to the children. Dave and Eve explained to Sam’s teacher about her condition and her teacher made the extra effort to make Sam feel more at home and in a safe and secure environment. 

Think of your child client who is experiencing agoraphobia related to school.  Could he or she benefit from being put in a smaller class?

♦ Characteristic #3 - Early Exposure
In addition to development and separation anxiety, the third aspect of childhood agoraphobia is early exposure. As you are aware, the most effective way to treat a phobic disorder is through the gradual exposure of the client to the feared object. With children, however, there is a certain stigma associated with it. For instance, to expose an adult client to a feared object is considered helping and aiding the adult to adjust to social situations.

On the other hand, instigating fear in a child is a practice that many parents resist. They would much rather avoid the situation altogether which may in fact worsen the child’s condition. Laura was a nine year old client of mine who experienced extreme symptoms of panic when exposed to large crowds. Her parents, Michael and Diane, were reluctant to try exposure therapy because the site of their daughter in pain was one they wished to avoid at all costs. 

However, eventually, they developed a system of exposure steps, along with my assistance, that would, hopefully, gradually reduce Laura’s anxiety. Exposure degrees came in the following order:

  1. A couple of children and Laura at home with Michael and Diane present.
  2. A larger group of children (7-9) at home with Michael and Diane present.
  3. A group of 7-9 children at home with only one parent present.
  4. A small group of children at a friend’s house with both parents present.
  5. A small group of children at a friend’s house with only one parent present.
  6. A larger group of children (7-9) at a friend’s house with no parent present.

The intensity of Laura’s anxiety would be carefully monitored to ensure she would not be overwhelmed. When the time came for a visit to a friend’s house without her parents, the overseeing adult was informed to watch Laura carefully and to encourage her a great deal.  Eventually, Laura became less and less anxious around social groups as she became more and more exposed to social situations. Replay section 6 for more information on exposure therapy.

In this section, we discussed three characteristics of childhood agoraphobia, which are development in childhood and adolescence; separation anxiety; and early exposure.

- Klerman, G. L. (1984). Interpersonal Psychotherapy of Depression. New York: Basic Books.

- Perugi, G., Frare, F., & Toni, C. (2007). Diagnosis and Treatment of Agoraphobia with Panic Disorder. CNS Drugs, 21(9), 741-764. doi:10.2165/00023210-200721090-00004 

Peer-Reviewed Journal Article References:
Gloster, A. T., Wittchen, H.-U., Einsle, F., Lang, T., Helbig-Lang, S., Fydrich, T., Fehm, L., Hamm, A. O., Richter, J., Alpers, G. W., Gerlach, A. L., Ströhle, A., Kircher, T., Deckert, J., Zwanzger, P., Höfler, M., & Arolt, V. (2011). Psychological treatment for panic disorder with agoraphobia: A randomized controlled trial to examine the role of therapist-guided exposure in situ in CBT. Journal of Consulting and Clinical Psychology, 79(3), 406–420.

Hoffart, A. (2016). Cognitive models for panic disorder with agoraphobia: A study of disaggregated within-person effects. Journal of Consulting and Clinical Psychology, 84(9), 839–844.

López Bermúdez, M. Á., García, R. F., & Calvillo, M. (2010). An application of functional analytic psychotherapy in a case of anxiety panic disorder without agoraphobia. International Journal of Behavioral Consultation and Therapy, 6(4), 356–372.

What are the characteristics of childhood agoraphobia?
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Section 11
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