Welcome to Pukipondas, the podcast where I explore big questions with brilliant people. Today's question is how can we recognise and respond to panic disorder in teenagers and I'm in conversation with Polly Wait. So I'm Polly Wait, I'm a clinical psychologist by background and I'm also a researcher so my official title is Associate Professor of Clinical Psychology and I'm based both at Reading and at Oxford universities. That's a very grand title Polly. So we're talking today about how we can recognise and respond to panic disorder in teenagers because you've done some recent research in this very specific area that was not very reassuring about how good we are at it so could you give us a little bit of an overview of that recent work? Yeah that's right so I've been doing research on panic disorder for the last couple of years we're actually just running a clinical trial treating young people with panic disorder at the moment and I became interested in it in the last few years where I recognised that we were seeing quite a number of young people with panic disorder but there was a general perception I think that it was less common in young people it really was only an adult disorder so just to give you a bit of background the latest data suggests that between sort of one and three percent of teenagers experience panic disorder the peak onset is in late adolescence actually so sort of 15 to 19 years old so I wonder if that's part of the issue is that often it presents relatively late so in 17 to 19 year olds about three percent of them have it but it's less common in younger adolescents and so basically it's when people experience repeated panic attacks so they basically have an intense surge of anxiety and then they have a number of physical sensations physical symptoms that can be really distressing because they feel so intense and full on so when people feel like their heart's beating really fast they might feel sick, light headed, they might sort of feel trembling shaky a whole bunch of different sensations so some that can be really disconcerting as well so often people might experience a sort of sense of unreality like they're not in their body like they're on autopilot and that can be quite worrying for people and often they they worry that there's something really seriously wrong with them even to the point of worrying that they're about to have a heart attack or die or worrying that they're going crazy and losing control so it can be a really distressing experience for people and so when people have panic disorder it's when they have more than one panic attack and that some of those panic attacks are followed by them being really worried about having further panic attacks and then potentially changing their behavior to try to prevent them so maybe they avoid things they might not go into the classroom they might avoid being in assemblies or maybe they do lots of things to try to stay safe so they change their behavior as a result of that worry about having further attacks and so it has quite an impact on their day-to-day life then in the end it has a huge impact actually I mean you know when we think about young people that have difficulties attending school in adolescence often they will have anxiety and panic disorder and social anxiety tend to be the two kind of anxiety problems that lead to young people not being able to attend school because if you're having really distressing sort of physical sensations and you're worried that there's something really wrong with you and you're worried that everyone in your classroom is going to notice and think you are silly or negatively evaluate you it can be really hard for young people to stay in classrooms focus on their work be able to participate in different things so for example you know if the young person's worrying that their heart beats really fast and they feel breathless doing things like PE or carrying on with sport like playing football regularly or other things like dance that you might have done as just part of your normal routine and things that you might have really enjoyed people then really pull back from because they're worried about what might happen when they overexert themselves so it can have a huge impact and if it's left untreated we tend to see it persist into adulthood so there's a you know really really important reason to be able to detect it and then do something about it while we can and at the moment I'm am I right in thinking that so we're not really picking it up we're perhaps thinking it's a different kind of anxiety disorder that we're seeing but that if we were to pick it up that it is quite treatable yeah that's right I mean actually there's there's in terms of the treatment data there isn't a huge amount partly because I think it's been relatively under recognised so there's been a research team in America led by a researcher called Donna Pinkers and they've done quite a lot of work developing an anxiety panic disorder treatment for adolescents specifically that comes from an adult treatment so they've evaluated that with a couple of trials but one of the trials that they've or one of the treatment versions that they use is an intensive treatment which makes sense because their context is there in the States so people might fly in from different parts of the States and it works to treat someone within a week or two of really intensive treatment that's actually less practical if we think about how our services work in the UK where typically a young person would be seen you know for regular sessions but over the course of a number of weeks so there's actually just this one relatively small trial that Donna's run with weekly sessions but it's effective so there is a treatment but beyond that in the UK we've got brilliant treatments for adults with panic disorder that have really great outcomes so that treatment was designed by Professor David Clark and those outcomes are in the sort of realms of 80 percent of adults are free of their panic disorder and that's at long-term follow-up as well so those they have great outcomes and in fact the trial that we're running at the moment is evaluating that treatment and comparing it to sort of more generic treatments in terms of the sort of standard treatment for anxiety in the UK generally clinicians tend to use a sort of generic what we call trans-diagnostic treatments so it's designed for a range of different anxiety problems which makes sense because they often tend to be really comorbid so it's very common not just have panic disorder but you might have social anxiety disorder as well maybe you also worry generally and you have generalized anxiety too so treatments tend to be very general but we don't know how young people with panic disorder specifically respond to those treatments because the trials tend to either not involve them so there are tons of trials looking at general these sort of trans-diagnostic treatments with children adolescents but only about 15 percent of them include young people with panic disorder and when they do they make up a tiny proportion of the sample normally less than 10 percent so it's really hard to know how did they do in these treatments rather than how does everyone in the whole sample do so although we have reason to think CBT is effective we've got this research in America that looks like this diagnostic specific treatment works well there's still a lot to learn really about how best to treat young people with panic disorder so just briefly there because I'm always aware we've got a very wide range of people listening so you mentioned very much in passing there CBT is effective what's CBT and why is it effective for panic yeah so cognitive behaviour therapy so that involves working with a therapist it can be delivered in a number of formats so it could be face-to-face with a therapist in a group or more recently there've been internet versions of treatment as well and it involves picking apart the problem very much working on the here and now to understand how you think and what you do and how that ends up typically contributing to kind of vicious cycle so going back to the example earlier if you have really intense sort of symptoms where you have a really tight chest and you worry that there's something wrong maybe you're going to have a heart attack and then you stop exercising and you do all of these things that actually what that means is you don't get to find out that actually those are just your body working normally and so CBT involves kind of understanding how you think what you're doing that might be inadvertently making the problem worse and then I'm picking that and testing out new ways of doing things to find out whether the world works in the way that you might be thinking how it's you know how it's been working or does it work in a different way which is actually that it might be the way that you're thinking about this might not be true you might understandably be interpreting your symptoms in a particular way but actually it might just be that they're very normal symptoms that you might experience when you're exercising or when you're feeling stressed and then that means doing different things instead so it's very much being a sort of detective trying to figure out how the problem is working and then trying out other different ways of doing it to see what makes it better or potentially what even might make it worse and then you have a better understanding of of how it's all working so CBT is it's a really well evaluated treatment actually we recently looked at adolescent anxiety disorder treatments and of all the anxiety treatments there was only one that wasn't a CBT treatment so the the huge lion share of the evidence base is on is looking at CBT and CBT is generally effective it's the nice recommended treatment of choice for anxiety disorders and that's with children and with adults too of course it's not effective for everybody but certainly with children and young people we typically see that about 60 percent of children young people with an anxiety disorder at the end of treatment no longer experience that anxiety disorder when they have CBT so at the moment if we were able to improve recognition of panic disorder then what would happen to those teenagers so if we're able to scale up the the workforce a bit and people feel a bit more confident saying actually I think that this might be panic disorder that I'm seeing is there a kind of known pathway or is your research kind of you know that much earlier on or does it depend where you live or what would be the outcome for that young person yeah it's it's really variable I mean I think that's one of the things that we learned through this survey that we did recently that you mentioned earlier on so we surveyed over 400 CAMHS clinicians to find out about their experiences in terms of what training they'd had but also we gave them a case study of a young person with panic disorder and asked them what they thought was going on and how they might treat that young person and what we found was that that around half the clinicians didn't identify panic disorder or panic symptoms as the main presenting problem for that young person so they tended to identify that the young person was anxious but not sort of specifically that it related to panic which in of itself may not be a problem if the best treatment is just a general anxiety treatment but given that the the evidence so far would suggest that maybe using the approach by Donna Pinkes's group might be the most effective that's where the evidence is so actually knowing that it's panic disorder would be really helpful because then you can do a very targeted treatment with the young person so we know that CAMHS clinicians tend not to identify panic so the majority of them will use a CBT approach that was the other thing we learned so just under 90 percent said I would use CBT with this young person which is really encouraging the challenge of course is that many of the CAMHS workforce may not have good CBT training which might come as a surprise given it's the main evidence-based treatment but we found that less than is around half of them had not had training in CBT specifically and we also found that 20 percent of the CAMHS clinicians had had no therapy training which was a real surprise because to be eligible for the study the CAMHS clinicians had to be working therapeutically with young people with anxiety disorders so I think there's a range of things that need to be done which is about skilling up and training clinicians and you know clinicians want that training there was a study done over 10 years ago actually where many of them again reflected on the lack of CBT training that was available to them and how they wanted more so I think it is about training them up in evidence-based treatments to teach them about panic disorder learning about you know specific panic disorder treatments in order to improve outcomes for young people at the same time I think our job is also to find out better what works with young people with panic disorder so that you know we've got this preliminary evidence for this CBT approach that's a specific approach but we also want to understand actually how well do these generic treatments work with young people with panic and really what is going to be the best approach to use and what are the things that the rest of us can be doing to support because even if a young person is able to get input from a CAMHS team and it seems that they may or may not get the kind of recommended treatment there but regardless they're going to spend the vast majority of their time with their family or in school with non-specialist staff or other adults who would I'm sure wants to be able to support so how could they recognize and then support a young person who might be struggling with this kind of disorder? Yeah I think it can be hard to spot young people with panic because often they feel really ashamed of their symptoms and what they're experiencing and so you know you might think actually it's going to be really obvious and these children will be easily identifiable but I think that's not always the case and actually you know so I think that it's about looking out for anything that you think you know might be panicky symptoms if a child you know does seem distressed or avoidant of particular situations maybe you're not seeing them have panic attacks but you know they're finding reasons not to go into assembly not you know participate in activities that the rest of the class are doing I think having the opportunity to talk to them about it in you know in a non-judgmental open curious way you know and maybe making suggestions you know sometimes people avoid you know doing these activities because they're worried about things might that be the case for you I think you know listening hearing what's going on because you know often these kind of I mean panic attacks can occur in a whole range of situations not just panic disorder so it's really important you know to be able to get a full picture and not put words into someone's mouth to understand what's going on for them young people's social anxiety might experience panic attacks but their worries will be different to those with panic disorder so trying to get a bit more information about what's going on for the young person and what they're worried about will be a really important starting point I think in terms of what you know what can often make the problem worse is avoidance and young people doing things in order to try to gain some kind of control so I think where possible exploring that with the young person and trying to sort of genuinely encourage them not to avoid and to sort of push themselves can be really helpful and that's not just about avoiding certain situations but it might be about noticing some of the things that they're doing to try to stay safe you know taking rescue remedies always having a bottle of water with you you know there are a whole range of activities that are really really common that young people that have panic do and just gently sort of encourage them to see how could they you know would they be able to manage if they didn't continually sip water could they do other things and what would you know what would happen because often actually by doing those things it makes the problem worse so I think it's about you know trying to better understand it understanding what they're worrying about and then gently encouraging them to see if they can try to do the opposite to see what happens because actually some of these things might be inadvertently making the problem worse and what's the difference between so you said a young person who was struggling with social anxiety for example might have repeated panic attacks and that might not be panic disorder but then you also said earlier on that there's a lot of comorbidity so that's all a bit confusing Polly it is confusing and I yeah that's right and I think that's one of the challenges isn't it so in our clinic actually we do diagnostic assessments and even by doing diagnostic assessments where you go stringently through each different kind of diagnosis you know then that helps you to get some sense but often it's a bit like a Venn diagram so you know so you might have a young person with social anxiety and with panic disorder and they might both worry about looking silly and other people judging them in a negative way but what we tend to see with panic disorder is also some very discrete worries that relate to the physical sensations themselves so they might worry about things like fainting that's really common in panic disorder because you experience that lightheadedness and feeling dizzy and then you worry you're going to faint and then because you worry you're going to faint you you make sure you're sitting down the whole time and you're not standing up and as soon as the sensations come on you do things to you know to stop yourself fainting although of course actually we know that you're very unlikely to faint because when you feel anxious if anything your body physiologically is the opposite of where you need to faint your blood pressure goes up not down so so so people with panic sort of tend to have discrete worries that relate to their physical sensations being sick worrying about fainting worrying about that there might be something wrong with their heart um in adults they often worry about having heart attacks but in young people we tend to see more of a worry about kind of sudden death because your heart suddenly stops working you know like kind of football is suddenly you know having um a heart condition that wasn't identified and suddenly collapsing on the pitch so I think the young people that image more comes to mind so those kind of worries about what's going on in your body um and that you might lose control or go crazy those tend to be specific to panic disorder so in a young person with social anxiety we see those same worries about looking silly and being negatively evaluated um and probably other worries too about what other people might think of them but they don't tend to have those worries about what the sensations themselves actually mean and presumably when we begin to explain to a young person what's actually happening in their body and we talk about it and we normalize it somewhat that in itself would have some impact on how they would interpret those those things because it is terrifying isn't it having a panic attack I've had thousands in my life and still every time I have one you feel like you're going to die and you know I find it very helpful often if I'm with someone who knows me well for them to remind me that you're going to be all right you have loads of these and it will be fine and actually just that in and of itself is helpful but you you lose it don't you in that moment it's very very hard oh completely that's right um I think that's exactly the experience that people have if it is it's hard to describe a panic attack without having had one but they are so huge and it feels like you know our young people have talked about things like it feels like a tsunami it's just this huge wave of intense sensations like nothing else and that is really hard to to be able to account for in you know in drawing on your normal experiences it feels really out of the ordinary and really scary for people so it's totally understandable that you think there can be no other explanation for this there is something really wrong here and I'm going to die and then of course you know as soon as the person's out of it they're like you know they're thinking about it in a completely different way but in that moment it really genuinely feels like that so I think that's right and that's a really important part of treatment um and in fact in our generic treatments and also in our panic disorder treatments one of the main points is really to better understand those physical sensations and how we might explain them in a different way that fits better with the idea of that this is actually your body working normally and this is how your body is designed to work um you know when you feel that there's some kind of threat that your body is preparing itself for action and it's preparing itself to run really hard and and then your body is responding in exactly the same way but you know if you don't know that it's really hard to make sense of isn't it and then naturally your your mind goes to like what's the worst possible explanation for this it's that I'm going to die yeah yeah and and presumably because that's coupled up with some of these kind of quite tricky thought patterns that we might get into if we are struggling with kind of yeah underlying um issues with our with our mental health so it might catastrophize or or yeah yeah exactly and you mentioned before that you know in terms of things that we um can do to help or to try and prevent making things worse that avoidance of things is something that will make things worse for a young person who is struggling with panic disorder so can you talk a little bit more about that and how someone might get into a cycle of avoidance and how as someone who cares for a child we can help them to you know put themselves in those situations which they really might not want to be in yeah that's so true and and actually this is one of the important parts of treatment so this is something that as clinicians and as parents and people supporting young people you know it's a real challenge isn't it because essentially what you're saying is you know that thing that you're really worried about let's let's now do that and let's make you do this and that is a really challenging and I think that's why actually starting by having some understanding of what's going on um is really helpful because otherwise you know it would be understandable that the young person just thinks absolutely no way am I going to do that you know why would I want to do that so I think that's right so I think if you can you know start by understanding what might be going on here and that actually it might not be this kind of catastrophic way you know interpretation that you might have but actually this might be normal then it is about trying to test that out in real life to find out whether actually the panic is you know is right or not so I think it's just about gently encouraging someone and it might be that you start off by doing it in a less threatening way so you know you might start by doing things in a home environment if the young person worries about looking silly you know maybe you start by sort of encouraging to do things where there aren't other people around but they can just sort of better understand this idea of if we bring on some of these sensations you know if we just go for a jog or we do some skipping or we do something else and those sensations come on let's just push through at the point where you'd normally stop let's see if we can carry on for a little bit and let's just see what happens so it's just about kind of gentle encouragement um those conversations will be always you know are often easier to have when you're the person is isn't experiencing them there and then in that moment but it might be about finding an opportunity when they're not having a panic attack and they're able to think about it in a slightly different way to say okay perhaps the next time you start to feel this way we could try out something a bit different to see what happens and to see if actually by avoiding although it feels better temporarily you know is it the case that that avoidance is making the problem worse in the medium to long term you get a bit of short-term relief but then actually get more of these panic attacks and being able to understand the pattern of what's happened with the panic over time so you know as you've avoided more what's happened to your panic attacks have you had more of them or have you had less of them typically people have had more of them so maybe the avoidance is part of that um you know part of that cycle and if we can just gently try and push back on it and try not to always do what the panic says and instead try to do other things let's just be you know that will help us sort of test out a bit better exactly what's going on here and how the problem's really working so if i'm understanding you're saying that even when someone takes really proactive measures to avoid the things that they think cause panic that actually we see the number of panic attacks increase yes that could well be the case so because it's sort of contributing you know in some ways it might make your beliefs all the more intense because if you believe that exercise is actually going to bring on those sensations and then you stop exercising completely in all likelihood that belief that um you know that you are going to die if you do exercise will only increase over time it certainly won't go down because you're not in a position where you can actually test it out so so the alternative then is to do the opposite of that and to start to test it out by doing the things that you might be holding back on now obviously you wouldn't be doing that if you've got somebody who you know it's really important with panic to check out first of all from a medical point of view whether whether you know that's okay but let's assume we've got somebody who you know has been medically investigated there is no cause to to you know there's no reason to think that they've got anything any kind of medical condition underlying all of this then on that basis then you would be encouraging them to do a bit of exercise now of course that will bring on the panic because it brings on those sensations but actually if they just kind of ride it out then they can see what happens so the um they're done a pinkers treat that I mentioned earlier on is called riding the wave and which sort of makes sense because it's about sort of seeing it through rather than stopping at the moment where those sensations start to come on is actually just sitting with them not doing anything to control it and seeing what happens over time so is that similar to distressed tolerance that we see in dialectical behavior therapy or is it different yeah I think there are you know dialectical behavior therapy you know a large part of that is about CBT so I think that's right it is about putting yourself in those situations to kind of build up your reserves and your kind of bandwidth to be able to cope in those kind of situations rather than kind of pushing back from them so I think there's lots of parallels in it yeah and why is riding the wave a good idea like will the panic always subside if we give it time yeah that's right so from a physiological point of view your body is prepped to deal with some you know immediate threat in the environment but after a period of time it can't sustain you know it can't sustain that so it event you know after sort of 20 minutes or whatever it might be typically um you know those sensations will decrease because your body realizes actually there isn't a threat here and then what that means is the more that you kind of see it through rather than avoiding over time your body you know it kind of the level at which it triggers panic will get higher and higher um whereas often what happens with people that are having a lot of panic attacks is that you know they're having panic attacks um the things that they're doing understandably inadvertently might make the problem worse and then the threshold kind of goes down so they get triggered even more easily because they're really sensitive to noticing things that go on so then what people might experience is not just feeling getting panic attacks when they feel anxious but they might get them at other times so you might have a cup of coffee um and then that might give you know give you the caffeine might bring on a few sensations and then actually you start to think oh hang on a minute I feel a bit like headed now and then as soon as you spot that sensation it can sort of spiral into it so um so I think when you start pushing back against that so you might have another cup of coffee with like you know twice the amount of caffeine and just to be able to sit with the idea of yes I do feel like headed but actually this isn't a problem I'm not fainting here I am standing on one leg no I'm still okay um so it's yeah it's about really kind of trying to push back on that to kind of reset that kind of alarm that goes off um that might have sort of become a bit faulty and get triggered too quickly and would it help to as you did just there kind of take almost a bit of a playful and like hearted approach to it because this presumably is quite a scary thing for a young person to do you know if they have these horrible feelings then saying yes let's do more of that is there a room for kind of humor and definitely I think that can be really helpful I think you know one of the hallmarks of CBT is collaboration it's working with as a you know as a team with the young person so that's about you as a therapist being a guinea pig the young person being able to say okay can you do all of the let's see you do it and if that's helpful and we'll provide them with information you know you want to be up for doing stuff and you can do things in a fun way similarly I think you know having a being playful let's stand on one leg let's do something else that we think you know might make it worse let's try this I think it can be really helpful because people with panic disorder will have an you know at some level they will know that actually these are just sensations and there's nothing wrong but you know when you're in a panic attack that's not how you feel so you get this disconnect with what you know in your head and what you feel in your heart deep down so actually being able to kind of harness that and mess around with a bit and play with it as long as that's acceptable to the young person and they're up for it and you can see that that approach works well with them then that I think can be really helpful and presumably we need to be careful here about how we support during a panic attack versus when we're trying to kind of reproduce those feelings in order to sit with them in a safe way because during a panic attack we're not going to be able to engage meaningfully with a young person and explore it I would guess because our brain is not quite there yeah your brain in freeze mode where it's just disconnected I think that's right and you know when we talk to young people about there is experiences at school or with friends you know they often talk about the experience of having a panic attack and people trying to be really helpful but actually you know all the things that people are saying might not be experienced as helpful in that moment so I think that's right I think you know if the if the person's in treatment and they've started to try and do some of the things that to try and unravel this then there might be an opportunity in there to start to you know experiment with doing things differently but I think in the absence of that let's say you're a teacher at school and you've got a student with a panic attack and you know then I think on that basis what you want to do is not intervene not start to suggest oh you know do some deep breathing or anything else I think it really is about you know letting the young person just deal with it trying to move everyone else away you know on not focusing on it not having people crowding around that person but distracting everyone else away from it and then having a conversation later on potentially about you know how how it might be managed going forward because different things help different people don't they so I find that having someone talking to me and touch are really helpful and other people the last thing they want when they're panicking is to is to have those kinds of of input so I think having an individualised plan what we'll do next time is is perhaps helpful isn't it but I think that's yeah that's yeah really good advice kind of moving moving people away and just going back again to the idea of when we're trying to support a young person to kind of face tricky moments that might induce that feeling of panic presumably here we have to be really careful to kind of scaffold and support those situations so that their fears aren't realised because could we not make things worse if they did go into full-blown panic or you know the thing that they're worried about did happen for example yeah I think it's really important to pick that apart so you know there are some things that are easier to measure in some ways if the person is feeling lightheaded and they're worried that they're going to faint you know often you will be able to get a sense of that um you know did you actually faint and objectively that's probably easier to measure although sometimes it may not be so sometimes what people might do as a way of dealing with it is sort of slumped to the floor in a conscious way but might later interpret that as I fell to the floor so it's really important to kind of disentangle all of this to better understand what is the evidence that's supporting these beliefs at the moment and you know what actually happened in real life versus what did they feel some worries might be harder or might need a little bit more work in exploring so let's say a person worries about looking silly and then you know after they've had a panic attack you know you might say and what happened and you know and they might well be saying well people were staring at me um and they've interpreted that in a particular way so you know when we're working with young people in treatment we would make sure that we really identify you know what actually is evidence for looking silly so it might not just be that people noticed you but did they look at you in a particular way so you know for a young person that's worried about being judged you know was the person who might have noticed you having a panic attack were they scour you know get them to define what being judged would actually look like and then you know often what young people say as well the person will be looking at me in a kind of disgusted way and these are the facial features that that that would look like and so really trying to nail it down so that we can really better identify whether or not that worry came true is really important and as we look to kind of you know push the boundaries a little bit then how much should we be kind of celebrating and noticing if a young person does something that's you know a little bit outside of their comfort zone is that likely to then make them notice and panic or is it something where we should be celebrating and joyful with them yeah that's such a good question and I think that's right because what often happens with these kind of difficulties is that understandably a lot of the focus becomes on the panic attacks and sometimes it's hard to notice when the person's doing things that are really brave and and that's really really important to celebrate of course different young people will want it celebrated in different ways and that's often quite helpful to check out with them you know especially those that might have social anxiety at the same time drawing attention to them and you know making a big deal of it you know might and for any teenager potentially might be pretty unexciting but I think an acknowledgement of it in whatever way it is appropriate for that young person's age and them generally so it might just be afterwards going up to them going I noticed that you did that I was super impressed well done you know just something that's maybe quite low key but just clocks it you know I know that will have been really hard for you to do then I could see it but I was blown away by the fact that you just walked up there and you did it and that's really brilliant but for others you know maybe making a bigger deal out of it having kind of concrete rewards for people you know might be really positive for them where you you know you've sort of planned in advance and you know if you've if there are things that they're going to do making sure that it's really marked and it might be about cooking a special meal you know it doesn't have to be something that's expensive but you know finding some way of rewarding it having some one-to-one time you know doing something like that can be really helpful too and if panic disorder is picked up and a young person is receiving kind of treatment or input how important is the kind of communication between the young person and school and home and anyone who might be involved in their treatment is that is that important and necessary or not really yeah a really good question we don't fully know the answer to that question actually the data on involving parents for example in adolescent treatment is is really poor so a lot of treatments do involve parents but they involve them in lots and lots of different ways and typically we really don't know very much about how critical their involvement was we did a study of a CBT internet treatment and we had parent sessions for half the participants and not parent sessions for the other half we found that that didn't actually make a difference to the young people's outcome but really importantly what we found was that virtually all our parents had some level of involvement so they may not have done these extra sessions but they still talked to their child about what they were doing in the treatment you know they might have looked over their shoulder to see what their treatment sessions involved so I think having some level of involvement is is you know probably helpful but I think if if young people don't want their parents involved then parents you know typically shouldn't be concerned at this age that that's going to have a detrimental impact on their young person's outcomes because the evidence certainly doesn't support that parents like to be involved and that's understandable in our treatment trial we do like to involve parents actually because we have relatively brief number of sessions we're doing the treatment in five sessions plus two boosters we want to get that as generalized as possible so it involves young people doing lots of stuff outside their sessions and we find the best way to support that is if parents know what the plan is and they can really facilitate the young person going and doing all of these different things and similarly we really like to have good liaison with schools too because you know if if the plan is that the young person does certain things then actually if school can support that that's really helpful and a lot of young people's worries are related to school it's very unusual that we'll see a young person who has panic or perhaps social anxiety or something else and none of those worries relate to school it's the school environment you know school is is it presents you with so many different challenges you know in terms of peers in terms of you know having to present things in front of people so it's such a rich environment but it but it potentially has lots of areas that can be stressful and anxiety-croaking for young people and so having them on side we think is really important too so a school's getting something wrong there or is it just that they're complex places with a lot going on oh that's a really good question isn't it um i mean i think it's it's hard isn't it to say what the optimum is i think it you know the school is a great environment because it gives children opportunities to build resilience to to acquire lots of skills that they're going to need as they grow up and they move to be independent so you know young people doing things like presentations having to perform in front of other people doing PE all of those things have got to be a good thing um but i guess there are times when you know the way it's done might not be optimum and you know some of the things that we might do might inadvertently actually increase young people's stress levels so for example with PE you know if there's kind of team picking or um you know moments where you know young there's some body shaming or other things then clearly that's not a good thing and it's really important that schools are encouraging children to do all of these things but in a way that's a kind of you know that's a win and that encourages children to kind of take on these new skills um so it's it's a great opportunity if you can kind of create a growth mindset get children doing things and when they fail as we all will in life on regular bases that they can interpret that as a learning opportunity rather than a failure so i think it's it's about all of those different things and that's a huge challenge isn't it when you've got so many students that you're working with and as a school you're under all these other pressures as well that you know we can't even begin to understand so it's you know it's a challenge for people to do well at every level with everyone absolutely and do you find that there's any link between uh child's anxiety and panic and um similar things presenting in their parents and carers yeah well i mean generally we do find that anxiety tends to run in families not in terms of a disorder specific way so if your parent has OCD for example that doesn't mean that their child might develop OCD um there doesn't seem to be that specific link but it is common that we see anxiety presenting in different generations of a family um but uh you know that doesn't mean that that parents that have an anxiety problem or a kind of other mental health condition necessarily will then have a child that has those kind of difficulties so we know that genes account for about a third of the variance in understanding the development of anxiety problems from generation to generation um uh but other factors that you know the other factor that's been looked at a lot is sort of parenting style but um but the critical thing that we know accounts for children developing anxiety problems is temperament that child's temperament is the overriding biggest factor um that accounts for them developing some kind of difficulty and the other thing to say with the genetics is that you know although some children might inherit a certain kind of genetic um sort of sensitivity it's not a gene that means that you're going to develop an anxiety disorder it just means that you're probably temperamentally a bit more of a sensitive person you're probably a really caring lovely person but that the flip side of that means that you're potentially more vulnerable to developing anxiety but the positive news is that when we've looked at that within clinical trials in terms of outcomes those kids that are genetically more sensitive to developing anxiety disorder actually do exactly the same in treatment and there's some evidence that they actually do better in treatment and perhaps that's because they you know in and when you teach them a new set of skills because they're quite tuned to look at novelty and you know and to pick things up that actually if you kind of develop an environment that's more enriching and that they've got the school the skill set now to develop you know so that they know how to deal with anxiety problems that actually they're really good at then picking up this new set of skills and then using them so just because you've got a sensitive child who potentially might develop anxiety and potentially there might have been some genetic element to that does not mean that you need to feel concerned guilty or anything and actually they'll do just as well if they get some good input and do you ever come across cases of panic disorder in younger children so you talked about this being a kind of mid to late teens typical onset yeah um so we do see it down to about the age of 11 but it's um but the kind of cognitions that we see that are much more specific and relate to something catastrophically wrong with them tend to get more developed as they get older so um so we might see those kind of thoughts in a you know in a 10 11 year old but actually the thoughts become much better defined as you get into sort of 13 14 so in the current trial that we're running we have a lot of 14 year olds 14 year olds up and it's much much less common in sort of years seven and eight but when we talk to the young people that we're working with often they'll describe having panic attacks earlier than that um and so they might describe you know being seven and jumping into a swimming pool and suddenly feeling that they couldn't breathe and that you know they needed to quickly swim to the side and and actually when they reflect back on it they think that was a panic attack or they might you know describe it as sort of social situation where they saw some other people talking about some other children in the playground talking about them and they had a panic attack so I think we see panic attacks younger but we tend to see panic disorder pretty much as a teenage phenomenon and and that's to do with um our ability to essentially think about what's happening to us you think rather than I think that probably is the case it's a kind of developmental thing where as your kind of way of making sense of the world and yourself develops your ability to notice those sensations and then not just think this feels horrible but actually think this feels horrible and maybe there's something wrong and then once you start to go down that line that kind of creates a life of its own potentially is why we tend to see it in in young in the older um age range of children and tell us a bit about the study that you're doing at the moment and you're recruiting I believe aren't you yeah that's right so we're doing a study it's called the panda study um it's for um it's been conducted in the andy research clinic at redding university so any child who has a baksha gp is eligible to take part and we're running it as a feasibility study and we're trying to understand um how how a bigger study might run so we are looking at two different treatments we're comparing two psychological treatments um and that is this um treatment that's been developed in adults cognitive therapy but we're also comparing that to this standard general treatment graded exposure um to see how effective those two treatments are so we have no reason to think one is better than the other they're both good CBT treatments they're both delivered face to face during covid we're delivering them um uh using video conferencing um but prior to that we were doing it face to face in the clinic and we'll continue to do that when it's when it's safe to resume those sessions um so we're comparing two forms of CBT face to face um they're five sessions plus two boosters and that will give us some information about you know some information about the effectiveness of those two treatments but also because it's a feasibility study it also helps us understand you know how these studies work are the treatments acceptable to people do people want to take part can we find enough young people with panic disorder so it answers lots of questions that are really helpful for us to then potentially scale this up into a much larger randomized control trial what does five sessions plus two boosters mean um so it means that we do the course of treatment over five weeks um and then we have two further sessions and they're more spaced out so those two extra sessions happen around a month and then a couple of months after the end of treatment so to some degree they look like treatment sessions in that we might do lots of sort of active work we might do some behavioral stuff within them um but it also means that the young person's having an opportunity to kind of live their life to use the skills that they've learned um and and then those two extra sessions are opportunities to problem solve how that's all going um and if there are any difficulties to sort of think right what should we do about that and put a plan in place so those extra sessions really are a bit more hands off where the young person's going ahead being quite independent doing stuff themselves and then it gives us an opportunity to check in with them challenge you know to to focus on any issues and maybe do a bit of extra treatment within the sessions too and who's eligible to take part so they've got to live in barkshire they have at the moment yes although we might extend it to other sites but currently it's just in barkshire they need to be aged 11 to 18 and they need to have panic disorder so essentially we wouldn't expect people to try and work out whether or not that's exactly what the young person's experiencing but if there's anyone that it's thinking about a young person that lives in this area who thinks that they might have panic attacks and it might be something like this then they can just email us and our email address is panda as in the panda bear panda at redding.ac.uk and then we'll get in touch with them we can have a chat with them and figure out what we think's going on if on the basis of that conversation some screening we think that that might be the case then we'll get them in do a full diagnostic assessment and then take it from there so the first step is really just if you think you've got someone and that young person thinks they would like help um that not only do they have these panic attacks but it's actually getting in the way of them being able to do things at school or at home or with their family um then please do get in touch with us and does the referral need to come from a gp or can it come from school or parents or the child it can come from anybody yeah that's right so um we're obviously working closely with schools um and with gps too but actually if people hear of this study and they'd like to get in touch with us directly then we welcome that and be happy to hear from anyone. And how long is it going on for? So it's NIHR funded and that funding finishes around the end of next year so we've got about 12 months now where we're actively recruiting young people so we started the study in october last year had a little bit of a pause when lockdowns uh kind of kicked in but actually now we've resumed treatment so we've recruited a number of young people into the study in fact our first people finished in april this year um but we'd still really really keen to recruit many many more young people to the study so we'll be actively recruiting probably until um about september next year. Okay and if anyone lives outside of Barksha but they would like to learn from the great work that you're doing have you got kind of resources and things that you can point people to? We on our andy clinic website we have got a list of resources for parents professionals and young people themselves um i'd be happy for people to email me if there are particular things i can point them in the direction of things like the donna pinker's workbook that um that people have talked about there's lots of um books that are written for adults so there are books on panic disorder there aren't any for young people um but we do hope to write one in you know once we've kind of got the results of this study and we know more that our plan is to put one together that's specifically for adolescents at the moment that isn't the case but there are some really nice resources although they're aimed at adults actually i think would be suitable still to recommend to to younger people so um there's a a book in the overcoming series so there's a series called overcoming um and has you know overcoming depression lots of different things and so there's one that relates to panic in that series and other things so so there are some resources they're not easy there's nothing that sort of jumps out as being appropriate because it's adolescent panic but there are other things that might be suitable so either looking at the andy website for resources or you know if someone wants to get in touch with me directly i'd be really happy to recommend things that's really kind and we can pop all those links into the show notes so that people can um easily access them great what thought would you like to wrap up and leave people with who've taken the time to listen into this what do they need to know as they go away i think it's just about being mindful that you know lots of young people might be experiencing difficulties they might not necessarily talk to people um some of the research that we've done recently where we've been asking young people who have anxiety problems or depression and it's clear that often they do worry about upsetting other people burdening them they feel embarrassed um and and that sometimes is a barrier to getting help so i think it's really about providing opportunities for young people to talk to you if you notice anything that you think is out of the ordinary or suggest that that person's experiencing any kind of difficulties listening to them in a really open non-judgmental way not over reassuring them or telling them don't be silly that won't happen it's really about listening to them and and then i think facilitating some kind of help and support you know if that young person wants to get that