Keeping Cool Keeping Cool About Your Anxious Child About Your Anxious Child

Presented by: Dr.Kevin Nugent Presented by: Dr.Kevin Nugent Child a & Adolescent PsychiatristChild a & Adolescent Psychiatrist

Our Goals:Our Goals:

• Understand why certain children are more vulnerable to Understand why certain children are more vulnerable to anxiety strugglesanxiety struggles

• Recognize the main types of anxiety symptoms/disorders Recognize the main types of anxiety symptoms/disorders and how they may look in children and adolescents and how they may look in children and adolescents

• Tease out the relationship between anxiety and ADHD as Tease out the relationship between anxiety and ADHD as well as L.D.’swell as L.D.’s

• Review preferable strategies and how you can best Review preferable strategies and how you can best support your child in managing their own anxietysupport your child in managing their own anxiety

Why are some children more Why are some children more prone to anxiety? prone to anxiety?

• Many children go through stages where they experience mild or Many children go through stages where they experience mild or transient anxiety problemstransient anxiety problems

• Indeed, stranger anxiety in infants, separation anxiety in toddlers, Indeed, stranger anxiety in infants, separation anxiety in toddlers, fear of the dark and “monsters” in pre-schoolers and some worry fear of the dark and “monsters” in pre-schoolers and some worry about death in school-age children is arguably “normal”about death in school-age children is arguably “normal”

• However, some children are temperamentally more shy and timid, However, some children are temperamentally more shy and timid, cautious, “slow-to-warm –up” and/or adapt poorly to change cautious, “slow-to-warm –up” and/or adapt poorly to change

• About 10% of children are exceptionally sensitive (Manassis)About 10% of children are exceptionally sensitive (Manassis)

The Highly Sensitive ChildThe Highly Sensitive Child• Emotionally sensitive children are more troubled by and reactive Emotionally sensitive children are more troubled by and reactive

to life’s events; perhaps they “feel more deeply”to life’s events; perhaps they “feel more deeply”• These children may try to cope with life’s stresses by trying to These children may try to cope with life’s stresses by trying to

“keep things the same”, so they appear resistant to change“keep things the same”, so they appear resistant to change• Such children more likely to have sensory hypersensitivity, i.e. Such children more likely to have sensory hypersensitivity, i.e.

they are more bothered by stimuli like loud sounds, the feel of they are more bothered by stimuli like loud sounds, the feel of clothing or new foodsclothing or new foods

• Such children often more attuned to/ worried about physical Such children often more attuned to/ worried about physical sensations or symptoms, perhaps with a lower pain thresholdsensations or symptoms, perhaps with a lower pain threshold

• All in all, they tend be more “stress sensitive”.All in all, they tend be more “stress sensitive”.

The Creation of an Anxious ChildThe Creation of an Anxious Child• The mixture of certain temperamental traits, high The mixture of certain temperamental traits, high

sensitivity and/ or genetic predisposition make some sensitivity and/ or genetic predisposition make some children more vulnerable to anxietychildren more vulnerable to anxiety

• There is a balancing act between a child’s innate There is a balancing act between a child’s innate vulnerability as well as the stressors they face and that vulnerability as well as the stressors they face and that child’s coping skills and supportschild’s coping skills and supports

• When the innate vulnerability and/or the stressors are When the innate vulnerability and/or the stressors are greater, the child is likely to develop anxiety symptomsgreater, the child is likely to develop anxiety symptoms

• In turn, children who avoid what they fear can become In turn, children who avoid what they fear can become quite disabled by themquite disabled by them

Pediatric Anxiety DisordersPediatric Anxiety Disorders• Occur frequently, likely affecting up to 10% of Occur frequently, likely affecting up to 10% of

children or teens children or teens • These “internalizing disorders” can be over-These “internalizing disorders” can be over-

looked or minimized by others looked or minimized by others • Strong genetic component, with heritability, Strong genetic component, with heritability,

accounting for 50% of varianceaccounting for 50% of variance• Enduring, often fluctuating, courseEnduring, often fluctuating, course• Significant impact can be seen over timeSignificant impact can be seen over time

Typical Early CourseTypical Early Course• Early on there are often diffuse, evolving and less Early on there are often diffuse, evolving and less

classical symptomsclassical symptoms• These might include excessive separation These might include excessive separation

difficulties, poor adaptation to change, difficulties, poor adaptation to change, exaggerated fears, multiple worries and stress-exaggerated fears, multiple worries and stress-induced physical symptomsinduced physical symptoms

• These children are often more vulnerable to peer These children are often more vulnerable to peer harassment and more troubled by it when it occursharassment and more troubled by it when it occurs

• Over time, they may develop symptoms of more Over time, they may develop symptoms of more classical anxiety disorder(s)classical anxiety disorder(s)

Associated ConditionsAssociated Conditions• Anxious children at elevated risk for other difficulties, including: Anxious children at elevated risk for other difficulties, including:

-School refusal/ “phobia” -School refusal/ “phobia” -Peer harassment/ isolation-Peer harassment/ isolation-Depression-Depression-Oppositional Defiant Disorder (mainly at home)-Oppositional Defiant Disorder (mainly at home)-School or career underachievement-School or career underachievement-Post-traumatic stress disorder-Post-traumatic stress disorder-Substance use problems-Substance use problems

• Rather a complex interaction between anxiety and ADHD or other Rather a complex interaction between anxiety and ADHD or other learning problemslearning problems

Separation Anxiety DisorderSeparation Anxiety Disorder

• Excessive and ongoing distress/ worry about Excessive and ongoing distress/ worry about separating (from major attachment figures)separating (from major attachment figures)

• +/- behaviors to avoid it and autonomic arousal +/- behaviors to avoid it and autonomic arousal upon separation/ somatic complaintsupon separation/ somatic complaints

• As many as 4% of children, peaking at 7- 9 yearAs many as 4% of children, peaking at 7- 9 year• Child’s developmental delays could be a factorChild’s developmental delays could be a factor• Parental response key to managementParental response key to management• Can be a predictor of future internalizing disorderCan be a predictor of future internalizing disorder

Selective MutismSelective Mutism• Persistent failure to speak in specific social Persistent failure to speak in specific social

situations, mainly outside of familysituations, mainly outside of family• Uncommon; formerly called “elective mutism”Uncommon; formerly called “elective mutism”• Usually shy, clingy, reticent childrenUsually shy, clingy, reticent children• Sometimes a “talking buddy” or sibSometimes a “talking buddy” or sib• May be some accompanying oppositionalityMay be some accompanying oppositionality• Perhaps a childhood antecedent of Social Perhaps a childhood antecedent of Social

Anxiety DisorderAnxiety Disorder

Specific PhobiasSpecific Phobias

Minor phobias occur commonly in development Minor phobias occur commonly in development with little impactwith little impact

To merit a diagnosis and intervention must be To merit a diagnosis and intervention must be present >6 mos. & significant impairment in present >6 mos. & significant impairment in social, educational or occupational functionsocial, educational or occupational function

Can be a marker for other anxiety problems, at Can be a marker for other anxiety problems, at present or later in lifepresent or later in life

Specific Phobia’sSpecific Phobia’s

Sub-types include: Animal Sub-types include: Animal Natural environmentNatural environmentBlood/ injection/ injuryBlood/ injection/ injurySituational (e.g. planes, elevators)Situational (e.g. planes, elevators)Other (e.g. sounds, vomiting)Other (e.g. sounds, vomiting)

Some can be quite life disruptive/ upsettingSome can be quite life disruptive/ upsettingMore serious phobic presentations include dramatic More serious phobic presentations include dramatic

fears of storms, dogs and stinging insectsfears of storms, dogs and stinging insects

Generalized Anxiety Disorder (DSM-IV)Generalized Anxiety Disorder (DSM-IV)

• Excessive anxiety and worry for 6 months or moreExcessive anxiety and worry for 6 months or moreANDAND• 3 or more of the following 6 symptoms:3 or more of the following 6 symptoms:

– restlessness or feeling keyed up or on edgerestlessness or feeling keyed up or on edge– being easily fatiguedbeing easily fatigued– difficulty concentrating or mind going blankdifficulty concentrating or mind going blank– irritabilityirritability– muscle tensionmuscle tension– sleep disturbance (difficulty falling asleep or sleep disturbance (difficulty falling asleep or

staying asleep, or restless, unsatisfying sleep)staying asleep, or restless, unsatisfying sleep)

Pediatric Presentation of G.A.D.Pediatric Presentation of G.A.D.• For a time called “Overanxious Disorder of Childhood”For a time called “Overanxious Disorder of Childhood”• Tense, reticent, high stress, worrying childrenTense, reticent, high stress, worrying children• Worry that “something bad” will happen, especially to Worry that “something bad” will happen, especially to

loved ones (particularly parents) or themselvesloved ones (particularly parents) or themselves• ““Overreact” to minor traumas, peer harassment and life Overreact” to minor traumas, peer harassment and life

changeschanges• Sleep disturbance (especially initial insomnia) and Sleep disturbance (especially initial insomnia) and

somatic complaints commonsomatic complaints common

Panic Attack (DSM-IV)Panic Attack (DSM-IV)Diagnostic criteria: recurrent panic attacksDiagnostic criteria: recurrent panic attacks

Cognitive Cognitive symptomsymptomss

Physical Physical symptomsymptomss

4 or more of the following4 or more of the following

• Dyspnea or the sensation of being smotheredDyspnea or the sensation of being smothered

• Depersonalization or derealizationDepersonalization or derealization

• Fear of going crazy or of losing self-controlFear of going crazy or of losing self-control

• Fear of dyingFear of dying

• Palpitations or tachycardiaPalpitations or tachycardia

• SweatingSweating

• Trembling or shakingTrembling or shaking

• Feeling of chokingFeeling of choking

• Chest pain or discomfortChest pain or discomfort

• Nausea or abdominal upsetNausea or abdominal upset

• Dizziness, feeling of unsteadiness/ faintnessDizziness, feeling of unsteadiness/ faintness

• Numbness or tingling sensationNumbness or tingling sensation

• Flushes or chillsFlushes or chills

Diagnosis (cont’d)Diagnosis (cont’d)

Anticipatory anxiety: one or more of the following Anticipatory anxiety: one or more of the following

for at least 1 month:for at least 1 month:

• Persistent concern about having another panic attack

• Worrying about the consequences of an attack (e.g., having a heart attack)

• Significant change in behaviour due to recurrent panic attacks

Panic Disorder Co-morbidityPanic Disorder Co-morbidity

• Lifetime prevalence of about 1%Lifetime prevalence of about 1%

• Association with phobias especially claustrophobia, Association with phobias especially claustrophobia, illness phobia and agoraphobiaillness phobia and agoraphobia

• Highly comorbid with other anxiety disordersHighly comorbid with other anxiety disorders

-social anxiety disordersocial anxiety disorder

-generalized anxiety disordergeneralized anxiety disorder

-obsessive-compulsive disorderobsessive-compulsive disorder

Panic Disorder Co-morbidity: Panic Disorder Co-morbidity: Major DepressionMajor Depression

• 65–90% of patients develop major depression or 65–90% of patients develop major depression or

serious demoralization serious demoralization

• Coexisting depression significantly increases:Coexisting depression significantly increases:

– morbiditymorbidity

– mental healthcare utilizationmental healthcare utilization

– suicide risk (increased further with comorbid suicide risk (increased further with comorbid substance abuse or personality disorder)substance abuse or personality disorder)

Pediatric Panic AttacksPediatric Panic Attacks

• Peak adult onset but does occur in teens and Peak adult onset but does occur in teens and occasionally in childrenoccasionally in children

• Even in adults, often years to diagnosisEven in adults, often years to diagnosis• Young people a difficult time describing experienceYoung people a difficult time describing experience• Unlikely to elicit full classic symptom pictureUnlikely to elicit full classic symptom picture• Can be a hidden cause of class or school refusalCan be a hidden cause of class or school refusal• Remember: marked risk for depression over timeRemember: marked risk for depression over time

Biological Explanation for Panic Biological Explanation for Panic Attacks Attacks • Adrenaline release is on a “hair trigger”, getting released for minor or Adrenaline release is on a “hair trigger”, getting released for minor or

non-existent “threats”non-existent “threats”• Adrenaline is body hormone responsible for “fight or flight reaction”Adrenaline is body hormone responsible for “fight or flight reaction”• Therefore adrenaline release speeds up heart rate, respiration and Therefore adrenaline release speeds up heart rate, respiration and

blood flow to the peripheral musclesblood flow to the peripheral muscles• Diverts blood away from the internal organsDiverts blood away from the internal organs• Limited supply of adrenaline means that the peak effects are time-Limited supply of adrenaline means that the peak effects are time-

limited, typically 10 or 20 minutes maximumlimited, typically 10 or 20 minutes maximum• Worsened when “the head tries to explain” the bodily reactionWorsened when “the head tries to explain” the bodily reaction• Often blame where they occur, so wish to avoid those placesOften blame where they occur, so wish to avoid those places

Social Anxiety Disorder (Social Phobia)Social Anxiety Disorder (Social Phobia)

• Marked or persistent fear of Marked or persistent fear of socialsocial or or performanceperformance situationssituations

• Individuals fear scrutiny, negative evaluation, humiliation Individuals fear scrutiny, negative evaluation, humiliation or embarrassmentor embarrassment

• Exposure to (or anticipation of) social/performance Exposure to (or anticipation of) social/performance situation provokes anxietysituation provokes anxiety

• Leads to avoidance of social/ performance situationsLeads to avoidance of social/ performance situations

• Significant distress or impairment in social and Significant distress or impairment in social and occupational functioningoccupational functioning

DSM-IV-modifiedDSM-IV-modified

Social Anxiety Disorder SubtypesSocial Anxiety Disorder Subtypes

Generalized (80%)Generalized (80%)• ““Most” social situationsMost” social situations

(DSM-IV)(DSM-IV)– performanceperformance– interactionalinteractional

• Overlaps with avoidant Overlaps with avoidant personality disorderpersonality disorder– 80–90%80–90%

Nongeneralized (20%)Nongeneralized (20%) (discrete, specific)(discrete, specific)

• 1 or 2 social situations1 or 2 social situations• Usually Usually performanceperformance

– writing in front of otherswriting in front of others

– eating in front of otherseating in front of others

– telephonetelephone

– public speakingpublic speaking

Interactional SituationsInteractional Situations

• Going to a party/ socializingGoing to a party/ socializing

• Lunch with peers/ making “small talk”Lunch with peers/ making “small talk”

• DatingDating

• Asking a teacher for helpAsking a teacher for help

• Speaking to a boss at workSpeaking to a boss at work

• Asking a salesclerk for helpAsking a salesclerk for help

• Asking for directionsAsking for directions

Performance SituationsPerformance Situations

• Public speakingPublic speaking

– formal; large groupsformal; large groups

– informal; small groupsinformal; small groups

• Writing in front of othersWriting in front of others

• Eating in front of othersEating in front of others

• Entering a roomEntering a room

• Using a public toiletUsing a public toilet

• Playing an instrumentPlaying an instrument

• Playing sportsPlaying sports

Social Anxiety Disorder: Social Anxiety Disorder: The Most Prevalent Anxiety DisorderThe Most Prevalent Anxiety Disorder

• Lifetime prevalence: 13%Lifetime prevalence: 13%

• Point prevalence in primary care: 5–7%Point prevalence in primary care: 5–7%

• Mean age at onset: 14–16 yearsMean age at onset: 14–16 years

• Only “Major depressive episode” greater lifetime Only “Major depressive episode” greater lifetime prevalence, arguably with more limited lifetime prevalence, arguably with more limited lifetime impactimpact

Ballenger JC, et al. J Clin Psychiatry 1998

Spectrum of Depression and Anxiety Spectrum of Depression and Anxiety Disorders: Lifetime PrevalenceDisorders: Lifetime Prevalence

Depression

Depression

Social Social

anxiety disorder

anxiety disorder

Posttraumatic

Posttraumatic

stress disorder

stress disorder

Generalized

Generalized

anxiety disorder

anxiety disorder

Panic disorder

Panic disorder

Obsessive-

Obsessive-

compulsive disorder

compulsive disorder

17%17%

13%13%

7.8%7.8%

5.1%5.1%3.5%3.5%

2.3%2.3%

Spectrum of Depression Spectrum of Depression and Anxiety Disordersand Anxiety Disorders

Generalized anxiety disorderGeneralized anxiety disorder

DepressionDepression

Social Social anxiety disorderanxiety disorder

Panic disorderPanic disorder

Obsessive-compulsive disorderObsessive-compulsive disorder

Posttraumatic Posttraumatic stress disorderstress disorder

Major Depression and Anxiety Major Depression and Anxiety Disorders: Symptom OverlapDisorders: Symptom Overlap

IrritabilityWorrying, guilt

Agitation/restlessnessNervousness, tension

Impaired concentrationAnhedoniaInsomniaFatigue

Major depressive

disorder

Anxiety disorders

Pediatric Soc.A.D. PresentationsPediatric Soc.A.D. Presentations

Anxious, timid, quietly suffering youthsAnxious, timid, quietly suffering youthsMarked accentuation of normal teen Marked accentuation of normal teen

hypersensitivitieshypersensitivitiesOften a history of peer harassment/ victimizationOften a history of peer harassment/ victimizationCan be an explanation for school refusalCan be an explanation for school refusalMarkedly elevated risk for depression over timeMarkedly elevated risk for depression over time

O.C.D. Diagnosis (DSM-IV) O.C.D. Diagnosis (DSM-IV) • Obsessions: recurrent, persistent ideas, thoughts, Obsessions: recurrent, persistent ideas, thoughts,

impulses or images (experienced as unwanted or alien)impulses or images (experienced as unwanted or alien)

• Compulsive behaviors: excessively repetitive behaviors Compulsive behaviors: excessively repetitive behaviors classically performed in response to an obsessionclassically performed in response to an obsession

• Can be quite time-consuming (up to hours/ day)Can be quite time-consuming (up to hours/ day)

• Can be marked distress associatedCan be marked distress associated

• Interference with social and occupational functioningInterference with social and occupational functioning

Obsessive and Compulsive Symptoms Obsessive and Compulsive Symptoms on Admission (n=560)on Admission (n=560)

• ObsessionsObsessions– contamination (45%)contamination (45%)– pathological doubt (42%)pathological doubt (42%)– somatic (36%)somatic (36%)– symmetry (31%)symmetry (31%)– aggressive (28%)aggressive (28%)– sexual (26%)sexual (26%)– multiple (60%)multiple (60%)

Rasmussen SA, et al. Psychopharm Bull 1988

• CompulsionsCompulsions– checking (63%)checking (63%)– washing (50%)washing (50%)– counting (36%)counting (36%)– need to ask/ confess (31%)need to ask/ confess (31%)– symmetry/ precision (28%)symmetry/ precision (28%)– hoarding (18%)hoarding (18%)– multiple (48%)multiple (48%)

Professional Screening for OCDProfessional Screening for OCD

• Intrusive or repetitive thoughts?Intrusive or repetitive thoughts?

• Excessive washing or checking?Excessive washing or checking?

• Needless counting or repeating?Needless counting or repeating?

• Alternatively, one can explain what obsessions and compulsive Alternatively, one can explain what obsessions and compulsive

behaviors are and then enquirebehaviors are and then enquire

Pediatric O.C.D.Pediatric O.C.D.

• Often onsets in adolescence, sometimes earlierOften onsets in adolescence, sometimes earlier• Typically a chronic waxing and waning courseTypically a chronic waxing and waning course• Exacerbations may be related to stress, but this is Exacerbations may be related to stress, but this is

not necessarily the casenot necessarily the case• Can be highly disablingCan be highly disabling• In severe cases, psychotic-like symptoms may In severe cases, psychotic-like symptoms may

occuroccur

P.T.S.D. Diagnosis (DSM-IV)P.T.S.D. Diagnosis (DSM-IV)

• Experience of a traumatic event with sensation of horror, Experience of a traumatic event with sensation of horror, helplessness or fearhelplessness or fear

• Re-experience of the traumatic eventRe-experience of the traumatic event

• Avoidance/numbing symptomatologyAvoidance/numbing symptomatology

• Increased arousal symptomsIncreased arousal symptoms

• Impaired functioningImpaired functioning

• Symptoms >1 month durationSymptoms >1 month duration

Re-experience of the TraumaRe-experience of the Trauma• The traumatic event is re-experienced in one or more of the The traumatic event is re-experienced in one or more of the

following ways:following ways:

– recurrent and intrusive distressing recollections of recurrent and intrusive distressing recollections of the eventthe event

– recurrent distressing dreams of the eventrecurrent distressing dreams of the event

– acting or feeling as if the trauma were re-occurringacting or feeling as if the trauma were re-occurring

– psychological distress and/or physiological reactivity psychological distress and/or physiological reactivity when exposed to cues that resemble an aspect of when exposed to cues that resemble an aspect of the traumatic eventthe traumatic event

Avoidance/Numbing SymptomatologyAvoidance/Numbing Symptomatology

• Patient will show avoidance of stimuli associated with the trauma Patient will show avoidance of stimuli associated with the trauma and a general numbing of responsiveness as indicated by three or and a general numbing of responsiveness as indicated by three or more of the following:more of the following:

– avoid thoughts, feelings or conversation associated avoid thoughts, feelings or conversation associated with the traumawith the trauma

– avoid activities that will arouse recollection of the avoid activities that will arouse recollection of the trauma (place or people)trauma (place or people)

– inability to recall an important aspect of the traumainability to recall an important aspect of the trauma

– markedly diminished interest in significant activitiesmarkedly diminished interest in significant activities

– feelings of detachmentfeelings of detachment

– restricted range of moodrestricted range of mood

– sense of foreshortened futuresense of foreshortened future

Increased Arousal SymptomsIncreased Arousal Symptoms

• The patient will have symptoms of increased arousal as The patient will have symptoms of increased arousal as indicated by two or more of the following:indicated by two or more of the following:

– difficulty falling or staying asleepdifficulty falling or staying asleep

– irritability or outbursts of angerirritability or outbursts of anger

– difficulty concentratingdifficulty concentrating

– hypervigilance hypervigilance

– exaggerated startle responseexaggerated startle response

Pediatric P.T.S.D.Pediatric P.T.S.D.• Clearly occurs, often less classical Clearly occurs, often less classical • Flashbacks, nightmares, sleep problems and Flashbacks, nightmares, sleep problems and

hypervigilance are most common featureshypervigilance are most common features• Also a desire to avoid triggering stimuli, but young people Also a desire to avoid triggering stimuli, but young people

may not have the “luxury” of such avoidancemay not have the “luxury” of such avoidance• Tendency for children to behaviorally re-enact trauma Tendency for children to behaviorally re-enact trauma

(e.g. in play or art work)(e.g. in play or art work)• Faulty cause and effect in kids can lead to self-blameFaulty cause and effect in kids can lead to self-blame• Clinicians should have a low threshold to screen for Clinicians should have a low threshold to screen for

trauma/abusetrauma/abuse

Somatizing DisordersSomatizing Disorders• Anxiety-prone children commonly present physical health Anxiety-prone children commonly present physical health

complaints in situations of stress, anxiety or worrycomplaints in situations of stress, anxiety or worry• Often related to anxiety about the school situationOften related to anxiety about the school situation• Pattern of symptoms often informativePattern of symptoms often informative• These children, and sometimes their parents, often These children, and sometimes their parents, often struggle to see the psychosomatic componentstruggle to see the psychosomatic component• Wide-ranging symptoms with abdominal pain, Wide-ranging symptoms with abdominal pain, nausea and headaches especially commonnausea and headaches especially common

Somatizing Disorders (cont.)Somatizing Disorders (cont.)

• Never helpful to use “all in your head” language, as Never helpful to use “all in your head” language, as individual feels their symptoms are being dismissed as individual feels their symptoms are being dismissed as “not real”“not real”

• More helpful to consider if there is some aspect ofMore helpful to consider if there is some aspect of “ “abnormal illness behavior”abnormal illness behavior”• Reasonable medical review appropriate, but sometimes Reasonable medical review appropriate, but sometimes these children get over-evaluated medicallythese children get over-evaluated medically• Important to work closely with child or teen’s physicianImportant to work closely with child or teen’s physician

School Refusal/ “Phobia”School Refusal/ “Phobia”• Many reasons why children are reluctant or refuse to Many reasons why children are reluctant or refuse to

attend schoolattend school• Anxiety commonly, but not always, a major factorAnxiety commonly, but not always, a major factor• Difficulties with academic work, peers or staff may be Difficulties with academic work, peers or staff may be

causes for their anxiety causes for their anxiety • Anxiety disorders likely to contribute include separation Anxiety disorders likely to contribute include separation

anxiety, social anxiety,panic disorder and somatization anxiety, social anxiety,panic disorder and somatization disorderdisorder

• Inadequate recognition, support or accommodation for Inadequate recognition, support or accommodation for ADHD or LD’s can sometimes be major contributorADHD or LD’s can sometimes be major contributor

• , ,

School Refusal/ “Phobia”School Refusal/ “Phobia”• Such children may present physical health complaints as Such children may present physical health complaints as

the reason they feel they should not go to school the reason they feel they should not go to school • Family dynamics sometimes serve to worsen the Family dynamics sometimes serve to worsen the

problem (e.g. over-emphasis on physical symptoms)problem (e.g. over-emphasis on physical symptoms)• Requires a well-coordinated, broad management Requires a well-coordinated, broad management

approach, with the child getting consistent messages approach, with the child getting consistent messages from important adults about their need to attend schoolfrom important adults about their need to attend school

• Sometimes medication assistance for their anxiety Sometimes medication assistance for their anxiety symptoms is an essential part of the plansymptoms is an essential part of the plan

• Critical to get “later” school refusers back to school ASAPCritical to get “later” school refusers back to school ASAP

Overview of ADHD-Anxiety RelationshipOverview of ADHD-Anxiety Relationship• ADHD and anxiety symptoms do have a significant co-morbidity ADHD and anxiety symptoms do have a significant co-morbidity

as many as 25% of anxious kids meet criterion for ADD/ADHD as many as 25% of anxious kids meet criterion for ADD/ADHD (Bernstein et al., 1996)(Bernstein et al., 1996)

• Usually though rather separate genetic contributionsUsually though rather separate genetic contributions• Many ways in which ADHD and Anxiety seem opposite, e.g.:Many ways in which ADHD and Anxiety seem opposite, e.g.: - fearless vs. fearful- fearless vs. fearful - impulsive vs. reticent - impulsive vs. reticent - reactive vs. obsessing - reactive vs. obsessing -“in the moment” vs. ruminating -“in the moment” vs. ruminating -externalizing vs. internalizing-externalizing vs. internalizing• Somewhat common exception is the triad of ADHD, Tourette’s Somewhat common exception is the triad of ADHD, Tourette’s

and Anxiety (especially OCD)and Anxiety (especially OCD)

Co-occurring Disorders in ADHD ChildrenCo-occurring Disorders in ADHD Children

Oppositional Defiant

Disorder40%

Tics11%

Conduct Disorder14%

ADHD alone31%

Anxiety Disorder

34%

Mood Disorders 4%MTA Cooperative Group. Arch Gen Psych 1999; 56:1088–96

(n=579)(n=579)

Overview of ADHD-Anxiety RelationshipOverview of ADHD-Anxiety Relationship• In addition to more classic anxiety presentations, children with In addition to more classic anxiety presentations, children with

ADHD may develop “secondary” anxiety related to areas of ADHD may develop “secondary” anxiety related to areas of under-function, such as in academic and social spheres; This under-function, such as in academic and social spheres; This contributes mainly to school, performance and social anxieties contributes mainly to school, performance and social anxieties

• Some likelihood that anxiety could be mistaken for ADD (rarely Some likelihood that anxiety could be mistaken for ADD (rarely ADHD) but this is rather easily distinguished with careful history; ADHD) but this is rather easily distinguished with careful history; i.e. they are “distracted” by i.e. they are “distracted” by severesevere worry or OCD symptoms worry or OCD symptoms

• In ADHD-Combined or H/I sub-types the over-activity, impulsivity and In ADHD-Combined or H/I sub-types the over-activity, impulsivity and other behavioral challenges are rather pervasive and more concerning other behavioral challenges are rather pervasive and more concerning than is usual for anxious kidsthan is usual for anxious kids

• Indeed, anxious children are not commonly seen as behavioral Indeed, anxious children are not commonly seen as behavioral concerns outside the home environmentconcerns outside the home environment

ADHD Symptoms Mistaken For AnxietyADHD Symptoms Mistaken For Anxiety• The following observations, common regarding pediatric ADD or The following observations, common regarding pediatric ADD or

ADHD, are sometimes mistakenly seen as “anxious”ADHD, are sometimes mistakenly seen as “anxious”-The child “acts up” (i.e. gets over-stimulated) in busy, noisy or exciting -The child “acts up” (i.e. gets over-stimulated) in busy, noisy or exciting environmentsenvironments-The child has difficulty making transitions or entering new -The child has difficulty making transitions or entering new environmentsenvironments-The child gets “anxious” (i.e. impatient) to leave situations (especially -The child gets “anxious” (i.e. impatient) to leave situations (especially when they are bored)when they are bored)- The child is “anxious” (i.e. demanding and impatient) to have their - The child is “anxious” (i.e. demanding and impatient) to have their wishes metwishes met-The child becomes frustrated and upset in the face of challenging -The child becomes frustrated and upset in the face of challenging tasks or when they don’t get their waytasks or when they don’t get their way

Overview of Anxiety/ L.D. RelationshipOverview of Anxiety/ L.D. Relationship• Children and teens with significant learning difficulties, including Children and teens with significant learning difficulties, including

various LD’s, may well develop anxiety related to specific subjects, various LD’s, may well develop anxiety related to specific subjects, performance tasks (e.g. tests) or unwelcoming learning environment.performance tasks (e.g. tests) or unwelcoming learning environment.

• Such children may feel singled out, embarrassed or intimidated by how Such children may feel singled out, embarrassed or intimidated by how certain teachers run their classrooms. certain teachers run their classrooms.

• Some children experience special help or placements as stigmatizing.Some children experience special help or placements as stigmatizing.• Such children are more likely to be targets of peer harassment and Such children are more likely to be targets of peer harassment and

they may be less equipped to deal with it. Traumatic situations may be they may be less equipped to deal with it. Traumatic situations may be more likely to produce PTSD symptoms in sensitive childrenmore likely to produce PTSD symptoms in sensitive children

• These are prime conditions for social anxiety symptoms, but children/ These are prime conditions for social anxiety symptoms, but children/ teens may experience other patterns (e.g. excessive worry, teens may experience other patterns (e.g. excessive worry, psychosomatic symptoms, school refusal) based on these problemspsychosomatic symptoms, school refusal) based on these problems

Anxiety and other MH Problems in L.D’s.Anxiety and other MH Problems in L.D’s.

• Children and young people with LD have been found to be up to four Children and young people with LD have been found to be up to four times more susceptible to mental health problems than their non-times more susceptible to mental health problems than their non-disabled peers (Wilson, 2004). disabled peers (Wilson, 2004).

• For children with LD, research evidence available suggests high levels For children with LD, research evidence available suggests high levels of anxiety disorders in children vary from 8.7% (Dekker & Koot 2003) of anxiety disorders in children vary from 8.7% (Dekker & Koot 2003) to 21.98.7% (Emerson, 2003)to 21.98.7% (Emerson, 2003)

• Studies have shown that the prevalence of psychiatric disorder among Studies have shown that the prevalence of psychiatric disorder among people with LD is higher than it is in the general population (Borthwick-people with LD is higher than it is in the general population (Borthwick-Duff, 1994; Allington-Smith, 2006). Duff, 1994; Allington-Smith, 2006).

• In children and adolescents, anxiety disorders may be associated with In children and adolescents, anxiety disorders may be associated with lowered linguistic abilities and cognitive flexibility (Toren et al, 2000) lowered linguistic abilities and cognitive flexibility (Toren et al, 2000)

SLD’s and Social DifficultiesSLD’s and Social Difficulties• Children with Non-verbal L.D.’s (as per Rourke, 1995 & 2000)Children with Non-verbal L.D.’s (as per Rourke, 1995 & 2000)

-often exhibit difficulty in processing new or complex social situations -often exhibit difficulty in processing new or complex social situations -they also struggle with non-verbal aspects of communication (e.g. -they also struggle with non-verbal aspects of communication (e.g. interpreting facial expressions, body language and tone of voice) interpreting facial expressions, body language and tone of voice) -in novel and other situations, they rely on repetitious or rote -in novel and other situations, they rely on repetitious or rote behaviors, because they excel in these skills. behaviors, because they excel in these skills. -their interactions with other children are stereotypical and lacking in -their interactions with other children are stereotypical and lacking in reciprocity reciprocity

• These difficulties are somewhat similar to those with Asperger’s S.These difficulties are somewhat similar to those with Asperger’s S.• Children with Verbal L.D.’s struggle more to keep up with the verbal Children with Verbal L.D.’s struggle more to keep up with the verbal

aspect of communication.aspect of communication.

Impact of the Social Difficulties in LD’sImpact of the Social Difficulties in LD’s• Such children often struggle to make and keep friends and to “fit in” Such children often struggle to make and keep friends and to “fit in”

which may lead to social isolationwhich may lead to social isolation• These children are also more likely to be targets of peer harassment These children are also more likely to be targets of peer harassment

and they also may be poorly skilled to deal with it effectivelyand they also may be poorly skilled to deal with it effectively• Their LD’s, especially if not recognized, contribute to academic Their LD’s, especially if not recognized, contribute to academic

struggles which can be demoralizing and lower self-esteemstruggles which can be demoralizing and lower self-esteem• Any or all of these factors increase the risk for anxiety and depression Any or all of these factors increase the risk for anxiety and depression

in these children over time.in these children over time.• Adults may not recognize the extent to which these difficulties impact a Adults may not recognize the extent to which these difficulties impact a

child’s peer interactions child’s peer interactions • Proper recognition and remediation of their LD’s are first steps!Proper recognition and remediation of their LD’s are first steps!

What are the Basics Facts about Anxiety?What are the Basics Facts about Anxiety?

1.1. Anxiety is unrealistic fear or worryAnxiety is unrealistic fear or worry2.2. Anxiety, especially when experienced as an ongoing stress, produces Anxiety, especially when experienced as an ongoing stress, produces

troubling physiological and psychological symptomstroubling physiological and psychological symptoms3. Parents and other involved adults often struggle about the extent to 3. Parents and other involved adults often struggle about the extent to

which they should “protect their child” from their anxieties, recognizing which they should “protect their child” from their anxieties, recognizing their genuine distress and struggles.their genuine distress and struggles.

4. Anxiety produces additional problems when it interferes with a child’s 4. Anxiety produces additional problems when it interferes with a child’s ability to engage in common age-appropriate activities ability to engage in common age-appropriate activities

5.5. The only way to overcome fear is to face it. The only way to overcome fear is to face it.

Anxiety: General ManagementAnxiety: General Management• Information is the key !!Information is the key !!• Parents role is in supporting the child to gradually confront their Parents role is in supporting the child to gradually confront their

fears and worries towards getting fully mobilizedfears and worries towards getting fully mobilized• ””Although this makes you nervous, we believe you can do this!”Although this makes you nervous, we believe you can do this!”• Parent needs to resist instinct to over-protect and may need to Parent needs to resist instinct to over-protect and may need to

see to their own stress levelsee to their own stress level• Maintain in school !!Maintain in school !!• Everyone needs to expect some fluctuation in symptoms and Everyone needs to expect some fluctuation in symptoms and

progress over time and not over-reactprogress over time and not over-react

More General Management GuidelinesMore General Management Guidelines• Some medical review may be warranted by Family Doc or Ped’nSome medical review may be warranted by Family Doc or Ped’n• A mental health assessment may be requiredA mental health assessment may be required• Child/youth deserves an explanation of their anxiety symptomsChild/youth deserves an explanation of their anxiety symptoms• Good management requires a team approach with key players Good management requires a team approach with key players (e.g. physician, school personnel, extended family) “on board”(e.g. physician, school personnel, extended family) “on board”• Child does best when active in learning coping strategiesChild does best when active in learning coping strategies• Adults in child’s life need to demonstrate their belief that the child/ Adults in child’s life need to demonstrate their belief that the child/

youth can attain better coping and functioningyouth can attain better coping and functioning• Encourage child/ youth to attain areas of successEncourage child/ youth to attain areas of success

Interventions:Interventions:• Educational and supportive counseling (child and parents)Educational and supportive counseling (child and parents)• Cognitive Behavioral TherapyCognitive Behavioral Therapy• Systematic Desensitization (Specific Phobias)Systematic Desensitization (Specific Phobias)• Relaxation Training/ Visualization/ Yoga/ etc.Relaxation Training/ Visualization/ Yoga/ etc.• Exercise/Fitness and Empowering sportsExercise/Fitness and Empowering sports• Recreation and Treatment Group ExperiencesRecreation and Treatment Group Experiences• Strategies and where necessary, adult support, to ongoing Strategies and where necessary, adult support, to ongoing “ “targets” of bullyingtargets” of bullying• Consider medicationConsider medication

Basic Cognitive Behavioral TherapyBasic Cognitive Behavioral Therapy• We cannot directly control our emotional or bodily feelingsWe cannot directly control our emotional or bodily feelings• Instead we need to challenge our thinking and behavior, which we Instead we need to challenge our thinking and behavior, which we

have more ability to influence and controlhave more ability to influence and control• Essentially our thinking is our “self talk”Essentially our thinking is our “self talk”• The self-talk of anxious or depressive individuals contains The self-talk of anxious or depressive individuals contains

frequent “cognitive distortions” frequent “cognitive distortions” • These need to be identified, challenged and amendedThese need to be identified, challenged and amended• Similarly our behavior can be redirected towards a more positive Similarly our behavior can be redirected towards a more positive

and constructive directionand constructive direction• Eventually these changes will likely improve how we feelEventually these changes will likely improve how we feel

Cognitive distortionsCognitive distortions• Arbitrary influenceArbitrary influence• Selective abstractionSelective abstraction• OvergeneralizationOvergeneralization• Minimization or MagnificationMinimization or Magnification• ““Black and White”/ Black and White”/ “ “All or Nothing” ThinkingAll or Nothing” Thinking• PersonalizationPersonalization• Emotional ReasoningEmotional Reasoning

Additional “kid contributions”:Additional “kid contributions”:

Control fallacies:Control fallacies:Fallacy of fairnessFallacy of fairnessFallacy of changing othersFallacy of changing others““Should” fallaciesShould” fallaciesFaulty “cause and effectFaulty “cause and effect””

Coping StrategiesCoping Strategies• Provide your child with reassuring information about anxiety Provide your child with reassuring information about anxiety

(that it’s common, non-fatal and defeatable; role of adrenaline)(that it’s common, non-fatal and defeatable; role of adrenaline)• Have child practice breathing, relaxation and visualization Have child practice breathing, relaxation and visualization

techniquestechniques• Distraction techniques can sometimes have valueDistraction techniques can sometimes have value• Learn and practice “coping self-talk”Learn and practice “coping self-talk”• Encourage your child to face their anxieties more independentlyEncourage your child to face their anxieties more independently• Label and “externalize” the anxiety or worry (e.g. have your child Label and “externalize” the anxiety or worry (e.g. have your child

give it a name, draw it or visualize it); then tackle it, e.g. “We’re give it a name, draw it or visualize it); then tackle it, e.g. “We’re not going to letnot going to let ‘Scaredy Bear’ push us around any more!” ‘Scaredy Bear’ push us around any more!”

Desensitization TechniquesDesensitization Techniques• Systematic desensitization is when one encourages a Systematic desensitization is when one encourages a

child to gradually approach and face their fearschild to gradually approach and face their fears• May include a gradual approach, gradual withdrawal of May include a gradual approach, gradual withdrawal of

your support and/or rewards for their successyour support and/or rewards for their success• Child needs to be supported in utilizing coping strategies Child needs to be supported in utilizing coping strategies

to outlast the anxiety symptomsto outlast the anxiety symptoms• Relaxation and deep breathing techniques helpfulRelaxation and deep breathing techniques helpful• Can be done by family on a common sense wayCan be done by family on a common sense way

Desensitization TechniquesDesensitization Techniques• Give the child some say about when to take next stepGive the child some say about when to take next step• Use pictures/ visualization for infrequent stressorsUse pictures/ visualization for infrequent stressors• Frequent exposures, in small manageable steps Frequent exposures, in small manageable steps

commencing as soon as possible after fear developscommencing as soon as possible after fear develops• May occasionally be need for “booster sessions” May occasionally be need for “booster sessions” • Watch “What About Bob” (with Bill Murray) with your childWatch “What About Bob” (with Bill Murray) with your child• ““Flooding” is full, immediate exposure- milder fears only!Flooding” is full, immediate exposure- milder fears only!

Dealing With WorryDealing With Worry• Children who worry excessively usually are caught in a cycle of Children who worry excessively usually are caught in a cycle of

“cognitive distortion” which serves to generate and amplify fears“cognitive distortion” which serves to generate and amplify fears• Tendency towards pessimism and “negative what-iffing”Tendency towards pessimism and “negative what-iffing”• Label and teach them to utilize these questions (Manassis):Label and teach them to utilize these questions (Manassis):• 1. How likely is it that what I’m afraid of will/has happened?1. How likely is it that what I’m afraid of will/has happened? 2. What other explanations are there for this situation?2. What other explanations are there for this situation? 3. What is the worst situation and how could I handle it?3. What is the worst situation and how could I handle it? 4. Can I do anything about the situation? If not, what can I do to take 4. Can I do anything about the situation? If not, what can I do to take

my mind off the worries?my mind off the worries?

CBT for Obsessions and CompulsionsCBT for Obsessions and Compulsions• A more specialized and challenging areaA more specialized and challenging area• Very important to gain the child’s understanding and involvementVery important to gain the child’s understanding and involvement• Stopping obsessional fears or worries:Stopping obsessional fears or worries:

-Techniques to challenge worries-Techniques to challenge worries-Thought stopping techniques-Thought stopping techniques-Audio-tape obsession and have child debrief until desensitized-Audio-tape obsession and have child debrief until desensitized-Positive distraction techniques-Positive distraction techniques

• Stopping rituals:Stopping rituals:-label the ritual and team up against it-label the ritual and team up against it-stop the ritual (“response prevention”)-stop the ritual (“response prevention”)-tackle as to the upsetting thoughts beneath-tackle as to the upsetting thoughts beneath

Possible Role For MedicationPossible Role For MedicationUnderstandable reluctance about use of medicationsUnderstandable reluctance about use of medicationsHowever, it can assist the anxious child in several ways:However, it can assist the anxious child in several ways:1.1. Making it easier for the child to face what is fearedMaking it easier for the child to face what is feared2.2. Blocking the most distressing physical symptoms of anxietyBlocking the most distressing physical symptoms of anxiety3.3. Reducing interference of anxiety in day-to-day activitiesReducing interference of anxiety in day-to-day activities4.4. Reducing the consequences of prolonged, untreated anxiety Reducing the consequences of prolonged, untreated anxiety 5.5. Treating those types of anxiety that respond particularly well to Treating those types of anxiety that respond particularly well to

medicationmedicationTherefore definitely an option. (from Manassis, 1996)Therefore definitely an option. (from Manassis, 1996)Also, helpful to seek child’s input as age-appropriateAlso, helpful to seek child’s input as age-appropriate

Limits to medication:Limits to medication:• No medication is effective 100 percent of the timeNo medication is effective 100 percent of the time• No medication can be guaranteed not to cause side effects in No medication can be guaranteed not to cause side effects in

your childyour child• Medication cannot give an unmotivated child the motivation to Medication cannot give an unmotivated child the motivation to

face what is feared; nor can it alter the child’s basic personality face what is feared; nor can it alter the child’s basic personality • Medication cannot ensure that over-protective parent(s) will make Medication cannot ensure that over-protective parent(s) will make

necessary shifts towards empowering their childnecessary shifts towards empowering their child• No medication can guarantee your child a future free from No medication can guarantee your child a future free from

anxiety-related problemsanxiety-related problems• Indeed, a risk that some kids and parents may not recognize the Indeed, a risk that some kids and parents may not recognize the

work they need to do, expecting a “medication miracle”work they need to do, expecting a “medication miracle”

Guidelines with MedicationsGuidelines with Medications• Need to recognize that it is always a “trial” of medication; careful Need to recognize that it is always a “trial” of medication; careful

graduated trials can take weeksgraduated trials can take weeks• Empower parents in stepping up process (e.g.Prozac liquid or Empower parents in stepping up process (e.g.Prozac liquid or

small, incremental doses)small, incremental doses)• Child/ youth deserves age-appropriate explanation about Child/ youth deserves age-appropriate explanation about

medication and needs to help evaluate trialmedication and needs to help evaluate trial• Episodic efforts to discontinue meds (especially when better Episodic efforts to discontinue meds (especially when better

coping skills are in place)coping skills are in place)• When stopping meds, need to taper med gradually and wait out When stopping meds, need to taper med gradually and wait out

any “discontinuation symptoms”any “discontinuation symptoms”• Medications can work to support other interventionsMedications can work to support other interventions

Guidelines with MedsGuidelines with Meds

• Judgment call about medications includes child’s level of distress Judgment call about medications includes child’s level of distress and how disruptive their symptoms are ( e.g. amount of “time and how disruptive their symptoms are ( e.g. amount of “time wasted” or opportunities being missed)wasted” or opportunities being missed)

• Sometimes kids are more open to medication assistance than Sometimes kids are more open to medication assistance than their parentstheir parents

• Commonly these kids have difficult evenings and some delayed Commonly these kids have difficult evenings and some delayed sleep latency (because they lie in bed worrying)sleep latency (because they lie in bed worrying)

• SSRI’s (e.g. Prozac, Zoloft, Luvox, Paxil, Celexa and Cipralex) SSRI’s (e.g. Prozac, Zoloft, Luvox, Paxil, Celexa and Cipralex) most studied, best tolerated and most effectivemost studied, best tolerated and most effective

• SSRI’s are chemically “close cousins” and likely similar efficacy, SSRI’s are chemically “close cousins” and likely similar efficacy, although they have slightly differing side-effect profilesalthough they have slightly differing side-effect profiles

MedsMeds• Definitely should use a serotonergic drug if significant Definitely should use a serotonergic drug if significant

OCD or PTSD symptomsOCD or PTSD symptoms• Anafranil (clomipramine) another option in OCD; It’s Anafranil (clomipramine) another option in OCD; It’s

sedative side-effect can be helpful with insomnia but can sedative side-effect can be helpful with insomnia but can sometimes is problematic during the daysometimes is problematic during the day

• Medication combinations and aggressive dosing are Medication combinations and aggressive dosing are sometimes warranted in severe OCDsometimes warranted in severe OCD

• Occasionally a consideration to look at the older, tricyclic Occasionally a consideration to look at the older, tricyclic anti-depressants (e.g. Nortriptyline, Imipramine, anti-depressants (e.g. Nortriptyline, Imipramine, Amitriptyline) in certain circumstances and with special Amitriptyline) in certain circumstances and with special precautionsprecautions

MedsMeds

• Limited use of benzodiazepines for anxiety nowadays due to Limited use of benzodiazepines for anxiety nowadays due to sedating properties and dependency risk; may sometimes be sedating properties and dependency risk; may sometimes be used briefly to initiate change or while awaiting SSRI impactused briefly to initiate change or while awaiting SSRI impact

• A consideration for panic attacks is Ativan (lorazepam), which A consideration for panic attacks is Ativan (lorazepam), which has a sub-lingual form and may offer a sense of security has a sub-lingual form and may offer a sense of security

• Occasional role for other meds which target anxiety (e.g. Occasional role for other meds which target anxiety (e.g. Clonazepam, Buspar, Neurontin).Clonazepam, Buspar, Neurontin).

• With anxiety-based school refusal, often advisable to have With anxiety-based school refusal, often advisable to have medication help as part of a plan to return to school ASAPmedication help as part of a plan to return to school ASAP

• Benadryl, Melatonin or “over the counter” preparations are Benadryl, Melatonin or “over the counter” preparations are sometimes helpful for initial insomniasometimes helpful for initial insomnia

Implications Regarding Stimulant Treatment Implications Regarding Stimulant Treatment of Anxiety-prone ADHD Children of Anxiety-prone ADHD Children • Always screen as well for anxiety symptoms and disordersAlways screen as well for anxiety symptoms and disorders• Family history of anxiety should raise suspicion re childFamily history of anxiety should raise suspicion re child• Proceed more carefully and slowly with anxious children or parents, Proceed more carefully and slowly with anxious children or parents,

e.g. offer medication “options”, allow them time to research and e.g. offer medication “options”, allow them time to research and contemplate choices, putting parent “in charge” of titrating up contemplate choices, putting parent “in charge” of titrating up

• However, don’t be hesitant to actively treat their ADHD! Their co-However, don’t be hesitant to actively treat their ADHD! Their co-morbidity adds to the importance of proper management!morbidity adds to the importance of proper management!

Managing ADHD with Co-morbid AnxietyManaging ADHD with Co-morbid Anxiety

• Consider active pharmacological treatment of anxiety symptoms either Consider active pharmacological treatment of anxiety symptoms either before or in addition to stimulants before or in addition to stimulants

• Indeed, if marked anxiety symptoms or sleep disorder at outset, Indeed, if marked anxiety symptoms or sleep disorder at outset, consider treating these symptoms first (Pliszka, et al., 2006)consider treating these symptoms first (Pliszka, et al., 2006)

• Although SSRI’s have advantages, TCA’s may still have a role Although SSRI’s have advantages, TCA’s may still have a role especially with co-existent nocturnal enuresis +/- sleep disorderespecially with co-existent nocturnal enuresis +/- sleep disorder

• Marked symptoms of ADHD and Anxiety raises consideration of Marked symptoms of ADHD and Anxiety raises consideration of Atomoxetine (Strattera) but stimulants might also need to be added Atomoxetine (Strattera) but stimulants might also need to be added for optimal symptom control (Pliszka et al., 2006), for optimal symptom control (Pliszka et al., 2006),

Possible Mechanisms of Stimulant Impacts Possible Mechanisms of Stimulant Impacts upon Anxietyupon Anxiety

• Stimulant medications are said to have a 50% likelihood of producing or Stimulant medications are said to have a 50% likelihood of producing or increasing anxiety symptoms in vulnerable kidsincreasing anxiety symptoms in vulnerable kids

PERCEIVED INCREASE IN ANXIETY:PERCEIVED INCREASE IN ANXIETY:• Stimulants increase anxiety by a direct, physiological “side effect” mechanism (?Stimulants increase anxiety by a direct, physiological “side effect” mechanism (?

dose-related)dose-related)• Child focuses attention more upon fears/ worries/ etc. (so more “symptomatic”)Child focuses attention more upon fears/ worries/ etc. (so more “symptomatic”)• Child is more focused and verbal, therefore better able to describe symptoms which Child is more focused and verbal, therefore better able to describe symptoms which

have been occurringhave been occurring• Greater focus upon child or child//parental anxiety about stimulants contributes to Greater focus upon child or child//parental anxiety about stimulants contributes to

perception of increased anxietyperception of increased anxietyDECREASE IN ANXIETY: DECREASE IN ANXIETY: Often individuals improved function in areas of impairment caused by ADHD Often individuals improved function in areas of impairment caused by ADHD

Implications Regarding Stimulant Treatment Implications Regarding Stimulant Treatment of Anxiety-prone ADHD Childrenof Anxiety-prone ADHD Children

• In using stimulants, preferable to “start low and go slow”.In using stimulants, preferable to “start low and go slow”.• Always advise that some early side effects may settle within daysAlways advise that some early side effects may settle within days• Monitor more closely than usualMonitor more closely than usual• If can’t swallow pills or sensitive to taste of pills, consider Adderall XR If can’t swallow pills or sensitive to taste of pills, consider Adderall XR

or Biphentin as capsule can be opened and “sprinkled”or Biphentin as capsule can be opened and “sprinkled”• With anxious children or parents, I am more open to negotiating a With anxious children or parents, I am more open to negotiating a

“school day’s mainly” course of stimulants (while informing them that “school day’s mainly” course of stimulants (while informing them that there is evidence of better results on a continuous program)there is evidence of better results on a continuous program)

Conclusions:Conclusions:• Lots of children and adolescents quietly suffering with anxietyLots of children and adolescents quietly suffering with anxiety• Anxious kids at increased risk for other difficulties Anxious kids at increased risk for other difficulties

(Watch especially for depression !)(Watch especially for depression !)• Often accompanied/ present with somatic complaintsOften accompanied/ present with somatic complaints• Oppositional stance, school refusal and other behavioral Oppositional stance, school refusal and other behavioral

components may emerge and need to be addressed; may be a components may emerge and need to be addressed; may be a need to separate and tackle the behavioral issues specificallyneed to separate and tackle the behavioral issues specifically

• Important to recognize, assess and manage activelyImportant to recognize, assess and manage actively• Parents can assist with their coping but you cannot eradicate or Parents can assist with their coping but you cannot eradicate or

protect your child from their anxiety strugglesprotect your child from their anxiety struggles