Introduction

Anxiety Disorders and Attention Deficit Hyperactivity Disorders (ADHD) may seem like odd companions. Consider that the hallmark of a typical youngster with ADHD is acting without thinking. In contrast we might say that a youngster with an Anxiety Disorder "thinks too much." It would seem then that having one of these disorders would "protect" you from having the other one.

Unfortunately this is not true. In fact, recent studies suggest that up to 25% of children with ADHD have an anxiety disorder and 25% of children with an anxiety disorder have ADHD. In order to understand the co-existence of these disorders, it is important to recognize and differentiate the different symptoms.

Attention Deficit Hyperactivity Disorders

Children with ADHD are inattentive, impulsive and hyperactive. Although all individuals are at some time restless and inattentive, these qualities are more persistent in children who have ADHD. ADHD is thought to be due to developmental and genetic factors that affect biochemical and metabolic function. Medication is the primary effective treatment, and behavioral management strategies are useful for those who may have behavioral problems. There are three major types of ADHD:

  1. The impulsive and hyperactive type- this is the least common type and is characterized by restlessness and fidgetiness. The impulsive and hyperactive kids are always moving, can't wait their turn, have trouble remaining seated and blurt out answers in class. They act quickly before thinking about the consequences of their actions.
  2. The predominantly inattentive, distractible and disorganized type- these kids lose things, forget their homework, daydream. They may be impulsive but they're not as active as the other types. The symptoms may be mild, moderate or severe. Some kids may be just a little fidgety; others may be in constant motion.
  3. The impulsive, inattentive and hyperactive type - the combination of all the symptoms is the most common type.

In order to meet the criteria for a diagnosis of ADHD, the symptoms and behaviors must:

* impair the child's functioning
* affect the child in more than one setting
* have lasted for a considerable length of time
* affect academic or social functioning.

The Anxiety Disorders

Anxiety is a normal emotion experienced by everyone, but a child or adolescent with an anxiety disorder experiences the symptoms more often, more readily and more intensely than other youngsters. In addition, the symptoms must cause significant distress or interfere with their functioning in at least one aspect of their lives, to warrant a diagnosis of an anxiety disorder. It is important to be aware that excessive anxiety can result in impaired concentration and restlessness, some of the same symptoms that are seen in children with ADHD. In addition, these disorders can cause a child to be excessively tired, on-edge, irritable, tense and to have problems sleeping. As a group, anxiety disorders in children are more common than any other psychiatric disorder. In the general population between 5-15% of children have an anxiety disorder.

What follows is a brief review of each of the types of anxiety disorders.

Separation Anxiety Disorder (SAD) Most infants go through a normal phase of separation anxiety that usually peaks at 18 months of age and rapidly diminishes after that. Separation anxiety is not a normal feature of school age or teenage children. Youngsters with SAD have an extreme fear of being away from home or from the people who routinely care for them. These children can show distress when separating or even when separation is anticipated; they may worry that a parent may be lost, harmed or that they themselves may be lost or kidnapped. As a result of these fears they may refuse to go to school, sleep alone and they may cling to and "shadow " their parents around the home. They often have nightmares with themes of separation. Many times these children end up in the school nurse's office with complaints or headaches or stomachaches and a wish to call home.

Generalized Anxiety Disorder (GAD) Children with this disorder are classic worriers. An older term for this disorder is Overanxious Disorder. These kids tend to be anxious about any number of things in their lives. They may have excessive and unrealistic worries about future events, school, their health, safety at home, natural disasters such as storms, hurricanes or earthquakes, being on time for appointments and family issues. Unlike children with social anxiety, the anxiety persists even if they are not being judged or observed by others. They may worry about doing well in school, including homework and exams, even if they have always done well. They have a tendency to ask parents and teachers for reassurance about how they are performing.

Social Phobia These children are painfully shy and feel intense discomfort in social situations. They are especially fearful of situations where they need to perform and are under scrutiny. These anxiety-provoking situations can include talking in front of the class, starting or joining conversations, eating in public and making friends. They often are concerned that they will do or say something that will result in their feeling humiliated or embarrassed. Often their anxiety extends to their anticipating events where they may have to perform. Younger children may not recognize that their fear is excessive. The emotional aspects of anxiety may produce physical symptoms such as blushing, tremors, sweating, feeling faint, muscle tension and heart palpitations.

When the symptoms are intense, children with social phobia may begin to avoid school and all social activities. Selective Mutism is form of social phobia that can start in young children but remain through the school years. This disorder is characterized by an inability to speak in many social situations. Often these children will only speak at home to parents and siblings. At times their behavior may seem oppositional, but in fact the refusal to speak is driven by intense anxiety.

Obsessive-Compulsive Disorder (OCD) This disorder is characterized by intrusive and inappropriate recurrent thoughts, images or impulses and/or repetitive behaviors. The thoughts are called obsessions; the behaviors are called compulsions. Typical compulsions include excessive hand washing; cleaning rituals; checking behaviors such as making sure that windows or doors are locked, faucets are shut etc.; hoarding (the inability to throw anything away) and arranging or ordering things such as books or clothes. Typical obsessions include impulses to harm or kill a family member; incessant worries about dirt, germs, contamination, religion; recurrent thoughts that something has not been done properly; feelings that certain things must always be in a certain place; thoughts of nonsense words, sounds, pictures or numbers.

Posttraumatic Stress Disorder (PTSD) In the face of the World Trade Center and Pentagon attacks and tragedy, this disorder takes on renewed significance. PTSD can develop after a youngster is exposed to an extreme trauma, such as the attacks, disasters, or abuse. The diagnosis requires that the child be directly exposed to an extreme traumatic situation involving an actual or threatened death or serious injury, or witnessing such an event, or hearing about such an event in regard to a family member. These youngsters will often relive the trauma by having recurrent intrusive thoughts, images, dreams and flashbacks. At times, they will avoid activities, thoughts, places or people that are associated with the trauma. Symptom of increased arousal such as difficulty concentrating, hyper vigilance and an exaggerated startle response will often accompany the other symptoms. Since many of these symptoms are not unusual immediately after a trauma, in order for this diagnosis to be made, the child must experience these symptom for at least one month.

Treatment of Anxiety Disorders

For SAD, GAD, Social Phobia and OCD, two treatments have been utilized: a form of therapy called Cognitive-Behavioral Therapy (CBT) and medication, particularly the Specific Serotonin Reuptake Inhibitors (SSRIs). A number of studies have shown these medications are helpful in treating OCD. A large multi-site study sponsored by the NIMH showed that fluvoxamine (Luvox) was efficacious in treating SAD, GAD and Social Phobia.

For children suffering from PTSD, specific treatments have been developed that include cognitive and behavioral techniques along with making changes in the environment to insure ongoing safety.

Differences in treatment for children with ADHD alone and those with ADHD combined with an Anxiety Disorder Children with both disorders are often referred for treatment at a later age than those without anxiety. Some speculate that this may be due to the fact that for some children the anxiety symptoms may inhibit the hyperactive-impulsive behaviors that are so often the trigger for a referral for evaluation.

Anxious ADHD children may be at lower risk for developing a conduct disorder. Children with ADHD + Anxiety may exhibit more social difficulties but no difference in school performance.

Treatment of the combined disorders

The presence of an anxiety disorder may influence how children respond to medication treatment. Some studies have found that children with the combined disorders do not respond well to stimulant treatment. In some youngsters there appeared to be an increase in side effects including tics and sadness. In addition there have been clinical suggestions that in some children stimulant treatment may worsen symptoms of anxiety. One study, however, found no difference in treatment response between children with anxiety and those without.1 In contrast, The NIMH Multimodal Treatment of Children with ADHD looked at a subgroup of children who had anxiety symptoms at the beginning of the study and found that methylphenidate (Ritalin) did not exacerbate anxiety symptoms with some children showing a reduction in anxiety symptoms following treatment.2 Some clinical studies that have looked at children with both conditions have found that the addition of an SSRI to stimulant treatment has been helpful.

In order to better evaluate the best treatment for youngsters with ADHD + Anxiety Disorder the NIMH has sponsored a multi-site trial. The study will examine the benefits of the stimulant medication methylphenidate (Ritalin) both alone and in combination with fluvoxamine (Luvox), a selective serotonin reuptake inhibitor (SSRI) for treating these co-occurring disorders in youngsters ages 6 to 17.

References and Related Books

1. Diamond IR, Tannock R, Schachar RJ. Response to methylphenidate in children with ADHD and comorbid anxiety. J Am Acad Child Adolesc Psychiatry 38: 402-409, 1999

2. MTA Cooperative Group. Moderators and mediators of treatment response for children with attention-deficit hyperactivity disorder. Arch Gen Psych 56:1088-96, 1999