Download Keeping Cool About Your Anxious Child

Keeping Cool
About Your Anxious Child
Presented by: Dr.Kevin Nugent
Child a & Adolescent Psychiatrist
Our Goals:
• Understand why certain children are more vulnerable to
anxiety struggles
• Recognize the main types of anxiety symptoms/disorders
and how they may look in children and adolescents
• Tease out the relationship between anxiety and ADHD as
well as L.D.’s
• Review preferable strategies and how you can best
support your child in managing their own anxiety
Why are some children more
prone to anxiety?
• Many children go through stages where they experience mild or
transient anxiety problems
• Indeed, stranger anxiety in infants, separation anxiety in toddlers,
fear of the dark and “monsters” in pre-schoolers and some worry
about death in school-age children is arguably “normal”
• However, some children are temperamentally more shy and timid,
cautious, “slow-to-warm –up” and/or adapt poorly to change
• About 10% of children are exceptionally sensitive (Manassis)
The Highly Sensitive Child
• Emotionally sensitive children are more troubled by and reactive
to life’s events; perhaps they “feel more deeply”
• These children may try to cope with life’s stresses by trying to
“keep things the same”, so they appear resistant to change
• Such children more likely to have sensory hypersensitivity, i.e.
they are more bothered by stimuli like loud sounds, the feel of
clothing or new foods
• Such children often more attuned to/ worried about physical
sensations or symptoms, perhaps with a lower pain threshold
• All in all, they tend be more “stress sensitive”.
The Creation of an Anxious Child
• The mixture of certain temperamental traits, high
sensitivity and/ or genetic predisposition make some
children more vulnerable to anxiety
• There is a balancing act between a child’s innate
vulnerability as well as the stressors they face and that
child’s coping skills and supports
• When the innate vulnerability and/or the stressors are
greater, the child is likely to develop anxiety symptoms
• In turn, children who avoid what they fear can become
quite disabled by them
Pediatric Anxiety Disorders
• Occur frequently, likely affecting up to 10% of
children or teens
• These “internalizing disorders” can be overlooked or minimized by others
• Strong genetic component, with heritability,
accounting for 50% of variance
• Enduring, often fluctuating, course
• Significant impact can be seen over time
Typical Early Course
• Early on there are often diffuse, evolving and less
classical symptoms
• These might include excessive separation
difficulties, poor adaptation to change, exaggerated
fears, multiple worries and stress-induced physical
symptoms
• These children are often more vulnerable to peer
harassment and more troubled by it when it occurs
• Over time, they may develop symptoms of more
classical anxiety disorder(s)
Associated Conditions
• Anxious children at elevated risk for other difficulties, including:
-School refusal/ “phobia”
-Peer harassment/ isolation
-Depression
-Oppositional Defiant Disorder (mainly at home)
-School or career underachievement
-Post-traumatic stress disorder
-Substance use problems
• Rather a complex interaction between anxiety and ADHD or other
learning problems
Separation Anxiety Disorder
• Excessive and ongoing distress/ worry about
separating (from major attachment figures)
• +/- behaviors to avoid it and autonomic arousal
upon separation/ somatic complaints
• As many as 4% of children, peaking at 7- 9 year
• Child’s developmental delays could be a factor
• Parental response key to management
• Can be a predictor of future internalizing disorder
Selective Mutism
• Persistent failure to speak in specific social
situations, mainly outside of family
• Uncommon; formerly called “elective mutism”
• Usually shy, clingy, reticent children
• Sometimes a “talking buddy” or sib
• May be some accompanying oppositionality
• Perhaps a childhood antecedent of Social
Anxiety Disorder
Specific Phobias
Minor phobias occur commonly in development
with little impact
To merit a diagnosis and intervention must be
present >6 mos. & significant impairment in
social, educational or occupational function
Can be a marker for other anxiety problems, at
present or later in life
Specific Phobia’s
Sub-types include: Animal
Natural environment
Blood/ injection/ injury
Situational (e.g. planes, elevators)
Other (e.g. sounds, vomiting)
Some can be quite life disruptive/ upsetting
More serious phobic presentations include dramatic
fears of storms, dogs and stinging insects
Generalized Anxiety Disorder (DSM-IV)
• Excessive anxiety and worry for 6 months or more
AND
• 3 or more of the following 6 symptoms:
– restlessness or feeling keyed up or on edge
– being easily fatigued
– difficulty concentrating or mind going blank
– irritability
– muscle tension
– sleep disturbance (difficulty falling asleep or
staying asleep, or restless, unsatisfying sleep)
Pediatric Presentation of G.A.D.
• For a time called “Overanxious Disorder of Childhood”
• Tense, reticent, high stress, worrying children
• Worry that “something bad” will happen, especially to
loved ones (particularly parents) or themselves
• “Overreact” to minor traumas, peer harassment and life
changes
• Sleep disturbance (especially initial insomnia) and
somatic complaints common
Panic Attack (DSM-IV)
Diagnostic criteria: recurrent panic attacks
4 or more of the following
• Dyspnea or the sensation of being smothered
• Depersonalization or derealization
• Fear of going crazy or of losing self-control
• Fear of dying
•
•
•
•
•
•
•
•
•
Palpitations or tachycardia
Sweating
Trembling or shaking
Feeling of choking
Chest pain or discomfort
Nausea or abdominal upset
Dizziness, feeling of unsteadiness/ faintness
Numbness or tingling sensation
Flushes or chills
Cognitive
symptoms
Physical
symptoms
Diagnosis (cont’d)
Anticipatory anxiety: one or more of the following
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-morbidity
• Lifetime prevalence of about 1%
• Association with phobias especially claustrophobia,
illness phobia and agoraphobia
• Highly comorbid with other anxiety disorders
- social anxiety disorder
- generalized anxiety disorder
- obsessive-compulsive disorder
Panic Disorder Co-morbidity:
Major Depression
• 65–90% of patients develop major depression or
serious demoralization
• Coexisting depression significantly increases:
– morbidity
– mental healthcare utilization
– suicide risk (increased further with comorbid
substance abuse or personality disorder)
Pediatric Panic Attacks
• Peak adult onset but does occur in teens and
occasionally in children
• Even in adults, often years to diagnosis
• Young people a difficult time describing experience
• Unlikely to elicit full classic symptom picture
• Can be a hidden cause of class or school refusal
• Remember: marked risk for depression over time
Biological Explanation for Panic Attacks
• Adrenaline release is on a “hair trigger”, getting released for minor or
non-existent “threats”
• Adrenaline is body hormone responsible for “fight or flight reaction”
• Therefore adrenaline release speeds up heart rate, respiration and
blood flow to the peripheral muscles
• Diverts blood away from the internal organs
• Limited supply of adrenaline means that the peak effects are timelimited, typically 10 or 20 minutes maximum
• Worsened when “the head tries to explain” the bodily reaction
• Often blame where they occur, so wish to avoid those places
Social Anxiety Disorder (Social Phobia)
• Marked or persistent fear of social or performance
situations
• Individuals fear scrutiny, negative evaluation, humiliation
or embarrassment
• Exposure to (or anticipation of) social/performance
situation provokes anxiety
• Leads to avoidance of social/ performance situations
• Significant distress or impairment in social and
occupational functioning
DSM-IV-modified
Social Anxiety Disorder Subtypes
Generalized (80%)
• “Most” social situations
(DSM-IV)
– performance
– interactional
• Overlaps with avoidant
personality disorder
– 80–90%
Nongeneralized (20%)
(discrete, specific)
• 1 or 2 social situations
• Usually performance
– writing in front of others
– eating in front of others
– telephone
– public speaking
Interactional Situations
• Going to a party/ socializing
• Lunch with peers/ making “small talk”
• Dating
• Asking a teacher for help
• Speaking to a boss at work
• Asking a salesclerk for help
• Asking for directions
Performance Situations
•
Public speaking
• Entering a room
– formal; large groups
• Using a public toilet
– informal; small groups
• Playing an instrument
• Writing in front of others
• Eating in front of others
• Playing sports
Social Anxiety Disorder:
The Most Prevalent Anxiety Disorder
• Lifetime prevalence: 13%
• Point prevalence in primary care: 5–7%
• Mean age at onset: 14–16 years
• Only “Major depressive episode” greater lifetime
prevalence, arguably with more limited lifetime
impact
Ballenger JC, et al. J Clin Psychiatry 1998
Spectrum of Depression and Anxiety
Disorders: Lifetime Prevalence
17%
13%
7.8%
5.1%
3.5%
2.3%
Spectrum of Depression
and Anxiety Disorders
Posttraumatic
stress disorder
Social
anxiety disorder
Depression
Panic disorder
Obsessive-compulsive disorder
Generalized anxiety disorder
Major Depression and Anxiety
Disorders: Symptom Overlap
Irritability
Worrying, guilt
Agitation/restlessness
Major
Nervousness, tension
depressive
Impaired concentration
disorder
Anhedonia
Insomnia
Fatigue
Anxiety
disorders
Pediatric Soc.A.D. Presentations
Anxious, timid, quietly suffering youths
Marked accentuation of normal teen
hypersensitivities
Often a history of peer harassment/ victimization
Can be an explanation for school refusal
Markedly elevated risk for depression over time
O.C.D. Diagnosis (DSM-IV)
• Obsessions: recurrent, persistent ideas, thoughts,
impulses or images (experienced as unwanted or alien)
• Compulsive behaviors: excessively repetitive behaviors
classically performed in response to an obsession
• Can be quite time-consuming (up to hours/ day)
• Can be marked distress associated
• Interference with social and occupational functioning
Obsessive and Compulsive Symptoms
on Admission (n=560)
• Obsessions
– contamination (45%)
– pathological doubt (42%)
– somatic (36%)
– symmetry (31%)
– aggressive (28%)
– sexual (26%)
– multiple (60%)
• Compulsions
– checking (63%)
– washing (50%)
– counting (36%)
– need to ask/ confess (31%)
– symmetry/ precision (28%)
– hoarding (18%)
– multiple (48%)
Rasmussen SA, et al. Psychopharm Bull 1988
Professional Screening for OCD
• Intrusive or repetitive thoughts?
• Excessive washing or checking?
• Needless counting or repeating?
• Alternatively, one can explain what obsessions
and compulsive behaviors are and then enquire
Pediatric O.C.D.
• Often onsets in adolescence, sometimes earlier
• Typically a chronic waxing and waning course
• Exacerbations may be related to stress, but this is
not necessarily the case
• Can be highly disabling
• In severe cases, psychotic-like symptoms may
occur
P.T.S.D. Diagnosis (DSM-IV)
• Experience of a traumatic event with sensation of horror,
helplessness or fear
• Re-experience of the traumatic event
• Avoidance/numbing symptomatology
• Increased arousal symptoms
• Impaired functioning
• Symptoms >1 month duration
Re-experience of the Trauma
• The traumatic event is re-experienced in one or more of the
following ways:
– recurrent and intrusive distressing recollections of
the event
– recurrent distressing dreams of the event
– acting or feeling as if the trauma were re-occurring
– psychological distress and/or physiological reactivity
when exposed to cues that resemble an aspect of
the traumatic event
Avoidance/Numbing Symptomatology
• Patient will show avoidance of stimuli associated with the trauma
and a general numbing of responsiveness as indicated by three or
more of the following:
– avoid thoughts, feelings or conversation associated
with the trauma
– avoid activities that will arouse recollection of the
trauma (place or people)
– inability to recall an important aspect of the trauma
– markedly diminished interest in significant activities
– feelings of detachment
– restricted range of mood
– sense of foreshortened future
Increased Arousal Symptoms
• The patient will have symptoms of increased arousal as
indicated by two or more of the following:
– difficulty falling or staying asleep
– irritability or outbursts of anger
– difficulty concentrating
– hypervigilance
– exaggerated startle response
Pediatric P.T.S.D.
• Clearly occurs, often less classical
• Flashbacks, nightmares, sleep problems and
hypervigilance are most common features
• Also a desire to avoid triggering stimuli, but young people
may not have the “luxury” of such avoidance
• Tendency for children to behaviorally re-enact trauma
(e.g. in play or art work)
• Faulty cause and effect in kids can lead to self-blame
• Clinicians should have a low threshold to screen for
trauma/abuse
Somatizing Disorders
• Anxiety-prone children commonly present physical health
complaints in situations of stress, anxiety or worry
• Often related to anxiety about the school situation
• Pattern of symptoms often informative
• These children, and sometimes their parents, often
struggle to see the psychosomatic component
• Wide-ranging symptoms with abdominal pain,
nausea and headaches especially common
Somatizing Disorders (cont.)
• Never helpful to use “all in your head” language, as
individual feels their symptoms are being dismissed as
“not real”
• More helpful to consider if there is some aspect of
“abnormal illness behavior”
• Reasonable medical review appropriate, but sometimes
these children get over-evaluated medically
• Important to work closely with child or teen’s physician
School Refusal/ “Phobia”
• Many reasons why children are reluctant or refuse to
attend school
• Anxiety commonly, but not always, a major factor
• Difficulties with academic work, peers or staff may be
causes for their anxiety
• Anxiety disorders likely to contribute include separation
anxiety, social anxiety,panic disorder and somatization
disorder
• Inadequate recognition, support or accommodation for
ADHD or LD’s can sometimes be major contributor
• ,
School Refusal/ “Phobia”
• Such children may present physical health complaints as
the reason they feel they should not go to school
• Family dynamics sometimes serve to worsen the
problem (e.g. over-emphasis on physical symptoms)
• Requires a well-coordinated, broad management
approach, with the child getting consistent messages
from important adults about their need to attend school
• Sometimes medication assistance for their anxiety
symptoms is an essential part of the plan
• Critical to get “later” school refusers back to school ASAP
Overview of ADHD-Anxiety Relationship
• ADHD and anxiety symptoms do have a significant co-morbidity
as many as 25% of anxious kids meet criterion for ADD/ADHD
(Bernstein et al., 1996)
• Usually though rather separate genetic contributions
• Many ways in which ADHD and Anxiety seem opposite, e.g.:
- fearless vs. fearful
- impulsive vs. reticent
- reactive vs. obsessing
-“in the moment” vs. ruminating
-externalizing vs. internalizing
• Somewhat common exception is the triad of ADHD, Tourette’s
and Anxiety (especially OCD)
Co-occurring Disorders in ADHD Children
ADHD
alone
31%
Tics
11%
Conduct
Disorder
14%
Mood Disorders 4%
MTA Cooperative Group. Arch Gen Psych 1999; 56:1088–96
Oppositional
Defiant
Disorder
40%
Anxiety
Disorder
34%
(n=579)
Overview of ADHD-Anxiety Relationship
• In addition to more classic anxiety presentations, children with
ADHD may develop “secondary” anxiety related to areas of
under-function, such as in academic and social spheres; This
contributes mainly to school, performance and social anxieties
• Some likelihood that anxiety could be mistaken for ADD (rarely
ADHD) but this is rather easily distinguished with careful history;
i.e. they are “distracted” by severe worry or OCD symptoms
• In ADHD-Combined or H/I sub-types the over-activity, impulsivity and
other behavioral challenges are rather pervasive and more concerning
than is usual for anxious kids
• Indeed, anxious children are not commonly seen as behavioral
concerns outside the home environment
ADHD Symptoms Mistaken For Anxiety
• The following observations, common regarding pediatric ADD or
ADHD, are sometimes mistakenly seen as “anxious”
-The child “acts up” (i.e. gets over-stimulated) in busy, noisy or exciting
environments
-The child has difficulty making transitions or entering new
environments
-The child gets “anxious” (i.e. impatient) to leave situations (especially
when they are bored)
- The child is “anxious” (i.e. demanding and impatient) to have their
wishes met
-The child becomes frustrated and upset in the face of challenging
tasks or when they don’t get their way
Overview of Anxiety/ L.D. Relationship
• Children and teens with significant learning difficulties, including
various LD’s, may well develop anxiety related to specific subjects,
performance tasks (e.g. tests) or unwelcoming learning environment.
• Such children may feel singled out, embarrassed or intimidated by how
certain teachers run their classrooms.
• Some children experience special help or placements as stigmatizing.
• 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
more likely to produce PTSD symptoms in sensitive children
• These are prime conditions for social anxiety symptoms, but children/
teens may experience other patterns (e.g. excessive worry,
psychosomatic symptoms, school refusal) based on these problems
Anxiety and other MH Problems in L.D’s.
• Children and young people with LD have been found to be up to four
times more susceptible to mental health problems than their nondisabled peers (Wilson, 2004).
• For children with LD, research evidence available suggests high levels
of anxiety disorders in children vary from 8.7% (Dekker & Koot 2003)
to 21.98.7% (Emerson, 2003)
• Studies have shown that the prevalence of psychiatric disorder among
people with LD is higher than it is in the general population (BorthwickDuff, 1994; Allington-Smith, 2006).
• In children and adolescents, anxiety disorders may be associated with
lowered linguistic abilities and cognitive flexibility (Toren et al, 2000)
SLD’s and Social Difficulties
• Children with Non-verbal L.D.’s (as per Rourke, 1995 & 2000)
-often exhibit difficulty in processing new or complex social situations
-they also struggle with non-verbal aspects of communication (e.g.
interpreting facial expressions, body language and tone of voice)
-in novel and other situations, they rely on repetitious or rote
behaviors, because they excel in these skills.
-their interactions with other children are stereotypical and lacking in
reciprocity
• 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
aspect of communication.
Impact of the Social Difficulties in LD’s
• Such children often struggle to make and keep friends and to “fit in”
which may lead to social isolation
• These children are also more likely to be targets of peer harassment
and they also may be poorly skilled to deal with it effectively
• Their LD’s, especially if not recognized, contribute to academic
struggles which can be demoralizing and lower self-esteem
• Any or all of these factors increase the risk for anxiety and depression
in these children over time.
• Adults may not recognize the extent to which these difficulties impact a
child’s peer interactions
• Proper recognition and remediation of their LD’s are first steps!
What are the Basics Facts about Anxiety?
1. Anxiety is unrealistic fear or worry
2. Anxiety, especially when experienced as an ongoing stress, produces
troubling physiological and psychological symptoms
3. Parents and other involved adults often struggle about the extent to
which they should “protect their child” from their anxieties, recognizing
their genuine distress and struggles.
4. Anxiety produces additional problems when it interferes with a child’s
ability to engage in common age-appropriate activities
5. The only way to overcome fear is to face it.
Anxiety: General Management
• Information is the key !!
• Parents role is in supporting the child to gradually confront their
fears and worries towards getting fully mobilized
• ”Although this makes you nervous, we believe you can do this!”
• Parent needs to resist instinct to over-protect and may need to
see to their own stress level
• Maintain in school !!
• Everyone needs to expect some fluctuation in symptoms and
progress over time and not over-react
More General Management Guidelines
•
•
•
•
Some medical review may be warranted by Family Doc or Ped’n
A mental health assessment may be required
Child/youth deserves an explanation of their anxiety symptoms
Good management requires a team approach with key players
(e.g. physician, school personnel, extended family) “on board”
• Child does best when active in learning coping strategies
• Adults in child’s life need to demonstrate their belief that the child/
youth can attain better coping and functioning
• Encourage child/ youth to attain areas of success
Interventions:
•
•
•
•
•
•
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Educational and supportive counseling (child and parents)
Cognitive Behavioral Therapy
Systematic Desensitization (Specific Phobias)
Relaxation Training/ Visualization/ Yoga/ etc.
Exercise/Fitness and Empowering sports
Recreation and Treatment Group Experiences
Strategies and where necessary, adult support, to ongoing
“targets” of bullying
• Consider medication
Basic Cognitive Behavioral Therapy
• We cannot directly control our emotional or bodily feelings
• Instead we need to challenge our thinking and behavior, which we
have more ability to influence and control
• Essentially our thinking is our “self talk”
• The self-talk of anxious or depressive individuals contains
frequent “cognitive distortions”
• These need to be identified, challenged and amended
• Similarly our behavior can be redirected towards a more positive
and constructive direction
• Eventually these changes will likely improve how we feel
Cognitive distortions
•
•
•
•
•
Arbitrary influence
Selective abstraction
Overgeneralization
Minimization or Magnification
“Black and White”/
“All or Nothing” Thinking
• Personalization
• Emotional Reasoning
Additional “kid contributions”:
Control fallacies:
Fallacy of fairness
Fallacy of changing others
“Should” fallacies
Faulty “cause and effect”
Coping Strategies
• Provide your child with reassuring information about anxiety
(that it’s common, non-fatal and defeatable; role of adrenaline)
• Have child practice breathing, relaxation and visualization
techniques
• Distraction techniques can sometimes have value
• Learn and practice “coping self-talk”
• Encourage your child to face their anxieties more independently
• 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
not going to let ‘Scaredy Bear’ push us around any more!”
Desensitization Techniques
• Systematic desensitization is when one encourages a
child to gradually approach and face their fears
• May include a gradual approach, gradual withdrawal of
your support and/or rewards for their success
• Child needs to be supported in utilizing coping strategies
to outlast the anxiety symptoms
• Relaxation and deep breathing techniques helpful
• Can be done by family on a common sense way
Desensitization Techniques
• Give the child some say about when to take next step
• Use pictures/ visualization for infrequent stressors
• Frequent exposures, in small manageable steps
commencing as soon as possible after fear develops
• May occasionally be need for “booster sessions”
• Watch “What About Bob” (with Bill Murray) with your child
• “Flooding” is full, immediate exposure- milder fears only!
Dealing With Worry
• Children who worry excessively usually are caught in a cycle of
“cognitive distortion” which serves to generate and amplify fears
• Tendency towards pessimism and “negative what-iffing”
• Label and teach them to utilize these questions (Manassis):
• 1. How likely is it that what I’m afraid of will/has happened?
2. What other explanations are there for this situation?
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
my mind off the worries?
CBT for Obsessions and Compulsions
• A more specialized and challenging area
• Very important to gain the child’s understanding and involvement
• Stopping obsessional fears or worries:
-Techniques to challenge worries
-Thought stopping techniques
-Audio-tape obsession and have child debrief until desensitized
-Positive distraction techniques
• Stopping rituals:
-label the ritual and team up against it
-stop the ritual (“response prevention”)
-tackle as to the upsetting thoughts beneath
Possible Role For Medication
Understandable reluctance about use of medications
However, it can assist the anxious child in several ways:
1. Making it easier for the child to face what is feared
2. Blocking the most distressing physical symptoms of anxiety
3. Reducing interference of anxiety in day-to-day activities
4. Reducing the consequences of prolonged, untreated anxiety
5. Treating those types of anxiety that respond particularly well to
medication
Therefore definitely an option. (from Manassis, 1996)
Also, helpful to seek child’s input as age-appropriate
Limits to medication:
• No medication is effective 100 percent of the time
• No medication can be guaranteed not to cause side effects in
your child
• Medication cannot give an unmotivated child the motivation to
face what is feared; nor can it alter the child’s basic personality
• Medication cannot ensure that over-protective parent(s) will make
necessary shifts towards empowering their child
• No medication can guarantee your child a future free from
anxiety-related problems
• Indeed, a risk that some kids and parents may not recognize the
work they need to do, expecting a “medication miracle”
Guidelines with Medications
• Need to recognize that it is always a “trial” of medication; careful
graduated trials can take weeks
• Empower parents in stepping up process (e.g.Prozac liquid or
small, incremental doses)
• Child/ youth deserves age-appropriate explanation about
medication and needs to help evaluate trial
• Episodic efforts to discontinue meds (especially when better
coping skills are in place)
• When stopping meds, need to taper med gradually and wait out
any “discontinuation symptoms”
• Medications can work to support other interventions
Guidelines with Meds
• Judgment call about medications includes child’s level of distress
and how disruptive their symptoms are ( e.g. amount of “time
wasted” or opportunities being missed)
• Sometimes kids are more open to medication assistance than
their parents
• Commonly these kids have difficult evenings and some delayed
sleep latency (because they lie in bed worrying)
• SSRI’s (e.g. Prozac, Zoloft, Luvox, Paxil, Celexa and Cipralex)
most studied, best tolerated and most effective
• SSRI’s are chemically “close cousins” and likely similar efficacy,
although they have slightly differing side-effect profiles
Meds
• Definitely should use a serotonergic drug if significant
OCD or PTSD symptoms
• Anafranil (clomipramine) another option in OCD; It’s
sedative side-effect can be helpful with insomnia but can
sometimes is problematic during the day
• Medication combinations and aggressive dosing are
sometimes warranted in severe OCD
• Occasionally a consideration to look at the older, tricyclic
anti-depressants (e.g. Nortriptyline, Imipramine,
Amitriptyline) in certain circumstances and with special
precautions
Meds
• Limited use of benzodiazepines for anxiety nowadays due to
sedating properties and dependency risk; may sometimes be
used briefly to initiate change or while awaiting SSRI impact
• A consideration for panic attacks is Ativan (lorazepam), which
has a sub-lingual form and may offer a sense of security
• Occasional role for other meds which target anxiety (e.g.
Clonazepam, Buspar, Neurontin).
• With anxiety-based school refusal, often advisable to have
medication help as part of a plan to return to school ASAP
• Benadryl, Melatonin or “over the counter” preparations are
sometimes helpful for initial insomnia
Implications Regarding Stimulant Treatment
of Anxiety-prone ADHD Children
• Always screen as well for anxiety symptoms and disorders
• Family history of anxiety should raise suspicion re child
• Proceed more carefully and slowly with anxious children or parents,
e.g. offer medication “options”, allow them time to research and
contemplate choices, putting parent “in charge” of titrating up
• However, don’t be hesitant to actively treat their ADHD! Their comorbidity adds to the importance of proper management!
Managing ADHD with Co-morbid Anxiety
• Consider active pharmacological treatment of anxiety symptoms either
before or in addition to stimulants
• Indeed, if marked anxiety symptoms or sleep disorder at outset,
consider treating these symptoms first (Pliszka, et al., 2006)
• Although SSRI’s have advantages, TCA’s may still have a role
especially with co-existent nocturnal enuresis +/- sleep disorder
• Marked symptoms of ADHD and Anxiety raises consideration of
Atomoxetine (Strattera) but stimulants might also need to be added
for optimal symptom control (Pliszka et al., 2006),
Possible Mechanisms of Stimulant Impacts
upon Anxiety
• Stimulant medications are said to have a 50% likelihood of producing or
increasing anxiety symptoms in vulnerable kids
PERCEIVED INCREASE IN ANXIETY:
• Stimulants increase anxiety by a direct, physiological “side effect” mechanism
(?dose-related)
• Child focuses attention more upon fears/ worries/ etc. (so more “symptomatic”)
• Child is more focused and verbal, therefore better able to describe symptoms
which have been occurring
• Greater focus upon child or child//parental anxiety about stimulants contributes to
perception of increased anxiety
DECREASE IN ANXIETY:
Often individuals improved function in areas of impairment caused by ADHD
Implications Regarding Stimulant Treatment
of Anxiety-prone ADHD Children
•
•
•
•
In using stimulants, preferable to “start low and go slow”.
Always advise that some early side effects may settle within days
Monitor more closely than usual
If can’t swallow pills or sensitive to taste of pills, consider Adderall XR
or Biphentin as capsule can be opened and “sprinkled”
• With anxious children or parents, I am more open to negotiating a
“school day’s mainly” course of stimulants (while informing them that
there is evidence of better results on a continuous program)
Conclusions:
• Lots of children and adolescents quietly suffering with anxiety
• Anxious kids at increased risk for other difficulties
(Watch especially for depression !)
• Often accompanied/ present with somatic complaints
• Oppositional stance, school refusal and other behavioral
components may emerge and need to be addressed; may be a
need to separate and tackle the behavioral issues specifically
• Important to recognize, assess and manage actively
• Parents can assist with their coping but you cannot eradicate or
protect your child from their anxiety struggles