Anxiety and ADHD: Too Many Hands on the Wheel

1. Anxiety and ADHD:Too Many Hands on the Wheel Chris McCurry, Ph.D. ABCD, Inc. Seattle, WA

2. In the next hour we will discuss The origins of child anxiety and ADHD within the contexts of normal development and parent-child transactions A new way of thinking about your child’s anxiety; one based on intention and attention Strategies for responding to your child’s anxiety by addressing attention

3. Anxiety Prevalence • Percentages of normal school children 4 to 12 years of age reporting: • fears 75.8 • worries 67.4 • scary dreams 80.5 • One year prevalence of anxiety disorders: between 6 and 20%. Equal to between 3 and 8 million children in the U.S.

4. Anxiety Facts • About half of all children with an anxiety disorder meet criteria for a second anxiety disorder • Girls are somewhat more likely to have anxiety disorders than are boys • Anxiety is more common than ADHD

5. Anxiety Facts The #1 cause of anxiety in children is scary information

6. Assessing Stress, Anxiety, and Fear Anxiety is a problem when… • The child is unable to meet age-appropriate and required challenges • The child’s response to these challenges is disproportionate to the situation or his age

7. Developmental Factors • The child does not have to recognize that his fear or worry is unreasonable • Somatic complaints (stomach ache, headache) are common • Crying, irritability, anger and defiance are common • A return of bedwetting, thumb sucking, or clinginess can be a sign of anxiety and stress

8. Between five percent and 15 percent of children in the general population are diagnosed with an anxiety disorder • Recent studies shown that one fourth of children with ADHD exhibit some symptoms of an anxiety disorder • These results would imply a high incident rate of anxiety disorders in children with ADHD compared to the general population 

9. ADHD Diagnosis by State

10. ADHD Diagnostic Facts • Approximately 9.5% or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD, as of 2007 • The percentage of children with a parent-reported ADHD diagnosis increased by 22% between 2003 and 2007 • Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 and an average of 5.5% per year from 2003 to 2007 • Boys (13.2%) were more likely than girls (5.6%) to have ever been diagnosed with ADHD • Rates of ADHD diagnosis increased at a greater rate among older teens as compared to younger children • Prevalence of parent-reported ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 15.6% in North Carolina

11. Combined Anxiety and ADHD • Children with both disorders are often referred for treatment at a later age than ADHD without anxiety • Children with both anxiety and ADHD tend to be less impulsive than children with ADHD alone • Anxious + ADHD children may be at lower risk for developing a conduct disorder • Children with Anxious + ADHD may exhibit more social difficulties • They may show no difference in overall school performance but have more information processing and working memory issues deficits

12. Response to Medications • Studies are all over the map: anxious + ADHD children had a less robust stimulant response (30% vs. 80%) or showed no difference (more recent studies) • In some children there appeared to be an increase in side effects including tics and sadness (earlier studies) • For some children stimulant treatment worsened symptoms of anxiety (earlier studies) • Some recent small-scale studies suggest a combination of stimulant and SSRI can be helpful

13. Sorting out Anxiety and ADHD • Inattention is a hallmark of ADHD. An anxious child may also be inattentive, but this is usually because the child is preoccupied by excessive worry, tension, and nervousness. When the anxious child is calm, there are few signs of poor focus, impulsivity, and distractibility • Children with ADHD and anxious children both can have trouble sleeping at night. Anxious children, however, have much more difficulty with fatigue during the day.

14. Sorting out Anxiety and ADHD • Anxious children often have physical complaints, such as headaches or stomach aches • Children with ADHD, when they are not medicated, typically do not have these complaints • However, some of the side-effects of drugs such as Ritalin are headaches and stomach problems • Children with ADHD may experience transient context-specific physical complaints; e.g., stomach ache the morning of test at school

15. Bottom Line • Assess for learning issues which may contribute to academic struggle and avoidance • Identify specific thoughts (e.g., worries) that suggest anxiety • Employ cognitive-behavioral techniques and environmental supports • Proceed cautiously if using medications

16. The Limbic System of the Brain • It makes sense that ADHD and Anxiety would be linked- both have their origins in the Limbic System deep within the brain • The limbic system is where our fight-or-flight system resides, which is activated under apparent threat (Modern Anxiety) • This system is responsible for motivation and goal seeking/attainment

18. The Frontal Lobes of the Brain • The part of the brain that guides goal-directed behavior and our fleeing or fighting is further forward in the frontal lobes • The frontal lobes are involved in Classic Anxiety: anticipation of threat • Bottom Line- anxiety and ADHD behaviors (thoughts, feelings, actions) originate in similar parts of the brain • Communication between the limbic system and the frontal lobes is crucial for self regulation

19. We are all descendents of the paranoid people

20. Diagnostic Issues • There is no “test” for either ADHD or Anxiety • Observations (parents, teachers) and self-report: Counting up the symptoms • Agreement between parent and child is low: parents typically identify more ADHD symptoms and fewer anxiety symptoms than does the child

21. The Hairball Model of Psychopathology

23. “I can act my way into feeling better sooner than I can feel my way into acting better” O.W. Mower

24. Characteristics of Very Young Thinking • Egocentric • Idiosyncratic / Magical • Fusion (internal and external) • Psychic Equivalence / Literality • Rigidity • Binary

27. Under stress, they (and we) will regress

28. Anxious Behavior Characterized by • Avoidance or escape • Freezing up • Attempts to get help or control the feelings • General distress and dysregulation

29. Gambits • Gambit: an opening move in chess in which a player sacrifices a pawn or other piece in order to gain an advantage • More generally, any maneuver by which a person hopes to gain an advantage, often by inviting another person to take part in the maneuver in some way

31. The Anxiety Gambit A child’s anxious behavior invites (compels) the caregiver to participate in the anxiety as a witness, confidante, cheerleader, task master, lifeguard, or most commonly, as a rescuer

32. The Anxiety Dance • Anxiety behaviors are an effort to engage the caregiver in the anxiety dance, in order to achieve … • Emotional Avoidance utilizing … • Escape/Avoidance • Attempts at Control

33. The Reactive Dance • Child becomes distressed (and regressed) • Child, seeking rescue, acts out his distress in dramatic, regressed, and/or confusing ways • Parent becomes distressed • Parent seeks escape from this situation • The immediate goal for both parent and childbecomes escape or control in the present, avoidance in the future

34. A Responsive Dance Child becomes distressed Child, seeking rescue, acts out his distress in dramatic, regressed, and/or confusing ways Parent becomes distressed Parent acknowledges the distress with specific language and makes connections to the cause and to the child’s current “wanna-do’s” Parent models distress tolerance and orients the child to the original goal, coping skills, or to a viable solution to the actual problem

35. The Role of Attention The word “attention” comes from the Latin attendere, meaning “to stretch forward” As opposed to “vigilance”

36. The Attention Spotlight • Shifting attention from negative thoughts and feelings to actionable goals • Breathing and orienting to an “affect neutral” stimulus • The distraction paradox

37. “Awareness creates the possibility of choice” Siegel and Hartzell

38. Strategies for the parent

39. S.O.B.E.R. • Stop • Observe • Breathe • Expand • Respond

40. S.O.R.B.E.T. • Stop • Observe • Relax • Breathe • Expand • Teach

41. Graybar’s First Law of Human Behavior “All behavior is a message, and a behavior won’t begin to change until the person knows his message has been received”

42. Validation • Closes the communication loop: “message received” • Provides accurate and nuanced emotional vocabulary • Replaces ineffective reassurance in many situations • Says nothing about your agreeing with them or the “appropriateness” of that thought or feeling at the time

43. Validation • Promotes mentalizing and undermines fusion and psychic equivalence • Links outer events with private events and the wanna-do’s • Articulates the process; both currently and what’s possible

44. Validation Strategies • Simple and specific statements; • “You’re feeling …” • “You’re having one of those ‘I can’t do it’ ideas” • Identify expectations; • “You thought there would be popsicles” • “You want me to carry you now” • “I wonder” and “Ah” statements

45. “Mommy needs to get mad at you in a weird calm voice now”

46. Whole Body Validation

47. Strategies for the child

48. Muscle Tone Exercises • Tense and Release • Really small face / Really big face • Turtle • Squeezing Lemons • Relaxation Plus • Spider Push-ups • Moving without moving

49. Breathing Exercises • Belly Breath • Finding Your Breath • Ferris Wheel Breath • Up and Over Breath • Darth Vader Breath • Alien Breath

50. Commitment and Acceptance: Two Sides of the Same Coin To Be A Good Student Effort, Frustration, and Sacrifice