Anxiety and ADHD: Too Many Hands on the

Wheel

Chris McCurry, Ph.D.

ABCD, Inc.

Seattle, WA

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

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.

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

Anxiety Facts

The #1 cause of anxiety in children is

scary information

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

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

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 

ADHD Diagnosis by State

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

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

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

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.

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

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

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

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

We are all descendents of the

paranoid people

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

The Hairball Model of Psychopathology

“I can act my way into feeling better sooner than

I can feel my way into acting better”

O.W. Mower

Characteristics of Very Young Thinking

Egocentric Idiosyncratic / Magical Fusion (internal and external) Psychic Equivalence / Literality Rigidity Binary

Under stress, they (and we) will regress

Anxious BehaviorCharacterized by

Avoidance or escape Freezing up Attempts to get help or

control the feelings General distress and

dysregulation

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

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

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

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 child becomes escape or control in the present, avoidance in the future

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

The Role of Attention

The word “attention” comes from the Latin attendere,

meaning “to stretch forward”

As opposed to “vigilance”

The Attention Spotlight

Shifting attention from negative thoughts and feelings to actionable goals

Breathing and orienting to an “affect neutral” stimulus

The distraction paradox

“Awareness creates the possibility of

choice”

Siegel and Hartzell

Strategies for the parent

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

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

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”

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

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

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

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

Whole Body Validation

Strategies for the child

Muscle Tone Exercises

Tense and Release Really small face / Really big

face Turtle Squeezing Lemons

Relaxation Plus Spider Push-ups Moving without moving

Breathing Exercises

Belly Breath Finding Your Breath Ferris Wheel Breath Up and Over Breath Darth Vader Breath Alien Breath

Commitment and Acceptance: Two Sides of the Same Coin

Effort, Frustratio

n, and Sacrifice

To Be A Good

Student

Cognitive Fusion

As described above- the tendency to treat thoughts and feelings as if they were directly and immutably connected to events in the external world

Also known as “literality” and “psychic equivalence”

Often seen as “thought-action fusion” and verbal rules

Defusion Exercises

Naming and cataloging Emotional vocabulary Boats on a river Center of the cyclone Illusions

More Defusion Exercises

Passengers on the bus

The Chessboard

Goggles

Faces / Vase

Mindfulness Exercises Observing the breath Eating Listening Smell Touch Seeing Taking your mind for a walk Descriptions v. Judgments

Descriptions v. Judgments

It’s cloudy today Dallas leads the NBA series 3

games to 2 I went to school on Monday This cup is blue and white This cup is special My brother got more than I did I’m good at soccer

Growing Stress-Resilient Kids

Regular exercise

Healthy diet

Good sleep habits

Promote friendships and community

Create context and narrative (spiritual, philosophical, historical) so that effort and struggle have meaning

Growing Stress-Resilient Kids

Listen and validate

Clear and (reasonably) consistent expectations

Model stress management and self-regulation: Think out loud as you cope and problem solve

Make time for yourself

Acknowledge mistakes and move on