Keeping Cool About Your Anxious Child

1
Keeping Cool About Your Anxious Child

• Presented by Dr.Kevin Nugent
• Child a Adolescent Psychiatrist

2
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

3
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)

4
The Highly Sensitive Child

• Emotionally sensitive children are more troubled
  by and reactive to lifes events perhaps they
  feel more deeply
• These children may try to cope with lifes
  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.

5
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 childs innate
  vulnerability as well as the stressors they face
  and that childs 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

6
Pediatric Anxiety Disorders

• Occur frequently, likely affecting up to 10 of
  children or teens
• These internalizing disorders can be
  over-looked 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

7
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)

8
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

9
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
• Childs developmental delays could be a factor
• Parental response key to management
• Can be a predictor of future internalizing
  disorder

10
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

11
Specific Phobias

• Minor phobias occur commonly in development with
  little impact
• To merit a diagnosis and intervention must be
  present gt6 mos. significant impairment in
  social, educational or occupational function
• Can be a marker for other anxiety problems, at
  present or later in life

12
Specific Phobias

• 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

13
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)

14
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

15
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
16
Diagnosis (contd)

• 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

17
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

18
Panic Disorder Co-morbidity Major Depression

• 6590 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)

19
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

20
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 time-limited, 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

21
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
22
Social Anxiety Disorder Subtypes

• Generalized (80)
• Most social situations
• (DSM-IV)
• performance
• interactional
• Overlaps with avoidant personality disorder
• 8090

• Nongeneralized (20) (discrete, specific)
• 1 or 2 social situations
• Usually performance
• writing in front of others
• eating in front of others
• telephone
• public speaking

23
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

24
Performance Situations

• Public speaking
• formal large groups
• informal small groups
• Writing in front of others
• Eating in front of others

• Entering a room
• Using a public toilet
• Playing an instrument
• Playing sports

25
Social Anxiety Disorder The Most Prevalent
Anxiety Disorder

• Lifetime prevalence 13
• Point prevalence in primary care 57
• Mean age at onset 1416 years
• Only Major depressive episode greater lifetime
  prevalence, arguably with more limited lifetime
  impact

Ballenger JC, et al. J Clin Psychiatry 1998
26
Spectrum of Depression and Anxiety Disorders
Lifetime Prevalence
17
13
7.8
5.1
3.5
2.3
Social anxiety disorder
Obsessive-compulsive disorder
Generalized anxiety disorder
Posttraumatic stress disorder
Depression
Panic disorder
27
Spectrum of Depression and Anxiety Disorders
Posttraumatic stress disorder
Social anxiety disorder
Depression
Panic disorder
Obsessive-compulsive disorder
Generalized anxiety disorder
28
Major Depression and Anxiety Disorders Symptom
Overlap
Irritability Worrying, guilt Agitation/restlessnes
s Nervousness, tension Impaired
concentration Anhedonia Insomnia Fatigue
Major depressive disorder
Anxiety disorders
29
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

30
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

31
Obsessive and Compulsive Symptoms on Admission
(n560)

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

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

Rasmussen SA, et al. Psychopharm Bull 1988
32
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

33
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

34
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 gt1 month duration

35
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

36
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

37
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

38
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

39
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

40
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 teens
  physician

41
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 LDs can sometimes be major
  contributor
• ,

42
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

43
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,
  Tourettes and Anxiety (especially OCD)

44
Co-occurring Disorders in ADHD Children
Oppositional Defiant Disorder 40
Tics 11
ADHD alone 31
Conduct Disorder 14
Anxiety Disorder 34
(n579)
Mood Disorders 4
MTA Cooperative Group. Arch Gen Psych 1999
56108896
45
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

46
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 dont get
  their way

47
Overview of Anxiety/ L.D. Relationship

• Children and teens with significant learning
  difficulties, including various LDs, 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

48
Anxiety and other MH Problems in L.Ds.

• Children and young people with LD have been found
  to be up to four times more susceptible to mental
  health problems than their non-disabled 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
  (Borthwick-Duff, 1994 Allington-Smith, 2006).
• In children and adolescents, anxiety disorders
  may be associated with lowered linguistic
  abilities and cognitive flexibility (Toren et al,
  2000)

49
SLDs 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 Aspergers S.
• Children with Verbal L.D.s struggle more to keep
  up with the verbal aspect of communication.

50
Impact of the Social Difficulties in LDs

• 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 LDs, 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 childs peer
  interactions
• Proper recognition and remediation of their LDs
  are first steps!

51
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 childs ability to engage in
  common age-appropriate activities
• 5. The only way to overcome fear is to face it.

52
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

53
More General Management Guidelines

• Some medical review may be warranted by Family
  Doc or Pedn
• 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 childs life need to demonstrate their
  belief that the child/ youth can attain better
  coping and functioning
• Encourage child/ youth to attain areas of success

54
Interventions

• 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

55
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

56
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

57
Coping Strategies

• Provide your child with reassuring information
  about anxiety
• (that its 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. Were not
  going to let Scaredy Bear push us around any
  more!

58
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

59
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!

60
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 Im 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?

61
CBT for Obsessions and Compulsions

• A more specialized and challenging area
• Very important to gain the childs 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

62
Possible Role For Medication

• Understandable reluctance about use of
  medications
• However, it can assist the anxious child in
  several ways
• Making it easier for the child to face what is
  feared
• Blocking the most distressing physical symptoms
  of anxiety
• Reducing interference of anxiety in day-to-day
  activities
• Reducing the consequences of prolonged, untreated
  anxiety
• Treating those types of anxiety that respond
  particularly well to medication
• Therefore definitely an option. (from Manassis,
  1996)
• Also, helpful to seek childs input as
  age-appropriate

63
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 childs 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

64
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

65
Guidelines with Meds

• Judgment call about medications includes childs
  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)
• SSRIs (e.g. Prozac, Zoloft, Luvox, Paxil, Celexa
  and Cipralex) most studied, best tolerated and
  most effective
• SSRIs are chemically close cousins and likely
  similar efficacy, although they have slightly
  differing side-effect profiles

66
Meds

• Definitely should use a serotonergic drug if
  significant OCD or PTSD symptoms
• Anafranil (clomipramine) another option in OCD
  Its 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

67
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

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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, dont be hesitant to actively treat
  their ADHD! Their co-morbidity adds to the
  importance of proper management!

69
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 SSRIs have advantages, TCAs 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),

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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

71
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 cant 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 days mainly course of
  stimulants (while informing them that there is
  evidence of better results on a continuous
  program)

72
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