Treating Children with ADHD and Anxiety Disorders

TREATING THE ANXIOUS CHILD WHO ALSO HAS ADHD.

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You are listening to ReachMD, The Channel For Medical Professionals. Children with a common presentation of both anxiety disorders and ADHD require a four-pronged treatment approach. What are the main stages of treatment? Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt, your host, and with me today is Dr. Katharina Manassis. Dr. Manassis is an Associate Professor in the Department of Psychiatry at the University of Toronto and a member of the Human Development and Applied Psychology Department at the Ontario Institute for Studies and Education. She leads several funded research studies to better understand and treat childhood anxiety disorders.

LESLIE LUNDT:

Welcome to ReachMD, Dr. Manassis.

DR. KATHARINA MANASSIS:

Thank you. Glad to be here.

DR. LESLIE LUNDT:

Let's examine the treatment of children with comorbid anxiety and ADHD, one component at a time. What's the first modality you use to treat these kids?

DR. KATHARINA MANASSIS:

Families often don’t like to hear this, but often we do consider medication first.

DR. LESLIE LUNDT:

That’s always a struggle with some families, but don’t stimulants pose a risk to the anxious child?

DR. KATHARINA MANASSIS:

There is no such thing as a risk-free medication, so certainly there’s always a risk of side effects and appetite and sleep effect are common ones as well as some increase in anxiety itself is a possibility, but in many cases the benefits outweigh the risks when anxiety is combined with ADHD.

DR. LESLIE LUNDT:

So, stimulants certainly can have anxiety as the side effect, but aren’t some of the commonly used antidepressants associated with anxiety, at least as a beginning side effect as well?

DR. KATHARINA MANASSIS:

They can be if the child becomes very activated particularly in the initial stages of treatment.

DR. LESLIE LUNDT:

So what do you do? What's your first choice for these kids that have both ADHD and anxiety?

DR. KATHARINA MANASSIS:

My preference is usually to start with a stimulant. There are 2 types of medications for which there is some evidence – one is stimulants, the other is atomoxetine, which is a norepinephrine reuptake inhibitor, but I prefer starting with stimulants just because it's fairly quick to determine whether or not a stimulant is going to work and in large proportion of kids they do work.

DR. LESLIE LUNDT:

Any particular stimulant, which you like in these kids?

DR. KATHARINA MANASSIS:

I use essentially there are these same ones that would risk children who have ADHD without anxiety, so Concerta or Adderall might be some reasonable choices again because they are longer acting, so will take the child through the whole school day.

DR. LESLIE LUNDT:

So, longer acting being the key, you haven’t found a difference really between the methylphenidate groups compared to the amphetamine group.

DR. KATHARINA MANASSIS:

Not really. I start with what’s easy and easy to explain to families.

DR. LESLIE LUNDT:

Ok, so modality #1 is stimulant. What's next? What's the second modality?

DR. KATHARINA MANASSIS:

Well, secondly, we would want to look at psychotherapy or some sort of psychosocial intervention, and I say the latter because sometimes it’s a matter of doing a full therapy like a cognitive behavioral therapy and other times good behavioral management is really important, but certainly medication needs to be combined with some psychosocial intervention because both behavior and thinking are affected by anxiety and ADHD in these kids.

DR. LESLIE LUNDT:

Any pros here on getting the family involved and motivated to make the psychotherapy happen?

DR. KATHARINA MANASSIS:

In my experience, many families are more willing to agree to psychotherapy than to medication treatment, and the cautionary note here is that because of the co-occurrence of ADHD, some of the children do need simpler versions of the traditional cognitive behavioral therapies or more individualized therapies so they have; for example, difficulties with distractibility and with working memory, so some of them do better with individual treatment as opposed to a group treatment.

DR. LESLIE LUNDT:

Ok, so we have gone over medication, psychotherapy. What's the third modality?

DR. KATHARINA MANASSIS:

The third modality really is working with the families around the whole treatment plan and the things to consider there I think are that the children are quite challenging to parents because they both have anxiety and ADHD, so for example, an ADHD child might forget their schoolbooks once in a while, that not be too concerned about it, but an anxious ADHD child with that the same situation might really panic and refuse to go to school the next day. So, the parents face very challenging situations often and sometimes they have some symptoms of either anxiety or ADHD themselves.

DR. LESLIE LUNDT:

So that’s always a dilemma. In our office if you have these ADHD kids being parented by ADHD parents, they sort of blow into the office in this sort of tangle of bodies and stuff. Any advice on how to handle really the family as a whole when you are treating multiple people that have ADHD?

DR. KATHARINA MANASSIS:

Its important to structure things even more than we normally do, so lots of reminder calls for appointments and for school meetings; for example, there is often the school that needs to be worked with, extra attention to medication adherence because they do forget and sometimes, I assume that they are going to forget and then talk about, you know, how to re-reduce the amount of forgetting as opposed to getting upset as they do miss doses and really talking with them about consistent behavioral management for their children where they can do the same simple things repeatedly to reinforce the behavior they want to see more and to ignore some of the negative chaotic behavior that can happen.

DR. LESLIE LUNDT:

If you are just joining us, you are listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. I am Dr. Leslie Lundt, your host and with me today is the author of Keys to Parenting Your Anxious Child, Dr. Katharina Manassis. We are discussing treating the anxious child who also has ADHD.

Dr. Manassis, the paper you recently published in current psychiatry talked about 4 modalities for treating these kids that have anxiety and ADHD. So, we have covered stimulants or medication today, psychotherapy, getting the family involved, but there is one more component, which is that?

DR. KATHARINA MANASSIS:

That’s really to individualize the treatment plan and include the school in working with these kids.

DR. LESLIE LUNDT:

And how do you do that?

DR. KATHARINA MANASSIS:

To look first of all at where the anxiety and the ADHD is interfering in the child's life and commonly it is at school, but also in other areas in the family and socially and then to try make a plan for those situations where it gets in the way the most. From the school's point of view often that’s looking at minimizing the distractions that the child might have, reminding the child to use their anxiety coping strategies if they are learning some coping strategies and psychotherapy and having really consistent behavior management that occurs in the same way at home and at school. Those are sometimes the challenges.

DR. LESLIE LUNDT:

Has it been difficult getting the schools to buy into these treatment plans?

DR. KATHARINA MANASSIS:

It can be, but the schools are tremendously variable. Some of them can be very flexible and others find it difficult when there’s a child, who does need something more individualized, but often times if there’s good communication between the treating physician, the school, and the family, and the school sees family and the clinician as allies rather than as adversaries, people can work together and develop these treatment plans.

DR. LESLIE LUNDT:

How do these kids typically present to the office?

DR. KATHARINA MANASSIS:

They often present with symptoms of either condition and then after one talks with the family for a while, its clear that both are present, so there may be a child, who presents with school difficulties related to ADHD, but then the families may mention in passing that the child is also very clingy at home; for example, or the child worries a lot. It's important to ask the child as well though because people don’t always recognize when children are anxious. ADHD symptoms are a little more obvious though with anxiety often it is important to ask the child as well as the parents some of the things that they are concerned about or they worry about.

DR. LESLIE LUNDT:

Are there any rating scales or screens that might be helpful? I am picking particularly to the primary care doctor, pediatrician, who may not have as much time as we do in psychiatry to sort out all these issues. Any advice you can give to them?

DR. KATHARINA MANASSIS:

There are some paper and pencil rating scales that are fairly quick though; for example, for anxiety, the MASQ or the SCARED are 2 very commonly used standardized rating scales that don’t take very long and the SCARED has both the child and a parent version. There is also a broader rating scale like the Conners, which includes ADHD, but also some anxiety items or something like the CBCL, which has internalizing and externalizing symptoms. I think that the thing is not to get bogged down in a 1000 rating scales, but to define the one that you are confident and is going to pick up both of those types of problems, both the inattention and also the presence of some anxiety remembering that, as I said with anxiety, after you have talked with the child as well as the parent.

DR. LESLIE LUNDT:

Now, any resources for the docs that are listening out there and where they can find out more information on this topic?

DR. KATHARINA MANASSIS:

One of the things that I often recommend is the American Academy of Child and Adolescent Psychiatry website, which does include some basic information on all types of psychiatric problems seen in children, in terms of working with parents of anxious children to help them manage some of the anxiety symptoms and there are a number of resources for helping children manage ADHD symptoms as well.

DR. LESLIE LUNDT:

As would your paper as well as people to go the current psychiatry website, they can download Dr. Manassis' paper without charge as well. Thank you so much for being on our show today.

DR. KATHARINA MANASSIS:

You are welcome.

DR. LESLIE LUNDT:

We have been speaking with Dr. Katharina Manassis about treating kids that have both ADHD and an anxiety disorder. I am Dr. Leslie Lundt. You are listening to ReachMD, The Channel for Medical Professionals. For a complete program guide and downloadable pod cast, visit our website at www.reachmd.com. We’re always interested in what you would want to hear on our channel, so give us a call then and let us know what you’re thinking and thank you for listening.

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