Is Your Child Worrying Too Much?
Anxiety is common in children — and even more so in kids diagnosed with ADHD. Here’s how parents can separate normal worry from anxiety, and how families can work together to manage and treat it.
Ralph had always been a shy and anxious child. He hated separating from his mother to go to preschool. This worsened when he started first grade. Every time his parents left the house, he worried that some tragedy would strike them and he would be left alone. His school-mates found him odd and distant, and he had few friends either at his school or in his neighborhood. Over the years his teachers expressed concern that Ralph’s behavior left him unable to engage in what was going on in the classroom.
Sometime after his seventh birthday, he began to straighten up everything in the house, and would become upset if anything was out of place. His parents hoped that he would grow out of it, but his fearfulness and obsessive rituals only got worse. Finally, their pediatrician insisted that they have a consultation with a child psychiatrist.
Anxiety Is Common in Kids
When anxiety interferes with academic attainment, making friends, and daily activities, it has become a disorder. About 15 percent of children in the general population, and about 25 percent of children with ADHD, have an anxiety disorder at some time during their childhood. Finding the causes and contributing factors to the development of an anxiety disorder, and implementing a successful treatment plan, is a challenge even for experienced clinicians.
Anxiety tends to run in families, and it is hard to determine how much anxious behavior is genetic and how much anxious behavior is learned from an anxious parent. Cognitive behavioral therapy to treat childhood anxiety is often done by parents who have anxiety disorders themselves. In most cases, it is better to treat the parent’s condition first, so that they can supply the structure and consistency needed to help their children.
Fear Versus Anxiety
It is important to distinguish between fear and anxiety. By definition, anxiety is a “baseless, apprehensive fear.” A person feels that something awful is about to happen for no apparent reason. Fear, on the other hand, is a normal response to real threats. A child who is afraid to go to school because he is being bullied, or because he is failing, does not have a disorder. People who are anxious are always fearful.
It is hard to distinguish anxiety disorders from ADHD. Most people who have ADHD struggle to find the words to describe their internal emotional states. Children and adults use the word “anxious” to describe the hyperarousal and agitation that are part of ADHD. The reverse also happens. A child who is constantly distracted by his anxious thinking seems to be inattentive to his teachers or parents, and gets labeled as having ADHD. Diagnostic difficulties are compounded when a child has both an anxiety disorder and ADHD.
The ADHD nervous system is extremely sensitive to the perception that someone has withdrawn their love, approval, or respect because the person with ADHD has disappointed them. This often leads people to fearfulness bordering on panic in situations in which they anticipate they will fail and be criticized. It is important to distinguish rejection sensitivity from anxiety because ADHD medication can treat these symptoms, and traditional treatments for anxiety disorders don’t affect them.
Research and clinical experience show the best outcomes are achieved with a combination of cognitive behavioral therapy (CBT) and medication. It doesn’t matter which modality of treatment is tried first. Both are usually started at the same time. If CBT is started without medication, the therapy often fails to lower a child’s anxiety and distractibility. If medication alone is used, the child continues, out of habit, in the same behaviors and thought patterns he developed to cope with his anxiety.
The Medication Piece
Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line treatments for anxiety disorders at all ages. For unknown reasons, some children become agitated and impulsive when they start an SSRI, so most clinicians start these medications with short-acting formulations, such as escitalopram (Lexapro), that can be stopped quickly. Anxiety lessens gradually over several weeks, especially if a low dose is used to avoid side effects. The most common side effects, nausea and headache, are usually mild, and resolve in a few days.
About 25 percent of children with anxiety disorders have ADHD. Many parents and clinicians fear that using a stimulant medication will worsen a child’s anxiety. The opposite is usually true. A recent review of 23 studies found that stimulants significantly reduced worry and anxiousness in the majority of children with coexisting ADHD and anxiety.
The CBT Piece
Anxious people view the world as threatening, and they are constantly vigilant. They overreact to every event, and have cataclysmic reactions to minor or imagined challenges. CBT helps people recognize this distorted way of thinking, and replaces it with healthier responses. It is often necessary to lower the level of fearfulness with medication, so that a child can engage with his therapy in the clinician’s office and at home. Likewise, if ADHD is present, stimulants are needed to improve attention and to control hyperaroused, impulsive behavior.
New behaviors learned through CBT must be practiced daily to become a child’s way of experiencing and managing anxiety. Parents must be committed to learning to help their children use these new techniques in the home, and to make sure that the therapy is done every day over a period of months.
Ralph was found to have both severe Generalized Anxiety Disorder, with obsessive-compulsive features, and ADHD. Ralph responded well to a rapidly fine-tuned dose of escitalopram. By the third week, he was noticeably less anxious, more outgoing, and more engaged in school. He started a stimulant medication at a low dose, which was adjusted over several weeks to achieve optimal effectiveness. He experienced a mild loss of appetite. Over the same time, he established a good working relationship with a cognitive behavioral therapist. Ralph took great pride in his newfound ability to control his anxiety and in his performance in general.
Anxious Parents Urge Less Treatment
There are two major impediments to the treatment of anxiety in a child. Anxiety disorders are genetic, and it is likely that a sufferer’s child will be impaired by the condition, as well. Anxious parents often demand that something be done for their child right away, but they are usually too fearful to agree to a course of treatment.
They can be so paralyzed by the “what if’s” that they do nothing at all. Any change, even change for the better, can frighten a person with an anxiety disorder. They get stuck between hoping that action will make them feel better and the fear that change will make them feel worse. The current situation might be as good as it gets. While they wrestle with this dilemma, they do nothing.
And as a way of feeling more in command of the situation, parents may become more rigid and controlling. This will lead to power struggles with the therapist. Ironically, their attempts to manage their own anxiety can prevent meaningful treatment for their child.