5/2/2019 Objectives Differentia iating Be Between Attention Defic icit it Hyp yperactivit ity Disorder and Anxie xiety Understand the overlap of symptoms & key Determine when a dual components to help differentiate the two diagnosis is appropriate Prepared for: CADDAC Centre for ADHD Awareness Workshop 1 2 3 May 4 th , 2019 By Dr. Julie Desjardins & Laura Ziebell Develop an approach to differential The Child and Adolescent Family Centre of Ottawa diagnosis of these conditions Putting families first What is Anxiety? Anxie An iety Simula Si lati tion Activ Ac ivit ity • Anxiety is defined as the expectation of future threats Imagine standing on a ledge 20 stories high and looking out…. • It is characterized by: 1. Feelings of tension Now imagine someone asking you: 2. Worried thoughts 3. Physical changes What is 129 x 3? • It is also regularly related to: Could you pay attention to 1. Muscle tension the math problem? 2. Preparation for future danger 3. Cautious or avoidant behaviours (American Psychiatric Association, 2013) Putting Putting families first families first Attention-Deficit/Hyperactivity Disorder (ADHD) ADHD Simulation Activity • Is defined by a reoccurring pattern of inattention and/or hyperactivity this is greater than expected for their age • It interferes with the functioning or development of the individual, with main symptoms including: • Inattention Hyperactivity • Distraction Impulsivity • Disorganization Children with ADHD often also have trouble with: • Functioning at home & school • Making & keeping friends • School work & homework Putting Putting https://www.youtube.com/watch?v=hufe8-veBWE • Social & emotional development families first families first (American Psychiatric Association, 2013) 1
5/2/2019 ADHD & Anxiety Symptom Overlap Co-occur There are several symptoms that overlap • Between 25% to 30% of children between ADHD and anxiety disorders, such with ADHD suffer from at least as: one anxiety disorder including 1. Restlessness/psychomotor agitation (but not limited to): 2. Concentration difficulties • Separation anxiety 3. Decreased attention • Social anxiety 4. Increased distractibility • Generalized anxiety 5. Mood swings 6. Anger outburst Putting Putting families first families first (Jarrett et al., 2008; Jenson et al., 1997) (Grogan et al., 2017) Inattentive, restless Social difficulties Anxiety: Shuts down the pre-frontal Anxiety: May have emotional outbursts It is important for service providers An Anxie iety ADHD Differentiation is key cortex to focus on being safe that alienate peers to distinguish between the two ADHD: Norepinephrine and dopamine ADHD: Struggle with social cues disorders because: Symptom Ov Symptom Overlap Overla rlap are off and they are paying attention Symptom Ov Overla rlap 1. It allows them to address the to too many things at once • Slow to complete work • Slow to complete work core issues, not just the • Slow to complete work • Attention • More aware symptoms • Social Difficulties • Social Difficulties difficulties • Social Difficulties of social cues Emotionality : Slow to complete work • Inattentive, restless • Inattentive, restless in multiple 2. It also allows them to choose • Inattentive, restless Anxiety: Fight or flight response, Anxiety: May be concerned with • Physical the most effective treatment settings • Lack of flexibility • Lack of flexibility impulsive or inappropriate behaviours perfectionism plan • Lack of flexibility symptoms due to nervousness • Difficulty ADHD: Difficulty with task initiation • Hyperactivity or talking • Hyperactivity or talking • Hyperactivity or talking ADHD: Difficulty with self-control and e.g. cognitive restructuring with too much too much executive functioning vs. rewarding efforts too much executive • Emotionality • Emotionality • Emotionality Hyperactivity or talking too much functioning Anxiety: When there is a perceived threat, Lack of flexibility the body prepares for fight or flight. The Anxiety: Loss of control energy has to go somewhere. ADHD: Executive functioning difficulty Putting ADHD: Body not able to slow down families first ook Like Wha hat an n Anxi xious Chi hild With th ADH DHD May Loo ADHD & Anxiety • Trouble managing emotions or using coping skills can affect kids’ Despite overlap in some symptoms: behaviour in different ways • Some behaviors that may be signs of • ADHD and anxiety symptoms anxiety in a child with ADHD: are expressed independently when they occur together Clowns around too much in class • ADHD is not simply a Seems irritable or argumentative manifestation of anxiety or Withdraws from people, perhaps by retreating vice versa to the bedroom or bathroom Lies about schoolwork or other https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/add-adhd/adhd-and-anxiety-what-you-need-to-know responsibilities he hasn’t met Putting Putting families first families first Plays video games or watches TV nonstop (Hammerness, et al., 2010; Jarrett & Ollendick, 2012) 2
5/2/2019 Diagnostic Considerations Case Study Alex is a 9-year old boy with a history of attention difficulties and difficulty sitting still. His current teacher reported that he often has a “blank stare” and struggles to answer questions in class • Attention Deficit Hyperactivity Additional information: Disorder (ADHD)? • He reported that the teacher talks a lot and it’s difficult to focus in class • Anxiety? • He is worried about being called on in class • He is afraid of what others think of him • Other? • His parents do not report any attention difficulties at home Putting Putting families first families first • Background Questionnaire • Social Emotional Questionnaires Comprehensive Assessment Questionnaires (e.g., CBCL, TRF, YSR) • Measures of Anxiety Comprehensive assessments generally involve (but (e.g., MASC, BAI, SCARED) are not limited to): • Multiple informant interviews (i.e., parents, teacher and child) • Social-emotional questionnaires from multiple informants (i.e., parents, teacher and child) • Background questionnaire • Intelligence test • Academic achievement • Memory test Putting Putting • Tests of attention families first families first Intelligence Testing Questionnaires • Behavioural observations • Scattered responses • Variability within indices • Children with ADHD generally have • Attention Questionnaires weaker working memory (e.g., Conner's - Parent, Teacher • Children with ADHD have more and Self-Report forms) difficulty with processing speed • They also demonstrate significantly • Executive Functioning worse performance on the Coding Questionnaires (e.g., BRIEF) subtest compared to Symbol Search subtest (Calhoun & Mayes, 2005) Putting Putting families first families first 3
5/2/2019 Memory Academic Achievement • Research Findings : An anxiety group consistently perform better on the WRAML-2 • Allows clinicians to rule out Learning Disabilities • Attention, short term, and long term memory (Specific Learning Disorders) are associated with the pre-frontal cortex • Behavioural observations: Impairment in this area is often related to ADHD • Sustained effort • Although children experiencing anxiety may • Difficulty initiating tasks display some memory deficits, they are • Difficulty with focus and concentration typically secondary to emotional distress • Irritability • Perfectionism Putting Putting families first families first (Herman, Pinjala, & Golden, 2015) Symptom Anxiety ADHD If symptoms are generally the same, Symptom does it really matter how they are treated? Difficulty Concentrating x x Checklist Restlessness x x Mood swings x x Anger outbursts x x Works slowly x x Social difficulties x x Executive functioning x Working memory x x Difficulty with focus at school AND home x Putting Putting families first families first When is a dual diagnosis When is a dual diagnosis appropriate? appropriate? 1. An individual meets criteria for both ADHD and anxiety based on the • Studies have found that around information gathered 1/3 of adults with ADHD also have 2. Treatment for ADHD an anxiety or mood disorder alone is not sufficient • For children, those with ADHD 3. Treatment for anxiety and anxiety have a comorbidity alone is not sufficient rate of 25% of the general population Putting Putting families first families first (“Managing ADHD”, 2007; Jarrett et al., 2016 ) 4
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