5/2/2019 Objectives Differentia iating Be Between Attention Defic - - PDF document

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Differentia iating Be Between Attention Defic icit it Hyp yperactivit ity Disorder and Anxie xiety

Prepared for: CADDAC Centre for ADHD Awareness Workshop

May 4th, 2019

By Dr. Julie Desjardins & Laura Ziebell The Child and Adolescent Family Centre of Ottawa

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Objectives

1 2 3

Understand the overlap of symptoms & key components to help differentiate the two Develop an approach to differential diagnosis of these conditions Determine when a dual diagnosis is appropriate Putting families first

What is Anxiety?

• Anxiety is defined as the expectation of future threats
• It is characterized by:

1. Feelings of tension 2. Worried thoughts 3. Physical changes

• It is also regularly related to:

1. Muscle tension 2. Preparation for future danger 3. Cautious or avoidant behaviours

(American Psychiatric Association, 2013)

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Imagine standing on a ledge 20 stories high and looking out…. Now imagine someone asking you:

What is 129 x 3?

Could you pay attention to the math problem? An Anxie iety Si Simula lati tion Ac Activ ivit ity

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Attention-Deficit/Hyperactivity Disorder (ADHD)

• 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
• Social & emotional development

(American Psychiatric Association, 2013)

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ADHD Simulation Activity

https://www.youtube.com/watch?v=hufe8-veBWE

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There are several symptoms that overlap between ADHD and anxiety disorders, such as:

• 1. Restlessness/psychomotor agitation
• 2. Concentration difficulties
• 3. Decreased attention
• 4. Increased distractibility
• 5. Mood swings
• 6. Anger outburst

Symptom Overlap

(Grogan et al., 2017)

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ADHD & Anxiety Co-occur

• Between 25% to 30% of children

with ADHD suffer from at least

• ne anxiety disorder including

(but not limited to):

• Separation anxiety
• Social anxiety
• Generalized anxiety

(Jarrett et al., 2008; Jenson et al., 1997)

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It is important for service providers to distinguish between the two disorders because: 1. It allows them to address the core issues, not just the symptoms 2. It also allows them to choose the most effective treatment plan

• e.g. cognitive restructuring
• vs. rewarding efforts

Differentiation is key

Symptom Ov Overla rlap

• Slow to complete work
• Social Difficulties
• Inattentive, restless
• Lack of flexibility
• Hyperactivity or talking

too much

• Emotionality
• More aware
• f social cues
• Physical

symptoms

An Anxie iety

• Attention

difficulties in multiple settings

• Difficulty

with executive functioning

ADHD Symptom Overlap

• Slow to complete work
• Social Difficulties
• Inattentive, restless
• Lack of flexibility
• Hyperactivity or talking

too much

• Emotionality

Symptom Ov Overla rlap

• Slow to complete work
• Social Difficulties
• Inattentive, restless
• Lack of flexibility
• Hyperactivity or talking

too much

• Emotionality

Lack of flexibility Anxiety: Loss of control ADHD: Executive functioning difficulty Emotionality: Anxiety: Fight or flight response, impulsive or inappropriate behaviours due to nervousness ADHD: Difficulty with self-control and executive functioning Social difficulties Anxiety: May have emotional outbursts that alienate peers ADHD: Struggle with social cues Inattentive, restless Anxiety: Shuts down the pre-frontal cortex to focus on being safe ADHD: Norepinephrine and dopamine are off and they are paying attention to too many things at once Slow to complete work Anxiety: May be concerned with perfectionism ADHD: Difficulty with task initiation Hyperactivity or talking too much Anxiety: When there is a perceived threat, the body prepares for fight or flight. The energy has to go somewhere. ADHD: Body not able to slow down

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Wha hat an n Anxi xious Chi hild With th ADH DHD May Loo

• ok Like
• Trouble managing emotions or using

coping skills can affect kids’ behaviour in different ways

• Some behaviors that may be signs of

anxiety in a child with ADHD:

Clowns around too much in class Seems irritable or argumentative Withdraws from people, perhaps by retreating to the bedroom or bathroom Lies about schoolwork or other responsibilities he hasn’t met Plays video games or watches TV nonstop

https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/add-adhd/adhd-and-anxiety-what-you-need-to-know

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ADHD & Anxiety

Despite overlap in some symptoms:

• ADHD and anxiety symptoms

are expressed independently when they occur together

• ADHD is not simply a

manifestation of anxiety or vice versa

(Hammerness, et al., 2010; Jarrett & Ollendick, 2012)

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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 Additional information:

• He reported that the teacher talks a lot and it’s difficult to

focus in class

• He is worried about being called on in class
• He is afraid of what others think of him
• His parents do not report any attention difficulties at home

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• Attention Deficit Hyperactivity

Disorder (ADHD)?

• Anxiety?
• Other?

Diagnostic Considerations

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Comprehensive Assessment

Comprehensive assessments generally involve (but 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
• Tests of attention

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Questionnaires

• Background Questionnaire
• Social Emotional Questionnaires

(e.g., CBCL, TRF, YSR)

• Measures of Anxiety

(e.g., MASC, BAI, SCARED)

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• Attention Questionnaires

(e.g., Conner's - Parent, Teacher and Self-Report forms)

• Executive Functioning

Questionnaires (e.g., BRIEF)

Questionnaires

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Intelligence Testing

• Behavioural observations
• Scattered responses
• Variability within indices
• Children with ADHD generally have

weaker working memory

• Children with ADHD have more

difficulty with processing speed

• They also demonstrate significantly

worse performance on the Coding subtest compared to Symbol Search subtest

(Calhoun & Mayes, 2005)

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• Allows clinicians to rule out Learning Disabilities

(Specific Learning Disorders)

• Behavioural observations:
• Sustained effort
• Difficulty initiating tasks
• Difficulty with focus and concentration
• Irritability
• Perfectionism

Academic Achievement

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• Research Findings: An anxiety group

consistently perform better on the WRAML-2

• Attention, short term, and long term memory

are associated with the pre-frontal cortex

• Impairment in this area is often related to ADHD
• Although children experiencing anxiety may

display some memory deficits, they are typically secondary to emotional distress

(Herman, Pinjala, & Golden, 2015)

Memory

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Symptom Checklist

Symptom Anxiety ADHD Difficulty Concentrating x x 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

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If symptoms are generally the same, does it really matter how they are treated?

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When is a dual diagnosis appropriate?

• 1. An individual meets

criteria for both ADHD and anxiety based on the information gathered

• 2. Treatment for ADHD

alone is not sufficient

• 3. Treatment for anxiety

alone is not sufficient

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When is a dual diagnosis appropriate?

• Studies have found that around

1/3 of adults with ADHD also have

an anxiety or mood disorder

• For children, those with ADHD

and anxiety have a comorbidity rate of 25% of the general population

(“Managing ADHD”, 2007; Jarrett et al., 2016)

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Outcomes for Co-occurring Anxiety/ADHD

(Hammerness et al., 2010)

Studies have found a negative impact on children’s school functioning when diagnosed with both ADHD & anxiety disorders Findings suggest those diagnosed with both:

• Required more extra help
• Were 2x as likely to be placed in a

separate, special class

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Outcomes for Co-occurring Anxiety/ADHD

(Jarrett, 2016)

Further studies revealed that groups diagnosed with ADHD and comorbid anxiety showed the greatest deficits in: 1. Self-regulation of emotion 2. Self-organization 3. Problem solving Compared to those diagnosed independently Deficits in emotion self-regulation self-organization and problem solving greatly overlap with abilities in working memory

• This perpetuates the difficulties already faced by these

individuals

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Treatment of Comorbid ADHD & Anxiety

• Pharmacology Considerations: Some

medications for ADHD can exacerbate anxiety symptoms

• Integrated Treatment: Parent-management

training & family-based cognitive behavioural therapy (CBT)

• Additional: Mindfulness, meditation,

exercise, nutrition, and sleep hygiene

(Hammerness, et al., 2010; Jarrett & Ollendick, 2012)

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Additional Things That Can Help

• Tune in to the child’s negative behaviors
• If the child tells you he/she feels

anxious, validate the feelings

• Learn to control your own anxiety
• Try not to take certain behaviors

personally

• Help the child see the big picture
• Use positive reinforcement
• Schedule
• Organize
• Use homework/notebook planners

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Questions?

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Thank You!

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Calhoun, S.L. & Mayes, S.D. (2005). Processing speed in children with clinic disorders. Psychology in the Schools, 42, 333-342. Herman, C., Pinjala, M. & Golden, C (2015). WRAML-2 Performance contrasts between Children with Attention Deficit-Hyperactivity Disorder, Combined Type and Those with Anxiety Disorders, Archives of Clinical Neuropsychology, Volume 30, Issue 6, 1 September 2015, Pages 532–533, Hammerness, P., Geller, D., Petty, C., Lamb, A., Bristol, E., & Biederman, J. (2010). Does ADHD moderate the manifestation of anxiety disorders in children? European Child & Adolescent Psychiatry, 19(2), 107–112. Jarrett, M. A. (2016). Attention-deficit/hyperactivity disorder (ADHD) symptoms, anxiety symptoms, and executive functioning in emerging adults. Psychological Assessment, 28(2), 245–250. https://doi.org/10.1037/pas0000190 Jarrett, M.A., Ollendick, T.H. (2009). A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: implications for future research and

• practice. Clinical Psychology Review, 28(7), 1266–1280

Jarrett, M. A., Wolff, J. C., Davis, T. E. I., Cowart, M. J., & Ollendick, T. H. (2016). Characteristics of children with ADHD and comorbid anxiety. Journal of Attention Disorders, 20(7), 636–644. https://doi.org/10.1177/1087054712452914 Jensen, P.S., Martin, D., Cantwell, D.P. (1997). Comorbidity in ADHD: implications for research, practice, and DSM-V. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1065–1079. Managing ADHD in Children, Adolescents, and Adults With Comorbid Anxiety in Primary Care. (2007). Primary Care Companion to The Journal of Clinical Psychiatry, 9(2), 129–138. Grogan, K., Gormley, C.I., Rooney, B., Whelan R., Kiiski,H., Naughton, M., & Bramham,J. (2017). Differential diagnosis and comorbidity of ADHD and anxiety in

• adults. British Journal of Clinical Psychology, 57(1), 99–115. https://doi.org/10.1111/bjc.12156

Weiss, M., & Murray, C. (2003). Assessment and management of attention-deficit hyperactivity disorder in adults. CMAJ: Canadian Medical Association Journal, 168(6), 715–722