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The Anxiety DisordersWhile anxiety is a normal emotion experienced byeveryone, a child or adolescent with an anxiety dis-order experiences this symptom more often, morereadily and often more intensely than other young-sters. In addition, the symptoms must cause signifi-cant distress or interfere with their functioning in atleast one aspect of their lives. It is important to beaware that excessive anxiety can result in impaired

concentration and restlessness, some of the samesymptoms that are seen in children with AD/HD.In addition, these disorders can result in their beingexcessively tired, on-edge, irritable, tense and hav-ing difficulty sleeping.

As a group, anxiety disorders in children are morecommon than any other psychiatric disorder. In thegeneral population, between 5–15 percent of chil-dren have an anxiety disorder.

by Glenn S. Hirsch, M.D.

andAnxiety Disorders

AD/HD

While anxiety is a normal emotion experienced by everyone, a child oradolescent with an anxiety disorder experiences this symptom moreoften, more readily and often more intensely than other youngsters.

and AD/HD make strange bedfellows. Consider the

hallmark of a typical youngster with AD/HD—acting without thinking.

In contrast, we might say that a youngster with an anxiety disorder ‘thinks

too much.’ It would seem then that having one of these disorders would

“protect” you from having the other one. Unfortunately this is not true.

In fact, recent studies suggest that up to 25 percent of children with AD/HD

have an anxiety disorder, and 25 percent of children with an anxiety

disorder have AD/HD. In order to understand this, it is important to be

aware of and able to recognize the symptoms of anxiety disorders.

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Anxiety Disorders and AD/HD Anxiety Disorders and AD/HD

CHADD does not endorse products, services, publications, medications or treatments, including those advertised in Attention!®

What follows is a brief review of each of thesedisorders.

Separation Anxiety Disorder (SAD)Most infants go through a normal phase of separationanxiety that usually peaks at eighteen months of ageand rapidly diminishes thereafter. Separation anxietyis not a normal feature of school-aged or teenagechildren.

Youngsters with this anxiety disorder have anextreme fear of being away from home or from thepeople who routinely care for them. These childrencan show distress when separating or even when sep-aration is anticipated. They may worry that a parentmay be lost, harmed or that they (the children) may belost or kidnapped. As a result of these fears, they mayrefuse to go to school, sleep alone and they may clingto and “shadow” their parents around the home. Oftenthey may have nightmares with themes of separation.Many times these children will end up in the schoolnurse’s office with complaints, headaches or stomach-aches, and a wish to call home.

Generalized Anxiety Disorder (GAD)Children with this disorder are classic worriers. Anolder term for this disorder is overanxious disorder. Thesekids tend to be anxious about any number of things intheir lives. They can have excessive and unrealisticworries about future events, school, their health, safe-ty at home, natural disasters such as storms, hurricanesor earthquakes, being on time for appointments andfamily issues. Unlike children with social anxiety, theanxiety persists even if they are not being judged orobserved by others. They may worry about doing wellin school, including homework and exams, even ifthey have always done well. They have a tendency to

ask parents and teachers for reassurance about howthey are performing.

Social PhobiaThese children are painfully shy and feel intense dis-comfort in social situations. They are especially fearfulof situations where they need to perform and areunder scrutiny. These situations can include talking infront of the class, starting or joining conversations,eating in public and making friends. They often areconcerned that they will do or say something that willresult in their feeling humiliated or embarrassed. Of-ten their anxiety extends to their anticipating eventswhere they may have to perform. Younger childrenmay not recognize that their fear is excessive.

The emotional aspects of anxiety may producephysical symptoms such as blushing, tremors, sweat-ing, feeling faint, muscle tension and sometimes evenheart palpitations.

When the symptoms are intense, these youngstersmay begin to avoid school and all social activities. Aform of social phobia that can start in young children,but remain through the school years is selective mutism.This disorder is characterized by an inability to speakin many social situations. Often these children willonly speak at home to parents and siblings. At timestheir behavior may seem oppositional, but in fact, thesymptom is driven by intense anxiety.

Obsessive-Compulsive Disorder (OCD)This disorder is characterized by intrusive and inap-propriate recurrent thoughts, images or impulses and/or repetitive behaviors. The thoughts are called obses-sions, while the behaviors are called compulsions. Typ-ical compulsions include excessive hand washing, clean-ing rituals, checking behaviors such as making surethat windows or doors are locked, or the faucets areshut off, hoarding (the inability to throw anythingaway) and arranging or ordering things such as booksor clothes. Typical obsessions include impulses to harmor kill a family member; incessant worries about dirt,germs, contamination or religion; recurrent thoughtsthat something has not been done properly; feelingsthat certain things must always be in a certain place; aswell as thoughts of nonsense words, sounds, picturesor numbers.

Post-traumatic Stress Disorder (PTSD)In the face of the World Trade Center and Pentagonattacks and tragedies, this disorder takes on renewedsignificance. PTSD can develop after a youngster is

exposed to an extreme trauma. The diagnosis requiresthat the child be directly exposed to an extremelytraumatic situation involving an actual or threateneddeath or serious injury, witnessing such an event, orhearing about such an event with regard to a familymember. These youngsters will often relive the traumaby having recurrent intrusive thoughts, images, dreamsand flashbacks. At times, they will avoid activities,thoughts, places or people who are associated withthe trauma. Symptoms of increased arousal such asdifficulty concentrating, hyper vigilance and an exag-gerated startle response will often accompany the oth-er symptoms. Since many of these symptoms are notunusual immediately after a trauma, in order for thisdiagnosis to be made the child must experience thesesymptoms for at least one month.

How are the anxiety disorders treated?For SAD, GAD, social phobia and OCD, two treat-ments have been utilized. A form of therapy calledCognitive-Behavioral Therapy (CBT) and medication,specifically the selective serotonin reuptake inhibitors

(SSRI’s). A number of studies have shown these med-ications are helpful in treating OCD. A large multi-sitestudy sponsored by the National Institute of MentalHealth (NIMH) showed that fluvoxamine was effica-cious in treating SAD, GAD and social phobia.

For children suffering from PTSD, specific treat-ments have been developed that include cognitive andbehavioral techniques, in addition to making changesto the environment to ensure ongoing safety.

What are the differences between children withAD/HD alone and those with AD/HD combined withan anxiety disorder? Children with the combined dis-order are often referred for treatment at a later agethan those without anxiety. Some speculate that thismay be due to the fact that for some children theanxiety symptoms may inhibit the hyperactive-impul-sive behaviors that are so often the trigger for a refer-ral for evaluation.

Anxious children with AD/HD may be at a lowerrisk for developing a conduct disorder. Children withAD/HD plus anxiety may exhibit more social difficul-ties, but no difference in school performance.

Anxiety disordersin children are more

common than anyother psychiatric dis-order. In the generalpopulation, between

5–15 percent ofchildren have ananxiety disorder.

Children with General-ized Anxiety Disordermay worry about doingwell in school, includ-ing homework and ex-ams, even if they havealways done well.

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Anxiety Disorders and AD/HD Anxiety Disorders and AD/HD

CHADD does not endorse products, services, publications, medications or treatments, including those advertised in Attention!® CHADD does not endorse products, services, publications, medications or treatments, including those advertised in Attention!®

Treatment of the Combined DisordersThe presence of an anxiety disorder may influencehow children respond to medication treatment. Somestudies have found that these children do not respondas well to stimulant treatment. In some youngstersthere appeared to be an increase in side ef fects, includ-ing tics and sadness. In addition, there have beenclinical suggestions that in some children stimulanttreatment may worsen symptoms of anxiety. One study,however, found no difference in treatment responsebetween children with anxiety and those without. Incontrast, the NIMH Multimodal Treatment of Chil-dren with AD/HD1 looked at a subgroup of childrenwho had anxiety symptoms at the beginning of thestudy and found that methylphenidate did not exacer-bate anxiety symptoms and some children showed areduction in anxiety symptoms following treatment.Some clinical studies have looked at children withboth conditions and have found that the addition of aselective serotonin reuptake inhibitor (SSRI) to stimu-lant treatment has been helpful.

In order to better evaluate the best treatment foryoungsters with AD/HD and anxiety disorder, theNIMH has sponsored a multi-site trial. The study willexamine the benefits of the stimulant medication me-thylphenidate both alone and in combination withfluvoxamine, an SSRI for treating these co-occurringdisorders in youngsters ages 6 –17.

Five clinical sites across the U.S. are participating inthis study. A diagnostic evaluation will be provided atno cost for all eligible participants, and families willbe reimbursed for travel expenses. Weekly clinic visitswill be required of all participants for the duration ofthe study (6–22 weeks, depending on response).

The sites and their contacts are listed below:

Duke University Medical Center, Durham, NC. Contact: PatGammon, Phone: (919) 416-2406, E-Mail: gammo002@mc.duke.edu

Johns Hopkins School of Medicine, Baltimore, MD. Con-tact: Sam Walford, Phone (410) 955-1542, E-Mail:swalford@jhmi.edu

New York State Psychiatric Institute (168th St. & Riverside

Dr.), New York, NY. Contact: Lisa Capasso, Phone: (212)543-5952, E-Mail: capassol@child.cpmc.columbia.edu

New York University Child Study Center (33rd St. & FirstAve), New York, NY. Contact: Pat Rentas, Phone: (212)263-7779, E-mail: patricia.rentas@med.nyu.edu

University of California, Los Angeles, Los Angeles, CA.Contact: Kim Jeter, Phone: (310) 825-6527, E-mail:kjeter@mednet.ucla.edu

A website sponsored by the NYU Child Study Center,www.aboutourkids.org, provides information aboutdevelopment and mental health in children and ado-lescents, and also has an extensive library of articlesdealing with the trauma related to the recent attackson our nation. ■

Glenn S. Hirsch, M.D., is Deputy Director, NYU Child StudyCenter and Assistant Professor of Clinical Psychiatry, NYU Schoolof Medicine.

Reference1 MTA Cooperative Group. (1999) A 14-month randomized clin-ical trial of treatment strategies for attention-deficit/hyperactivitydisorder. Archives of General Psychiatry, 56, 12.

The emotional aspectsof anxiety may produce

physical symptomssuch as blushing, trem-

ors, sweating, feelingfaint, muscle tension

and heart palpitations.

Recent studiessuggest that up to25 percent of childrenwith AD/HD have ananxiety disorder, and25 percent of childrenwith an anxiety dis-order have AD/HD.