Double jeopardy: How to treat kids with comorbid anxiety and ADHD
Medication and CBT usually are necessary for these highly impaired children.
Aaron, age 10, has been diagnosed with an anxiety disorder and attention-deficit/hyperactivity disorder (ADHD) but is not being treated with medication because his parents do not believe in psychopharmacology. They bring him to a specialized child anxiety clinic and ask for “urgent CBT” because his behavior at school is out of control.
Aaron rearranges the therapist’s office furniture during much of the assessment interview. He also acknowledges many anxiety symptoms. The therapist doubts that cognitive-behavioral therapy (CBT) would help without other interventions.
Children with anxiety disorders and ADHD—a common comorbid presentation—tend to be more impaired than those with either condition alone.1 Effective treatment usually requires 4 components (Table 1), including medication plus behavioral or cognitive-behavioral therapy. This article discusses clinical issues related to each component and describes how to successfully combine them into a treatment plan.
Comorbid ADHD and anxiety: 4 treatment components
Successful treatment usually involves combining 4 components:
Make individual adjustments as needed, depending on the child’s symptom profile, social context, and developmental level
ADHD: attention-deficit/hyperactivity disorder
Stimulants, atomoxetine, and selective serotonin reuptake inhibitors (SSRIs) have been advocated for children with anxiety and ADHD. Given the high risk of behavioral disinhibition with SSRIs in children,2 stimulants or atomoxetine are suggested as first-line medications.3,4
Stimulants target ADHD symptoms primarily, but anxiety decreases in some children (24% in a recent trial) as ADHD symptoms are controlled.4 Because it is a selective norepinephrine reuptake inhibitor (SNRI), atomoxetine may target both ADHD and anxiety symptoms. When initiating these medications, “start low and go slow.” Recommended dosing is no different for children with ADHD and anxiety than for those with ADHD alone (Table 2).5
Stimulant response rates for children with ADHD and anxiety vary among studies. Some report lower response rates than for children with ADHD alone and possibly more treatment-emergent side effects.6 The National Institute of Mental Health’s Multimodal Treatment Study of Children with ADHD (MTA) found that comorbid anxiety did not adversely affect behavioral response to stimulants but did moderate outcomes (Box 1).7,8 Adding intensive psychosocial intervention to stimulant treatment appeared to yield greater improvements in anxious children with ADHD, compared with stimulants alone.8
Cognitive impairments related to inattention do not consistently improve with stimulant treatment.9 This is clinically important because children with ADHD and comorbid anxiety disorders can be very cognitively impaired.10
Add an SSRI? Monotherapy is simpler and usually more acceptable to families, but a placebo-controlled study examined adding an SSRI (fluvoxamine) to methylphenidate treatment.4 Children with anxiety and ADHD who received adjunctive fluvoxamine did no better than those who received methylphenidate plus placebo.
Atomoxetine. A large, randomized, controlled trial of atomoxetine in this population found good tolerability and statistically significant reductions in ADHD and anxiety symptoms compared with placebo. Effect size was greater for ADHD symptoms than for anxiety symptoms,11 however, which supports smaller trials that show more consistent evidence of atomoxetine reducing ADHD symptoms than anxiety symptoms.
Similar to antidepressants with the SNRI chemical structure, atomoxetine’s effectiveness for a given child takes several weeks to determine. This can be a problem in children who are highly distressed or impaired and require rapid symptomatic improvement.
Recommendation. Consider a stimulant or atomoxetine initially for children with anxiety disorders and ADHD, and seek concurrent behavioral or cognitive-behavioral therapy. Caution families that:
- >1 medication trial might be needed, as response may not be as consistent as in children with ADHD alone
- medication-related improvements in ADHD symptoms will not necessarily be associated with reduced anxiety symptoms or improved academic ability
- improvements with atomoxetine might not be evident for several weeks.
Medication dosing for children with ADHD*
Recommended starting dosage
Recommended maximum dosage
5 most common side effects in descending prevalence
Methylphenidate hydrochloride (Ritalin)
5 mg tid
Total 60 mg/d
Insomnia, nervousness, decreased appetite, dizziness, nausea
Methylphenidate hydrochloride (Concerta)
18 mg every morning
54 mg every morning
Headache, abdominal pain, decreased appetite, vomiting, insomnia
Dextroamphetamine sulfate (Dexedrine)
5 mg every morning
Total 40 mg/d
Palpitations, restlessness, dizziness, dry mouth, decreased appetite
Mixed amphetamine salts (Adderall)
10 mg every morning
30 mg every morning
Decreased appetite, insomnia, abdominal pain, emotional lability, vomiting
Decreased appetite, dizziness, stomach upset, fatigue, irritability
ADHD: attention-deficit/hyperactivity disorder
* Recommended dosing is no different for children with ADHD and anxiety than for children with only ADHD
Source: Reference 5
CBT has been shown effective for child-hood anxiety disorders in randomized controlled trials,12 but even those that included children with comorbid ADHD required that an anxiety disorder be the primary, most impairing diagnosis.13 Thus, little is known about CBT’s effectiveness for children with anxiety plus ADHD. Given the evidence for cognitive deficits in comorbid anxiety and ADHD10 and the challenge of working with highly distractible children, one would expect CBT to be more difficult in this population.
The potential for distraction to adversely affect learning of coping strategies is higher in group than in individual therapy, and children with anxiety and ADHD can be disruptive to other children in CBT groups. Consider individual CBT, and seek a therapist who has experience with this population. Having the child on medication for ADHD symptoms usually helps reduce these symptoms’ impact on sessions.
For children younger than about age 8 or too cognitively impaired to benefit from CBT, behavioral intervention alone may be helpful. The largely behavioral psychosocial intervention in the MTA study of ADHD children age 7 to 9 (Box 2)8,14 helped many of those with comorbid anxiety.
Although programs as intense as that used in the MTA study rarely are provided in community practice, consider behavior modification. For example:
- To reduce anxiety, have the child follow regular, predictable routines, and reward the child for gradually facing previously avoided situations.
- To reduce distractibility in class, have the child sit near the teacher, break work into small chunks, and reward completion of each chunk.
Even small improvements in the child’s home or school behavior may reduce negative interactions with others and the attendant effects on self-esteem.
CASE CONTINUED: Weighing the options
The therapist seeing Aaron’s family listens to their concerns about medication and reassures them that their son will not be denied psychotherapy. She tells them, however, that psychotherapy will not address his urgent school problems and is unlikely to work in the absence of medication, given Aaron’s behavior in the office. The therapist provides accurate information about the risks and benefits of medication and CBT, and the parents agree to think about all treatment options.
By the next office visit, the school has threatened to suspend Aaron. He and his parents agree to combined treatment with a stimulant medication and CBT and to having the therapist provide a behavioral consultation at the school.
Medication + psychosocial treatment
shows best outcomes for ADHD with anxiety
The National Institute of Mental Health’s Multimodal Treatment Study of Children with ADHD—the largest study to date—found that comorbid anxiety did not adversely affect behavioral response to stimulants but did moderate outcomes.
In the parallel group design study, 579 ADHD children age 7 to 9 were enrolled at 6 treatment sites, thoroughly assessed, then randomly assigned to 4 groups: medication treatment alone, intensive psychosocial treatment alone, a combination of both treatments, or usual community care. The first 3 interventions were designed to reflect best practices for each approach, and these children were closely monitored and studied for 14 months. All 4 groups were reassessed periodically for 24 months, evaluating multiple outcomes.
For the total sample, combined and medication treatment were more effective than psychosocial treatment and community care. For ADHD children with comorbid anxiety disorders:
- combined treatment was more effective than either medication treatment alone or psychosocial treatment alone
- both monotherapies were superior to community care.
ADHD: attention-deficit/hyperactivity disorder
With families of children with behavioral challenges, adopt a patient, educational approach rather than acquiescing to their wishes or arguing with them. Either can result in treatment failure. Discuss potential benefits and risks of all treatment options and the impact of comorbidity on treatment.
Parents’ rigid insistence on a particular course of action—such as refusing psychopharmacology—may be caused by anxiety or misinformation. Elicit the source of any anxiety, and provide realistic information and reassurance if possible.
Anxiety in family members may be constitutional—as anxiety is highly heritable15—or relate to aspects of treatment. Families may feel overwhelmed by:
- their child having 2 disorders rather than 1
- your suggestion to start medical and nonmedical intervention together
- hearing about the possibility of multiple medication trials.
Negotiating medication. Discuss with the family the difficulties of a child learning CBT strategies when ADHD is not well-controlled and the cognitive difficulties in many of these children that may necessitate individualized CBT. If the family remains reluctant to consider combining medication with CBT, try contracting for a limited number of CBT sessions (perhaps 3 or 4) before re-evaluating the need for medication.
The child’s perceptions (and potential anxieties) about his or her difficulties also must be understood, validated, and addressed. Children are more likely to engage in a treatment if they participate in the decision to adopt it.
Anxiety can heighten vigilance in the child or the parents to treatment-emergent side effects, which you may exacerbate by providing exhaustive lists of potential ad-verse events. Limit discussion to serious side effects—with emphasis on their rarity—and those that are common.
ADHD traits in families can affect treatment success. Because of their own distractibility and organizational difficulties, parents with ADHD traits may have difficulty ensuring the child’s medication adherence and treatment participation.16
Behavior modification can require a high degree of consistency in parents’ behavior toward the child. This may be difficult to achieve in families where:
- 1 or both parents are inattentive because of ADHD
- a high degree of conflict exists between parents.
To help these families, provide reminder calls about appointments and schedule sessions at a consistent time. To improve consistency of medication use:
- combine medication administration with an essential daily activity
- check adherence with pill counts or other means.
If the child participates in CBT, provide separate notebooks for in-session and homework exercises—anticipating some loss of homework notebooks.
Individualized care is important to return each child to his or her best possible level of functioning. The child’s symptom profile, environment, and developmental level can affect treatment.
For example, in a child whose ADHD-related impairment is substantial but whose anxiety-related impairment is mild, pharmacotherapy for ADHD and some pa-rental guidance may be adequate to manage remaining anxiety symptoms.17 As mentioned, some children show decreased anxiety as their ADHD is better controlled.4 Conversely, if ADHD-related impairment is mild but the child is highly anxious, consider CBT alone—preferably on an individual basis—provided the child can manage the cognitive aspects of therapy.
School personnel can monitor change in relation to various interventions, as many of these children’s symptoms manifest in the classroom. Behavioral interventions are more likely to succeed if they are administered consistently across home and school environments8 and teachers participate in behavior modification.
To elicit cooperation from school personnel, listen to their concerns and observations and help them understand the child’s difficulties and the rationale for various treatments. This approach often reduces negative feedback toward the child, a benefit that may further improve outcomes.