Disentangling and Treating ADHD and Anxiety

Transcription

1 Disentangling and Treating ADHD and Anxiety Oscar Bukstein, MD Andrew Potash, PsyD 1 Disclosures of Potential Conflicts Source Research Funding Advisor/ consultant Employee Speaker s Bureau Books, Intellectual Property In-kind services Stock or Equity Honorarium or expenses for this meeting Routlege Press x Wolters Kluwer Health X 1

2 Prevalence ADHD DSM-V 5% of children, 2.5% of adults (APA DSM-V, 2013) Other sources 2011: U.S. children currently diagnosed according to parent report 8.8%. Ever diagnosed 11% (CDC, 2018) 4.4% of adults (Kessler et al., 2006) Anxiety disorders 33.7% lifetime rate, 21.3% annual rate for U.S. population (Kessler et al., 2012) 3 Comorbidity Percentage of children with ADHD and another disorder 4 (CDC Website, 2018) 2

3 Overlapping Symptoms ADHD LD ASD PTSD ODD/CD Anxiety Depression Personality Disorders ADHD -vs- Anxiety Inattention -vs- Preoccupation Hyperactivity -vs- Hyperarousal Impulsivity -vs- Escape/Avoidant Behavior 6 3

4 Anxiety posing as ADHD 7 Unfocused Reactive Talkative Fidgety Pressured On Edge Dependent on Accommodations Avoidant Preoccupied Restless Keyed-up Nervous Arousal Worried Attention-Seeking Fatigued at End of School Day Impatient ADHD -vs- Anxiety Neurodevelopmental -vs- State-based 8 4

5 ADHD + Anxiety =? Response inhibition (physiological anxiety) Sustained attention More inattentive than impulsive Working memory Auditory emotion recognition Response inhibition (cognitive anxiety) (Jarrett et al., 2016) 9 Impact on Overall Functional Impairment ADHD+Anxiety Increases: Overall impairment Symptom severity Attentional problems School fears Sluggish Cognitive Tempo (i.e., reduces tempo) Decreases Overall attentional, cognitive, and executive functioning Impulsivity Social competence ( Rejection Sensitive Dysphoria ) Anxiety has a greater negative impact on working memory than does ADHD. Presence of 2 or more anxiety disorders leads to poorer outcomes and greater functional impairment. (Brown et al., 2008; Greene et al., 2001; Karustis et al., 2000; Manassis et al., 2007; Newcorn et al., 2001; Newcorn et al., 2004Pliska, 1992; Tannock et al., 1995; Sciberras et al., 2014) 5

6 ADHD leading to anxiety 11 Persistence of ADHD into adulthood is associated with generalized anxiety disorder (OR, 5.19). 12 6

7 Anxiety Behavior Inhibition ADHD vs Anxiety ADHD Behavior Disinhibition Both systems share Frontal connectivity Through different subcortical networks Frontal cortex amygdala Anterior cingulate: cognitive/emotional responses striatum 13 Assessment Measures Anxiety Screen for Child Anxiety Related Disorders (SCARED) Multi-dimensional Anxiety Scale for Children (MASC) ADHD Vanderbilt Connors IOWA Connors SNAP IV ADRS - adult CAARS - adult Global scales with anxiety/adhd subscales Child Behavior Checklist (CBCL) Behavioral Assessment System for Children (BASC) Conners Comprehensive Behavior System (CBRS) 7

8 Assessment Diagnostic Interview history and chronology ADHD Rating scales children: parent, teacher Adults: self and significant other Anxiety Rating Scales - self-report, (parents for children) Which to Treat First?? The disorder that has the greatest effect on current functioning/causes more impairment Children: Usually ADHD Exception: extreme avoidance (school refusal) Adults: Usually Anxiety Depends on severity, impairment, avoidance 8

9 Does Successful Treatment of ADHD Improve Anxiety Symptoms? Direct or Indirect Effects Abikoff et al 2005 Coughlin et al., 2015 Meta-analysis Risk of anxiety decreased with stimulants (vs placebo) both low and high dose stimulants Likely indirect effects Other Studies Kendall et al., 2001: remission of primary ANX predicted remission of comorbidity Lack of control of medication status Control of ADHD Symptoms? 9

10 Children: ADHD as Initial Treatment Hyperactivity/Impulsivity/comorbidity with CD/ODD Parents/teachers, not children, decide on referral to Tx Anxiety has not progressed enough Exceptions: high level of avoidance ( school refusal ; Selective Mutism) Adults: Anxiety D/O as Initial Treatment Adults get to decide on (self-) referral Comorbidity with mood disorders Progression and impairments of Anxiety Disorder(s) in adulthood Difficulty in ascertaining improvement in ADHD sx if anxiety/(mood) unimproved 10

11 Do Children with ADHD + Anxiety Respond as well to Stimulants? Studies from early 90 s suggest that MPH not as effective in those with Anxiety D/Os (Buitelaar et al., 1995; Ter-Stepanian et al., 2010) Multi-modal Treatment Study of ADHD (MTA): no difference +/- stimulant response Improved response to behavioral treatment (Combination TX) in those with anxiety (Jensen et al., 2001) Children: Treatment Plan 1. Control ADHD sx and associated problems (including DBDs) A. Stimulants (MPH/AMP)/non-stimulants as needed B. PMT/school resources 2. Re-evaluate ANX sx 3. Control ANX sx and associated problems (including mood disorders) A. Augmented CBT for ANX (consider family-based B. SSRIs 11

12 Adult Treatment Plan 1. Control ANX sx and associated problems (including mood disorders) A. CBT for ANX B. SSRIs 2. Evaluate ANX symptoms 3. Control ADHD sx A. Stimulants (MPH/AMP)/non-stimulants as needed B. (CBT for ADHD) Medications for ADHD-ANX D/O Stimulants, alpha-agonists, and atomoxetine improve ADHD (AHRQ, 2018) Stimulant medication may increase the effectiveness of CBT (Hinshaw, Henker, & Whalen, 1984) 12

13 Anxiety Side Effects of Stimulant Medication Anxiety and nervousness common side effects Abdominal pain, anorexia, constipation, dizziness, dry mouth, headache, insomnia, jitteriness, irritability, nausea, and palpitations (Greenhill, 2001) Jitteriness and social withdrawal (AAP, 2001) Anxiety in Children Treated with Stimulants Risk of anxiety STIM<Pl (RR=0.86) Higher doses of STIM associated with reduced risk of anxiety vs PL (p=0.019) 13

14 Treatment Issues for Anxiety CBT requires habituation (exposure) Inattention/distractibility/over activity may interfere with exposure Psychoeducation, participant modeling, cognitive restructuring Cognitive interventions largely ineffective for ADHD Other ADHD Comorbidities: CD, ODD 27 Explanations for Improved Anxiety with Stimulants 1. Stimulants have a direct effect in reducing anxiety no evidence 2. Stimulants indirectly reduce anxiety by improving ADHD symptoms Reduction in anxiogenic situations Fewer academic problems Reduced peer, parent conflict ADHD + SAD/GAD anxiety with STIM RX (Golubchik et al., 2014) ADHD + ANX D/O anxiety w/ STIM > Anx RX (Abikoff et al., 2005) 14

15 Selection of ADHD Medication Stimulants still #1; prefer long-acting MPH before AMP? 2 nd line: Atomoxetine (especially for adults) Alpha agonists Start low, go slow Atomoxetine- Adults Social anxiety disorder Adler et al (2010) Adler et al (2009) Donnelly et al (2009) Ravindran et a(2009) ATX significantly better than PBO Response rate better in ADHD (51%) than ADHD plus SAD (42%) CAARS:Inv:SV score improvement better in ADHD than ADHD + SAD ATX significantly improved ADHD symptoms (CAARS:Inv:SV) and anxiety scores (LSAS; CGI-OS; STAI), and quality of life (AAQoL) compared to PBO in Pts with ADHD and SAD. SAS was markedly improved ATX-mediated improvements in ADHD directly correlated with anxiety improvement in Pts with ADHD and SAD ATX not different from PBO in Pts with GSAD and without ADHD (LSAS) 15

16 Kratochvil et al (2005) Atomoxetine - Children RCT 7 17 years ATX plus PBO not significantly different from ATX and fluoxetine. Significant improvements in ADHD symptoms (ADHD-RS) and anxiety symptoms (MASC) Geller et al (2007) RCT 8 17 years ATX significantly improved ADHD symptoms (ADHD- RS) and anxiety (PARS) * ATX did not exacerbate comorbid anxiety Alpha Agonists for Anxiety Guanfacine XR vs PL for Primary ANX D/O in children safe but outcome ns except CGI-I (Strawn et al., 2017) Clonidine for panic, GAD in adults decrease anxiety symptoms; 17% worse (Hoehn-Saric et al. 1981) 16

17 Effect of ADHD on Anxiety Treatment - CAMS CAMS (Child/Adoles Anxiety Multi-Modal Study) CBT only, Med-only, Combo CBT only group: poorer immediate Tx response/remission rate Need Rx or other psychosocial interventions (Halldorsdottir et al., 2014; 2015) Counseling Approaches: Behavioral Therapy Operant Conditioning Parent Management Training School-based behavioral strategies Exposure-based therapy for anxiety 34 17

18 Counseling Approaches: Cognitive Restructuring Often helpful for anxiety Alter thought processes around internal and external cues Misperception of risk Sometimes helpful for ADHD Alter distortions around symptoms, self-efficacy Misperception of time/ability 35 Counseling Approaches: Interpersonal/Social Belonging Targets sense of social effectiveness Indirectly addresses impulse control, attunement/engagement 36 18

19 Counseling Approaches: Physiological Calming Transfers control from sympathetic (fight/flight) to parasympathetic (rest/digest) nervous system modes Enhances effectiveness of prefrontal/executive controls while reducing power of limbic/emotional Increases awareness of physiological state and sense of self-control 37 Can build Counseling Approaches: Mindfulness Self-awareness Self-acceptance Ability to purposely direct attention Ability to sustain attention 38 19

20 Counseling considerations and potential problems Focusing on one diagnosis at the expense of another Behavioral parenting training can increase anxiety, emotional dysregulation, and relational stress School-based behavioral interventions can increase stigma Social skills training can lead to contagion or stigma 39 Counseling considerations and potential problems Many therapies assume intact executive functioning Inattention/distractibility/hyperactivity may interfere with exposure and habituation Other comorbidities (CD-ODD-ASD-LD) may all impact treatment Increasing reliance on structure and planning Must be developmentally- (not age-) appropriate Contraindicated for OCD Increasing insight may also increase sense of hopelessness 40 20

21 Clinical Recommendations for ADHD-ANX d/o Comorbidity for Children Adequate assessment Flexibility in administration of ANX CBT Increased structure Interactive tasks to facilitate engagement Creative in presenting information in multiple ways Adapting Parent Management Training (PMT)/Operant strategies Including problem-solving skills Role play/homework 21