31. ADHD, Anxiety, or both? Making the right diagnosis with Dr. Jeffrey Strawn

ADHD and Anxiety and highly intertwined, so how can you tease them apart?
Join us as Dr. Jeffrey Strawn shares clinical pearls about how to detect whether a child has ADHD, anxiety, or both! We discuss:

* the consequences of untreated ADHD (especially social and educational impacts)
* how ADHD and anxiety are related  and that 30% of kids w/ ADHD have anxiety, too!

Some take home messages are:

1 – When screening kids for ADHD, also consider using the SCARED-5 to screen them for anxiety!

2 – Good clinical question to ask kids about anxiety

o   “How good are you at worrying?”

o   “What would happen IF (the thing they fear occurred)?”

3 – To distinguish between clinical anxiety disorder and an anxiety trait..

            Ask, is [ the thing they are worried about] reasonable/expected?

            Is the anxiety proportional to the stressor?

Dr. Jeffrey Strawn is a Professor of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine.  Dr. Strawn directs the Anxiety Disorders Research Program and conducts clinical trials and neuroimaging studies in patients with anxiety and related disorders.  He is an internationally recognized expert int he field of child and adolescent anxiety disorders.

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

Welcome to PsychEd4Peds the child mental health podcast for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco child psychiatrist and mom. Today on psyched for peds, we are very excited to have with us. Dr. Jeff Strawn. He's a fantastic child and adolescent psychiatrist and a star psychopharmacologist. He's a professor of psychiatry and behavioral neuroscience at the university of Cincinnati college of medicine, where he directs the anxiety disorders, research programs, and conducts clinical trials and neuro imaging studies in patients with anxiety and related disorders. He's an internationally recognized expert in the field of child and adolescent anxiety. And I'm really excited to listen to his ideas about ADHD and anxiety and how can we help understand them better and how can we treat the kids who suffer from both. So, first off, welcome to the pod, Dr. Jeff Strawn.

Dr. Jeffrey Strawn: 1:21

Thanks so much. It is great to be

Dr. Elise Fallucco: 1:23

here. Thank you so much for joining us. So, let's start and talk generally about ADHD and anxiety. We know that the two illnesses are commonly comorbid, that kids who have one will often develop the other. Can you tell us a little bit about how you think through that?

Dr. Jeffrey Strawn: 1:40

Absolutely. Oftentimes we're focused in the pediatric primary care setting on ADHD and ADHD screening, but ADHD symptoms really overlap with many anxiety symptoms and similarly anxiety symptoms overlap with ADHD. We also know from many of the studies that we have, like the multimodal treatment of ADHD study, that about 30 percent of kids with ADHD will actually have an anxiety disorder. But I think really you touched on something even more important in that beyond this overlap and shared comorbidity. These symptoms of ADHD and symptoms of anxiety reverberate with one another. So when we think about that classic child with ADHD that has inattention and hyperactivity, impulsivity, all of the symptoms of ADHD, they're more likely to have those maladaptive behaviors in school settings and social settings. That tends to lead to a situation in which they may experience more criticism or humiliation or just other negative events, which I think for many of these kids, unfortunately, then results in feelings of shame and helplessness. They may feel inadequate. And as a result of that, they then become more fearful of making mistakes and of being criticized. And I think that really sets the stage for interpersonal sensitivity that we see that then produces these cognitive distortions that are really the hallmark of anxiety. And then, of course, from there, we know where we go, we see increasing avoidance, we see withdrawal, and we also see more of that increased attention to one's thoughts and this bias towards I'm going to do something wrong, I'm going to mess something up, I'm not good enough, Those other things that we then think of as more anxiety symptoms, you're clearly coming from or at least worsened by the underlying ADHD. So it really becomes kind of a feed forward cycle, if

Dr. Elise Fallucco: 3:50

you will. That was so beautifully put. one of the things that we cannot underestimate is the social impact of ADHD, just exactly as you're describing. So a child who has trouble keeping their hands to themselves, or is always blurting out answers or, maybe getting in trouble in school. Yeah. The other kids notice and they think this kid's a little different and it's very easy to get excluded or to get made fun of, or to have trouble kind of socially fitting in because of some of the symptoms of ADHD. And then as you put it, you internalize, well, wait a minute, why are kids not including me in things? What's wrong with me? And then it causes more self doubt. The longer the child goes having ADHD symptoms that are causing problems in school and maybe with friends the more their self esteem is getting impacted. so if there's something we could do to try to help and support them, then,

Dr. Jeffrey Strawn: 4:41

absolutely. And I, I think those social impacts and just, broader educational impacts, you know, when we see that child that's struggling in school, whether it be educationally or socially or both because of the untreated ADHD. We see secondary symptoms as well, right? So we see that child becoming demoralized, no longer liking school, potentially even starting to avoid some activities at school, perhaps it's group work, even evolving into school avoidance or school refusal.

Dr. Elise Fallucco: 5:12

so then thinking proactively about what we can do to treat ADHD, let's say you've got a kid in your office. They have a family history of anxiety, one of the parents has anxiety and the child's presenting with symptoms of ADHD meets criteria for ADHD, is there a go to stimulant that you would use for a child with ADHD and a positive family history of anxiety to try to minimize the likelihood of worsening anxiety?

Dr. Jeffrey Strawn: 5:40

So I'm going to take a step back from that question. before we think about the medication, we have to really make sure that we've gotten the diagnosis right. In looking at the child that you just described, I think the most important thing you've set up the scenario where we have some genetic loading. So family history of anxiety, but we may or may not have the anxiety symptoms. And so, one of the things really that the clinician treating the child you described has to do is to Really smoke out what's primary? Are there anxiety symptoms or those anxiety symptoms related to ADHD? or is this anxiety that's causing inattention? and it's so critical to figure out if those symptoms that are presenting in the office with that child are driven primarily by anxiety or if they're driven by ADHD. And oftentimes because we do a much better job of screening for ADHD than we do for anxiety, I think in the primary pediatric care setting, we may be biased towards seeing those symptoms as related to the ADHD.

Dr. Elise Fallucco: 6:44

When you're talking about smoking out what is the primary in somebody who has ADHD and some anxiety symptoms, just like we collect Vanderbilt's or Connor scales to assess for ADHD, would you also recommend that pediatric clinicians are in primary care that they routinely check some sort of anxiety screener along with that?

Dr. Jeffrey Strawn: 7:03

I would, but I do think it's helpful just in terms of kind of asking the question. I used to use the SCARED, it's nice. It's, uh, 41 items. I find it somewhat burdensome to score, but it does provide a really nice inventory of generalized separation, social anxiety disorder symptoms, as well as avoidance, uh, and other associated symptoms. But in, in more recent years, I've actually shifted to the scared five. So it's something that is a lot easier to score. Um, it's, as the name implies, made up of five items as opposed to 41. Uh, and so it's, it's a little bit faster as

Dr. Elise Fallucco: 7:45

well. You know, I'm a huge fan of the SCARED, and I recognize 41 items is so long, so I like the idea of pairing, you know, your Vanderbilt or your Connors with the SCARED5. And then of course, knowing that screening tools are not diagnostic, it just gives you a starting off point.

Dr. Jeffrey Strawn: 8:03

I'm so glad you brought this up. When I do use a screening tool, it's important to mention that it's just really paired with my clinical interview. When we often ask about anxiety, we say things like, do you worry? Which again, these are patients that really want to please us and they're concerned in terms of how we're perceiving them. And so I like to flip that question. So the way that I often ask it is, how good are you at worrying? And so once they say, you know, I'm pretty good at worrying, I can then really try to flesh out, well, is this something that is appropriate because Maybe they have a learning weakness and they're really worried about reading and reading comprehension and how they're doing in language arts, in which case it's it's expected and proportional to that context versus is this the anxiety that is typical of a generalized anxiety disorder, social or separation anxiety disorder.

Dr. Elise Fallucco: 9:02

What an excellent clinical pearl on assessing anxiety in kids. So I just want to repeat this. You said in, you know, how you ask kids about anxiety is you ask them, how good are you at worrying? Right. So, it flips, it turns it around, so they're like, I mean, I'm really good at worrying.

Dr. Jeffrey Strawn: 9:23

Right, right. And then the other thing that I also talk about, and this is something that I borrowed from our good friend, Dr. John Walkup, is, you know, when I'm thinking about anxiety, I think about two things. So we know that anxiety is normal. It has a role. It's important. It motivates us. One of the things that's really hard for us sometimes is looking at something that's a normal emotion, but something that also overlaps with pathology. And so I, I like walk ups approach to this. He thinks about anxiety in terms of two criteria. Is it proportional? And is it expected? And for me, when I'm going through that situation that the patient's describing where there's some anxiety and I'm thinking with them often out loud and trying to really measure this with them, is it proportional and is it

Dr. Elise Fallucco: 10:14

expected? Excellent. So then, you know, just like with your example of the child who has difficulty reading and they're spending all night working on their little book reports if they're worried only about that or specifically about that in the context of stress in that area, that makes sense.

Dr. Jeffrey Strawn: 10:31

And those are the kids that, you know, again, are a little bit challenging because you ask and, you know, we may have a tendency to dismiss that in terms of, yeah, he worries a little bit about reading or he worries a little bit about school performance. But one of the things that I like to really do in those situations to try to help me distinguish between what is an anxiety disorder versus perhaps just a trait is I'll say, but what would happen if. What would happen if and as they present the next step in this scenario, I'm essentially asking what would happen and oftentimes in those situations I'll get the I'm worried about my school performance because this will affect what classes I get into in high school and that will determine what college I get into and that will determine what I end up doing as a career and as a job and that's really important because I know that I have a family history of cardiac disease and I know that if I don't get good insurance in terms of this job, Then I'm more at risk of adverse medical outcomes and so forth. And, you know, we stop and say, wow, this came from a sixth grade book report. Um,

Dr. Elise Fallucco: 11:34

What would happen if I like that? So not just stopping it. Okay. So we're worried about reading and that makes sense because it's expected, but then taking it a step farther and asking, so what happens if you fail language arts or what happens if you get a C in language arts? What does that mean? Right. You know, and if the answer is, Oh, I guess I have to do summer school. Like that would be a bummer, would that be okay? Or is it this catastrophic series of unfortunate events that end up 20 years down the road? Exactly, exactly. Well, we started this conversation with the question of what would be your favorite med for somebody with ADHD and anxiety.

12:12

And you'll notice that your approach and your response to that was a, such a great reminder for us to really think first in terms of. Our clinical diagnosis and making sure we're not missing potential anxiety in somebody who presents with symptoms of ADHD. And reminding us that even among kids who have a clear cut diagnosis of ADHD, that 30% of them will also have a comorbid anxiety disorder. And you've also shared some really great clinical pearls with us.

Dr. Elise Fallucco: 12:42

One. When you're assessing somebody for ADHD with a Connor's or Vanderbilt consider pairing the scared five, which is the brief version of the scared 41 item. To also screen for anxiety. Second Pearl. If you get a positive screen for anxiety, remember that it's not diagnostic. And think about asking the following clinical questions as a followup. First of all, how good are you at worrying and then when you're talking about what they're worrying about, ask them, what would happen if. The thing that they're worried about. Comes true. And finally. When we try to distinguish between an anxiety disorder versus just an anxiety trait. Ask yourself. The question. Is it reasonable or expected that the child is worrying about something and. Likewise. Is there worry, proportional to the stress that they're experiencing or does it seem out of proportion? Great. So we will continue part, two of this conversation about ADHD and anxiety next week.

13:43

And talk specifically about medication options for treating ADHD and anxiety. I hope you'll join us as always check out our website, psyched, the number four paeds. If you want to link to the scared five or any other resources we talked about.

Dr. Elise Fallucco: 13:59

And please, if you have not already click, follow or subscribe on your apple podcast app for the show or Google play or wherever you are listening to it. Thanks for joining. See you next time.