From Assessment to Action: Managing Anxiety in Neurodivergent Young People

In this ASDP podcast episode, Dr David Chinn joins Dr James Carter to explore the complexities of managing anxiety in neurodivergent children, particularly those with autism and ADHD, highlighting the limited evidence for SSRIs in autism and the importance of careful assessment, tailored pharmacotherapy, and non-medication supports. The conversation also touches on ADHD prescribing reform in New Zealand and the importance of strength-based, person-centred care that builds long-term wellbeing and self-efficacy for children and families.

Transcript

James 0:12
Tēnā koutou, tēnā koutou, tēnā koutou, Hello everybody, it's Dr. James Carter, General Paediatrician coming to you from the Queenstown ASDP 2025 Conference where the theme is wellbeing, speaking well, thinking well, being well. And joining us now on the podcast is Dr. David Chinn, a child and adolescent psychiatrist who works at the Infant, Child, Adolescent and Family Service based in the Hutt Valley Mental Health Addiction and Infant. Intellectual Disability Service. David's also an affiliate researcher and clinical senior lecturer in the Department of Psychological Medicine at the University of Otago and a member of the Farmac Mental Health Subcommittee here in New Zealand, which we hopefully will touch on a bit later on today. Tēnā kwe, David. Tēnā kwe. Thank you. Thank you for joining us. Oh, thanks for having me. To begin with, the theme of this year's conference is wellbeing, speaking well, thinking well, being well. Can I begin by you telling us what you might do to look after your wellbeing? Thank you. 

David 1:15
So, in addition to being busy looking after two young children, who certainly divert one's attention from work matters, I play football. So, I play masters football. So, that's essentially football for old people locally. And I've also done a bit of acting recently. So, I've been in some amateur productions down in the local theatre group. So, that keeps me busy in non-work-related activities. 

James 1:43
Those who do most do best. And it sounds like you've got a few strings to your bow. I need to clarify a few things. You said you play football for old people and that you play masters. To the listeners who can't see, David, I can assure you, he looks much younger than me. Masters in my part of the world is generally over 40. Is that what it is? Over 35. Over 35. I won't ask you. But he's a young looking gentleman. And football, of course, has many definitions, particularly in Australia, where football might refer to Australian rules, rugby union, rugby league, or, of course, soccer. So, when you say football, you mean… This is soccer. This is soccer. Okay. Fantastic. And you are a thespian as well. 

David 2:19
Oh, I've been in a couple of small local productions recently. The last production was action-packed. It was a Shakespearean production. And I was involved in a sword fight. But unfortunately, I came out on the wrong side of that fight and had to die each night in a very dramatic fashion. 

James 2:35
It sounds like a Shakespearean fight. Somebody's dying in a sword fight. That sounds like a Shakespearean fight. Well, hopefully I get to see a scene of that at some point. Now, having read your bio, our listeners will be very interested to hear that you originally emanate from the Isle of Man. And you documented for us that the Isle of Man is best known for two things, tailless cats, and, of course, the Isle of Man Tourist Trophy, which is touring… Tourist Trophy. Tourist Trophy. The Isle of Man Tourist Trophy. So, listeners, for those of you who don't know that, that is a motorcycle race, a long-standing motorcycle race. And I did do a little bit of research, according to a Gemini AI search, David, the Isle of Man TT has seen over 275 recorded competitor deaths since 1910, which far outweighs, as a point of comparison, it far outweighs the amount of deaths in the Paris-Dakar rally. So, look, I'm not a mathematician, but by my reckoning, that is not good for your well-being, having that many deaths on this annual event. Absolutely. 

David 3:45
And I think that that probably are the competitors, but, unfortunately, the number of spectators who emulate the riders have had some really serious accidents as well. In fact, after finishing my medical training, I spent a year back on the Isle of Man, and over TT week, so there's a practice week and a competitive week over TT week, they actually bring the British Army in to help staff the hospital because the injuries in the TT are the closest you're going to get to a war zone. So, it's fairly dramatic stuff. Yeah. 

James 4:14
Who wouldn't want to sign up to participate in that race? Absolutely. Fantastic. Fantastic. All right. So, listen, David, you've just given a presentation here at the 2025 conference, which was very well attended. The doors had to be locked. And basically, you were largely talking about pharmacotherapy, particularly addressing anxiety in the neurodiverse population. So, particularly those with the diagnosis of autism and ADHD. The topic of your talk was mulling over management of anxiety in the neurodiverse population. Perhaps we could begin by you just giving us a little bit of a summary of where you see the data, what the research has given us so far in regards to pharmacotherapy for the purposes of managing anxiety in those populations, and also a comparison with pharmacotherapy in management of the OCD type symptoms as distinct from anxiety. 

David 5:17
Yeah, absolutely. So, we looked at a few different studies of treatments for anxiety, both in the neurotypical and neurodivergent population. In the neurotypical population, SSRIs would be the predominant medication used for children with anxiety. They can also be used for children in the neurodivergent population, but particularly for ASD. From a literature review, there seem to be very few supportive studies for the use of medication, SSRIs, in that population. There are no randomized control trials for anxiety specifically with the ASD population in young people. There are studies of SSRIs, but they tend to be for the repetitive behaviors you can get with ASD rather than for anxiety per se. There were a couple of other study types that did have suggestive results for SSRIs helping in the ASD population, but I would say that the evidence was far from convincing, And one of the concerns being that behavioral activation can occur with kids with ASD and can make use of SSRIs quite problematic. And so, there are other medications one can think about beyond the SSRIs. So, mitazapine, in fact, mitazapine seems to be the only treatment with evidence, with an RCT, sorry, in the youth ASD population. It wasn't statistically significant, the difference between mitazapine and placebo, but the results were suggestive, and it was probably slightly underpowered to detect that difference. So, I think that there may well be another study with that medication in the offing at some point, which would be useful to look at in more detail. Other medications one might think about would be things like buspirone, alpha agonists, which is clonidine or guanfacine, or even medications like quetiapine. But the range of evidence one might have to support those medications is also quite limited. For ADHD, on the other hand, the evidence seems to suggest that, if possible, treating the ADHD symptoms in the first instance also is helpful for anxiety. Now, some children may have anxiety exacerbated by medications like stimulants, but on the whole, it seems like controlling ADHD has a positive effect on anxiety symptoms for children with ADHD. For OCD, that was the other question you were asking, the evidence for OCD, there isn't a great deal of evidence for the treatment of OCD with medications in the ASD population. I guess one thing I'd say to begin with is really being very careful with assessment, because OCD, the obsessions can be distressing, are unwanted, can really cause interference with one's life. One might contrast that with some of the restricted interests people with ASD might develop, but for them, generally, these are wanted cognitions. These are things, actually, when you disrupt someone's access to them, people can get distressed, rather than the cognitioners themselves being inherently distressing, as they might be for OCD. So I think thinking carefully about assessment in that first instance is important. For OCD treatment for neurotypical children, SSRIs would be the first-line therapy, generally at medium to high doses. And if they're not helpful, maybe something like clomipramine, or if they are also insufficiently helpful, perhaps augmenting with an atypical antipsychotic. We don't have such good evidence in the ASD population, and so we might be extrapolating data from the neurotypical population, but being much more cautious, particularly around the behavioral activation I mentioned earlier. So you'd be probably starting at much lower doses and increasing the dose at an even slower rate than you would do for neurotypical children. 

James 9:17
Thank you. I mean, and look, there's a lot of information in there, and there's a lot of follow-up questions. But yeah, I mean, that was a really, I think, a key point that you're making initially with the pharmacotherapy, that actually in the setting of the cohort of patients who have a diagnosis of autism spectrum disorder and comorbid anxiety, that there's actually not a lot of great studies out there. There's not a lot of great data for us to draw on. To follow on from that, there's a few other things that you've said in that answer that I want to come back to, but just to follow on from that, one of the data points you mentioned in the study was that, and please correct me if I'm wrong, but there's about a prevalence rate of around about 50% of anxiety disorders in children and adolescents with autism spectrum disorder. I've got that correct? 

David 10:03
Yeah, up to that. I mean, and there are a number of studies done there, and they all seem to come out at 40% to 50%, so reasonably high rates. Yeah. 

James 10:11
And then a similar data point was that in adults up to the age of 30 years who have a diagnosis of autism spectrum disorder, it was a similar sort of number. 

David 10:20
Yes. 

James 10:21
So it is high, but it actually sort of struck me, I was a bit surprised by it thinking, well, it sort of seems a little bit lower than what my practical experience is, because if you ask me to put a number on my patients who I see who sit somewhere on the autism spectrum, I'd be thinking it'd be closer to about 100% of who have a cohort. I guess the difference being, they may not have a formally diagnosed anxiety disorder, but certainly will and truly display anxiety, and anxiety to the point where it is impactful on their daily function. 

David 10:48
I think that's probably right. I think, you know, we're thinking specifically around anxiety disorders with those figures, but having a diagnosis of ASD can be a challenging experience when you consider trying to live in the modern world. All the different things that perhaps aren't sufficiently adapted for young people with ASD. Like, for example, education systems. There are many aspects to education that can be very challenging for young people with ASD. And so anxiety can arise as a result of interacting with a world that isn't well designed for people with this condition. That doesn't necessarily mean they all have an anxiety disorder per se, but may experience quite distressing anxiety around many different aspects of the world that you might want to try to modify even before you get down the route of trying different sorts of medicines. 

James 11:40
To come back to another of the points you made a little bit earlier, I think this is probably a really, really key take-home message for our podcast listeners, particularly our advanced trainees. I was speaking to an advanced trainee just after you finished. Was this point you just made about stimulant medications may well be beneficial for addressing anxiety in the ADHD cohort, patients who have been assessed as meeting criteria for ADHD? And I think that is a really crucial learning point and take-home message for anybody who's prescribing because, yes, we all do have that concept in our mind of there's the potential for stimulants to exacerbate anxiety. And I'm sure that many clinicians, including myself, have had patients and families come back to us and swear that, yes, anxiety has worsened since they've started stimulants. But by God, I've had a few people who have come back. I've certainly, I've got one patient in mind, mother, very medically literate, mother, what I consider to be very, very sensible with her care, approach to her children's care. And she was really averse to stimulant medication for her child. She has a diagnosis of autism and ADHD and has good going anxiety. And so she was really averse to stimulant medication for quite a while and ultimately started on Ritalin and then Vyvanse. And particularly once she got onto longer acting, I should say the child got on the longer acting version. She said it was far bigger than the effects on concentration and impulsivity was anxiety. Now, that's just one anecdotal case study. But what you clearly presented to the group in that data was, hey, guys, this can be really beneficial for anxiety. So I think the take-home message is when we're presenting the pros and cons of these medications to our families, we've really got to make sure we're giving them both sides of the story. 

David 13:29
Yes, yes. I think the data would suggest that as a group, it likely leads to anxiety improving more than it can exacerbate. You know, for individuals, it certainly can exacerbate anxiety, particularly, I think, once you get to the higher dosages of stimulants. That can be one of the challenges is that anxiety can be exacerbated. But as a whole, it seems like treating ADHD can improve various challenges one might experience in life that can reduce anxiety-generating scenarios. 

James 14:04
Great, great. You mentioned a medication that I really don't have much familiarity with at all in Buspirone. And you said that there was a specific niche for that within generalized anxiety disorder. Can you just talk a little bit more to that? 

David 14:20
Yes. I mean, Buspirone is used, I think, probably predominantly in adult rather than younger person's populations. It particularly has a niche with generalized anxiety disorder. So these would be people who may worry about a large number of different events or maybe worry about worry, often with physical signs to go along with those cognitive challenges as well. And Buspirone seems to develop a bit of a niche in that population. And what it presented was that there are some suggestive studies that Buspirone may be helpful for the anxiety experienced by young people with ASD. Now, neither was a randomized control trial. There were lower grades of evidence than that. But both showed promising results for Buspirone with that population. 

James 15:12
Okay, great. Another one that, in fact, one of the questions that was asked of you is, um, adamoxetine, is it coming back in? Or words to that effect. Somebody, one of the delegates asked that question. It's sort of my impression that, at least within the pediatric group, that it is prescribed, you know, far less these days than perhaps it was. You made a comment that you tend to think about adamoxetine if you're noticing difficulties with the young person at the bookends of the day. Can you just take that a bit deeper as well? 

David 15:44
Yeah, I think, I mean, stimulants can be very, very effective medications. But one of the challenges that young people and their families can sometimes experience is sometimes you're waiting for the medicine to, in inverted commas, kick in at the start of the day. Or sometimes you'll wait, you've got challenges at the end of the day when the stimulant medication's worn off. And one of the advantages to adamoxetine is that because it's taken on a daily basis, but the effects that you're experiencing aren't the results of the medicine you're taking that day. They're the cumulative effects of taking adamoxetine over several weeks. Then you get less of that variability in response. And so if you are noticing challenges, particularly at the start, the end of the day, then adamoxetine may not be an unreasonable medicine to consider. I think as a rule, you think about adamoxetine probably having a efficacy rate of about 60% for young people with ADHD, which is lower than that of stimulants. You know, the first stimulant often has a response rate of around 70%, so slightly lower response rate, but nevertheless may be a helpful medicine to think about for that particular niche. 

James 16:53
Now I made a comment to you while we were in, or as we were leaving the conference room, that it felt to me like you had about 100 people in there who were all lining up for a secondary consultation with myself being one of them, trying to consult on our most challenging patients. And look, I know this is really, really an unfair question, but if we were to really dumb things down and oversimplify things, would you be able to give the listeners, say, in terms of your approach, like a default approach to a patient? Let's say it's a patient with autism, comorbid anxiety. What might be your sort of hierarchical approach when we're talking specifically about pharmacotherapy? Obviously, in an ideal world, we've got cognitive behavioural therapy or talk therapy of some kind going on. We've got adjunct pharmacotherapy. We're thinking about introducing a pharmacotherapy. Have you got sort of a default hierarchy where you might go top three or top four? 

David 17:51
Yes, I mean, I think that you're right. So with the caveats that you're thinking about talking therapy being covered and other kind of elements that might provoke anxiety for a young person being attended to as well. So non-medication alternatives, such as thinking about someone's sensory environment, you know, the way the environment is structured around them, such in terms of schooling, making sure that support is provided there and at home. When you're thinking about medication, I'd be having an informed consent discussion with the family, just really laying out the possible options. I'd be guided by several things. I'd be guided by the response other people in the family may have experienced with medications, especially SSRIs. There's some evidence that in addition to inheriting lots of things from our parents, we inherit liver enzymes, which are a less glamorous thing to inherit than other physical attributes. But nevertheless, that can determine the extent to which somebody may or may not respond to a particular medication. So I'd be interested in that, say, for example, someone's first degree relative had tried various medications. That would be informative to me. I would also be thinking about the side effect profile of the relative medications. So there are marked differences between some of them. 

This may be contrasted with mirtazapine, which is another medicine with some evidence for the treatment of anxiety disorders in the ASD population, which can cause increased appetite, increased weight and sedation. Now, if somebody was having significant difficulties falling asleep, perhaps the anxiety was making it challenging for eat on a regular basis as well, then mirtazapine would not be an unreasonable medicine to use there. So I would be thinking about the SSRIs. I'd be thinking about medicines like mirtazapine as well. I think in this population, what I'd be bearing in mind as well, especially when using SSRIs, is the potential for behavioral activation. And so I'd be starting at a really quite a low dose, increasing that dose gradually. I'd be working carefully with the parents as well. What I often say is, you know, say, for example, we want to get to a target dose of 50 milligrams a day of sertraline. I'd be mapping out four, five steps to get there and letting the parents know that, say, if the anxiety peaked when it went from step three to step four, let's just go back down to step three for a few more days. We don't win any prizes if we're getting there quickly. I'd rather get there without making the journey particularly unpleasant for that young person. And often by doing that, you can help that medication regime to be more tolerable than just white-knuckling it through. 

James 20:30
Yeah, great. Can you give us some numbers for metazapine as you're starting your doses of mirtazapine? What numbers would you start out there? 

David 20:36
I mean, it's a little challenging based on the size of the tablets we have available here in New Zealand. I understand in Australia you might have a 15 milligram tablet. I think the smallest we can get here generally is a 30 milligram tablet, which means that the smallest you can easily divide that to is seven and a half milligrams. So I'd often start at that dose. I think if I had access to a 15 milligram tablet, I'd start at 3.75 milligrams. So I'd start at seven and a half milligrams. And then I'd increase that every week or two. I'd be looking to get to a dose of at least 15 milligrams to begin with. But if that's not sufficiently helpful, then I'd be looking to get to a dose of 30 milligrams. It is challenging with the mirtazapine. Mirtazapine is sedating. And it can also increase appetite. So I'd be wanting to stay in good touch with that family to make sure that we weren't creating more challenges than we were solving. 

James 21:23
Fantastic. That's a really comprehensive answer. Look, I could talk to you for a long time about pharmacotherapy. Listeners, we've just touched on a few of the things here. I would encourage you, once the ASDP sessions are all available online, I'd really encourage you to have a look back and listen to David's talk, because it really did present the data very well. And I think everybody who sees it will just be able to rationalise their approach to pharmacotherapy quite well. So I'll leave your talk there, the contents of your talk there for now, David. I would like to move on to the fact that you are a member of the Pharmac Mental Health Subcommittee here in New Zealand. And that means you've got a voice in the systemic way in which medications might be prescribed. It sounds as though here in New Zealand, you're currently addressing a similar issue to what's being addressed across the Tasman in regards to the rules around prescription of stimulant medications. Can you take us through that, starting off with just sort of an explanation, particularly addressing the Australian audience who may not be familiar with exactly how it occurs in New Zealand, what the system is, sorry, what the situation is currently with the rules of prescribing and what changes you're hoping might occur? 

David 22:38
Sure, absolutely. Thank you. So the rules at the moment in New Zealand are that stimulant medications can only be initiated by a specialist. So this would be generally a psychiatrist or a paediatrician, or it can be undertaken by another doctor with the consultation of one of these specialists. But a specialist needs to be involved somewhere along the line. There have been real concerns and political concerns in relation to not meeting the needs of the population of people with ADHD because the access to these specialists can be really, very, very challenging. Either there have been long waiting lists or access has been almost non-existent, especially for adults who may not meet the criteria for an assessment through a community mental health team or have the ability to undertake a private assessment with a psychiatrist. And it's in response to this difficulty meeting demand that there have been lots of discussions about ways of increasing the pool of practitioners who are able to initiate stimulant medications. This led to, as well as some discussions in the mental health subcommittee, there have been discussions among a range of different professionals. So there's been a working group established with the medical advisory boards in New Zealand. So that's our MedSafe organization, Pharmac, which essentially looks at the funding for medication in New Zealand, and various other professional groups. That includes nurse practitioners, general practitioners, pediatricians, psychiatrists, and a whole host of other important professionals, such as pharmacists, talking about the rules and really trying to balance the importance of having sufficient access for assessments, but also making sure that the professionals asked to do that, have the support to be able to do that job and to feel confident doing that job. When the nurse practitioners and the general practitioners have been really keen to be clear that they already diagnose and treat a wide range of conditions, mental health and non-mental health, with, you know, really high levels of complexity, and therefore maybe a group that will be well placed to undertake these assessments. There are discussions about separating out the assessment for children and young people as opposed to that in adults. And at the moment, the rules that are going to be put into place in New Zealand are that from February 2026, general practitioners and nurse practitioners will be able to initiate stimulant medications for adults or people aged over 18 with a diagnosis of ADHD. So I think there's a lot to be worked out there still, various elements, including the logistics of this. I mean, how long an assessment would we expect a general practitioner to undertake for such a condition? What would the cost be? How would that be recouped for the general practitioner in terms of that time? The amount of training for a general practitioner to undertake this additional work? I think these are all areas that need to be looked at in more detail. For younger people, the rules are staying largely the same. The one change is that nurse practitioners who are working in scope, so i. e. within a general pediatric or psychiatric setting, are also going to be part of the group that can initiate stimulant medications for people with ADHD in that younger population. 

James 26:23
So thanks for that, David. It sounds like we're pretty much at similar stages of progress on both sides of the Tasman in this regard. For our Kiwi listeners in Australia, it's the situation at the moment where a few states have already made these legislative changes. Some states have not. I think you touched on some important issues there, David, where we are talking about two separate issues, really. One is one of those issues being the GPs and nurse practitioners prescribing or co-prescribing medications. And the other issue is their involvement in assessment and so forth. When it comes to prescribing, as you touched on, David, they already are managing complex medications, which in my opinion, a lot of those medications have far more likely adverse events than something like a stimulant medication. But that is an area that we will wait and see how all of that transpires. Thank you very much for your input on that as well. One final question that we're asking all of our guests, David, is we're talking, the theme of our conference is well-being. We're talking about well-being. When we think about well-being, we think about the past, the present and the future. From your point of view, in your clinical practice, is there one thing, is there one intervention that when you're seeing your patients, something that you're doing today that you think this will be changing this person's life in five or 10 or 20 years from now? It might be a person, it might be a system, it might be anything. Is there one thing that you identify that this is likely to be beneficial for this person in five or 10 or 20 years from now? 

David 28:04
I think one of the things I try to focus on when I'm seeing young people and their families is considering the amount that they bring to the consultation and their lives from the off. And so I think a lot of the time when somebody consults a psychiatrist, lots of the narratives can be very problem-saturated. And I think some of this may be mediated by society as well. What I would like to do is to think about the strengths a person brings, that they bring, their families bring, and all the things that may have been hitherto overlooked or overshadowed by some of the problems that that person may be experiencing. I think a lot of the time some of the solutions are already happening for that person in their lives. Maybe they're present, but there's an insufficient light being shone on it. So one thing I like to consider is the sense of efficacy that a person or a system may already have within it, or may be kind of better realized with some tweaking as well, or considering the ways that that can be accentuated by the environment around that young person and the system. And I think that's important because no matter how many times I see a person, that's only going to be a tiny, tiny, tiny fraction of that person's life. Even if I think a consultation has gone very well, that's a tiny amount of time in someone's week. So I think more important is the ability for that person to, and that family, to have positive views of themselves and the interactions they can have with their environment going forwards, and their sense of efficacy and ability to advocate for themselves and take positive life steps for themselves down the track well beyond any kind of mental health intervention that's ongoing at the present time. 

James 30:03
That is a perfect way to finish on this, given this conference, so much of the emphasis at this conference has been on function, strengths, capability, and that's what all of us listeners, we should all be addressing. And we're preaching to the converted here, I know, but that really has to be the priority for every single patient we're seeing, to be focusing on the strengths and the capabilities of the person. David Chin, it's been an absolute pleasure to talk to you. Thank you very much for doing this podcast for the benefit of ASDP listeners, and we wish you all the best with all of your works for the future. Thank you very much, it's been a pleasure. Thanks, James. Kia ora.