July 2022

How do you distinguish between ADHD and anxiety in children?

This is a great question because ADHD — Attention-Deficit/Hyperactivity Disorder — is often co-occuring with anxiety in kids and in adults but they can also look very similar. Let’s dig into that a little bit. Let’s talk about the ways anxiety can look similar to ADD or ADHD? Well, some of the symptoms show up in both diagnosis. Symptoms like:

  • Fidgeting
  • Distraction
  • Difficulty keeping track of things
  • Do not seem to listen
  • Problems staying focused
  • Problems staying organized
  • Forgetfulness
  • Impulsivity

These symptoms are present in ADD and ADHD because the child’s brain works differently. They tend to struggle with executive functioning, which basically means the part of their brain that does the planning and organizing works differently than neurotypical people. People with ADD/ADHD may be able to hold a lot of thoughts at once — I tell kids it means they have a busy brain — and tend to struggle with staying on task. This can be confusing since they also are able to hyper focus, which means to put all of their attention on one thing no matter what else is going on. This is the child who can lose themselves in building legos even if there is a literal tornado going on around them. 

Ok back to the symptoms that are also present in Anxiety.

Anxious children may also fidget, get distracted, have trouble focusing, listening, being organized and keeping track of things. They may be forgetful. This is because they are on high alert. Anxious children are often keyed up. They may be quick to respond to perceived threats so may seem impulsive. They may also struggle with executive functioning because their planning, organized brain is off-line since they are living in their more reactive brain. Anxious children may spend a lot of time in fight, flight, or freeze mode and so they aren’t thinking with their calm, cool and collected higher order brain.

It gets even more complicated when we consider that about one third of those who are diagnosed with ADD/ADHD also meet criteria for an anxiety diagnosis. There are some studies that indicate that number might be even higher.

Let’s consider why this might be true.

First of all, we live in a world where we expect people to have neurotypical brains. That means our systems — our schools, our workplaces, our childcare centers, our parenting books — assume that we all have brains that function like the average brain. Those children and teens whose brains work differently have to contend with being quote WRONG end quote. They may not get the circle time activities, or appreciate the social nuances of middle school. They may not get why the workplace protocol operates the way it does. They may feel like square pegs getting shoved into round holes and that can create real anxiety. If they feel that they are always missing the point or missing the boat, that’s going to make them feel anxious about their day to day functioning. 

Think of a child who struggles with impulsivity. They are the kids who are reaching out to touch the museum display before you can tell them, “Don’t touch!” They are often in trouble and aren’t sure why or how to be different. You can see how it would make a person anxious, right?

The other thing is that this high impulsivity — this immediate jump from a thought to a behavior — can also happen with an immediate jump from a thought to another more anxious thought. If a child has anxiety and has ADD/ADH, they are more likely for feelings to run away with them. If they think about a dinosaur, they may immediately go to thinking about being eaten by a dinosaur. That executive functioning that helps them slow down and be logical isn’t as strong as that impulsivity. 

Remember in previous episodes we’ve talked about the information processing bias the comes with anxiety — anxious brains tend to be more negative, spotting potential danger even in neutral situations. As you can imagine, when ADD/ADHD is also present, it’s simply easier to jump to the worst possible conclusion more quickly.

Where it definitely matters is when we’re thinking about medication. Stimulant medication, which we use to treat ADD/ADHD, can make anxiety worse. But that’s a discussion to have with your doctor. 

It also matters when we’re talking about school accommodations since your child or teen will need to have an assessment and diagnosis in order to inform the IEP or 504 plans.

But when it comes to treatment, we’re addressing the child and their symptoms and having a clear diagnosis may help with case conceptualization but those of us who work with kids tend to expect things to overlap and be complicated. Knowing if it’s anxiety or if it’s ADD/ADHD may be less important than trying things to see if they’ll work. Sometimes it’s in trying things that we learn what is the most pressing issue. I can think of times when I was working with a child who came to me with an ADD/ADHD diagnosis and as we dove in and made plans with their parents to address their concerns and their child’s challenges, we were able to figure out where anxiety was most present and how to address it with each individual child. In other words, often it is through working with the child that we are able to make recommendations for a better diagnosis and case conceptualization.

How do I make a decision about anxiety medication for my child?

This is not a question that I can easily answer for the podcast because not only am I not a prescriber, but I haven’t met your child or teen. 

I personally feel very cautious about treating child anxiety with medication andI definitely don’t think you should rely on a podcast for that information. Think of this just as a kind of intro; ultimately you need to reach out to your child’s doctor and talk to them about it.

When you’re thinking about medication for your child, what that means obviously is that you and your child are struggling in some way and you’re wanting to know how best to help. 

It’s important to understand that medication is not a cure for anxiety. It’s not like having a headache and taking ibuprofen, and then you feel better. Medication is part of an anxiety treatment plan.

Not every child who meets clinical criteria for an anxiety diagnosis is going to need or benefit from medication. Again, this is very personal. It depends very much on the child and on their environment and on what else might be going on.

The first thing you should do. Is make sure that what you’re dealing with, what your child is dealing with is in fact anxiety.

Anxiety sometimes gets misdiagnosed as other things. Other things sometimes get misdiagnosed as anxiety. So if you’re considering medication, your child is going to need a thorough assessment from someone who is able to do that, and that would be a counselor or a social worker, a psychologist. 

If you wanted to a full neuro psych workup, that would be someone who is sitting with your child and doing a full assessment of how their brain works, how they might be struggling, what their strengths are. Honestly, I think that is really your best bet when you’re thinking about medication, because a neuro psych is going to be qualified to also diagnose ADHD and autism spectrum disorders. Counselors, and social workers are able to do some of that depending on their training, but a neuro psych has that background and the ability to do the full workup. If your child is seeing a counselor, obviously that counselor will know them really well but a neuro-psych is doing a more formal assessment. 

Before you go to medication, it’s important that you try other avenues first. Having your child meet with a counselor for treatment would be a great thing to do. 

Talk therapy, play therapy, basically cognitive behavioral therapy in whatever form is most accessible for your child is a first step in treatment. Also, and you know that I’m going to mention this, you getting your support in order to make sure that your family is creating the healthiest systems for your anxious child is also a first course of treatment. 

A program like mine or another kind of support group, working with your own counselor, family therapy — these are all things to do to make sure that your child is getting the skills that they need. Those are the first steps before you look at medication. 

If it does turn out that it is an appropriate treatment for your child, there is no one who will say, just give your kids the meds and don’t do anything else because meds are only part of it. our child is also going to need to learn their skills. You are going to have to need to learn your skills. And then together with the people who are helping your family, you can start thinking about medication. 

I’m going to link here to a PDF made available by the American academy of child and adolescent psychiatry. That is their specific guide  on treating anxiety disorders with medication, and they’re going to give you information about what medications are available and how they work and how to get access to them. 

A really important thing to know is that there aren’t really a lot of medications that are FDA approved for children, particularly younger children. Now that said there are medications that people use off-label that means it hasn’t specifically been approved for the treatment of kids by the FDA. But there are studies that show that they can be effective and the physician prescribing it believes they can be effective. They are using evidence-based information to make that decision. But you do need to know that because as you’re making your decisions, you should have all the facts right in front of you.

If the child or teenoes meet criteria for medication to be part of their treatment plan the goal is the calm down the anxiety enough for them to access their other treatment, their counseling, their cognitive behavioral therapy and the skills that you’re working at at home, 

That is to say that medication alone is not the recommended form of treatment for kids; it’s medication, along with something else.  

You need to have a plan for who else is going to be supporting your child. What is the plan to get them off medication eventually? Is that going to be part of the plan? Maybe it is, maybe it isn’t — that’s between you and your child’s prescribe and of course your child, as they get older and have more decision-making about their medication. But sometimes we’re going to use medication  or a shorter time so the child can access those skills with the hope to eventually take them off their medication. 

Sometimes we’re doing medication for a very short time over specific anxious periods, such as the child who needs to get on a plane or is dealing with short term things that are really difficult. 

Generally when children are prescribed for anxiety, they are given antidepressants and those are the SSRI. Or the SNRI and those change the chemical neurotransmitters in their brain to help regulate anxiety, mood, and social behavior.  

Children who are on SSR eyes, sometimes show an increase of suicidal ideation.  Don’t be so alarmed by that, that you say, absolutely I am not going to allow my child to get on medication. No, it just means that if medication is appropriate for your child, you need to have a plan about that and in that case, I do strongly recommend counseling. 

If the child is on SSRI, I think that it is just that much more important to make sure they’re in counseling. So there’s someone else’s eyes on them, someone who is trained to assess for suicidality and who can support your family in just keeping an eye on your child. 

Another medication that sometimes children are prescribed are Benzodiazepines, we sometimes call those benzos. Those are used for short-term treatment because they can be addictive. And also sometimes the prescriber will say we’re just going to use Benadryl. So if the child is scared of flying and they need to take a flight, That the doctor may say, we’re just going to do some Benadryl or we’re going to do some beta blockers or something like that. 

Those are short term solutions, the SSRI. And SNR eyes tend to be longer-term solution. Benzos, benadryl things like that are kind of one-off medications that might be used in specific circumstances.

Again, these are things you need to talk about with doctor with because treating anxiety is complicated, which goes to, how do you find someone to prescribe this for your kids? 

If your child is going to get medication for mental health then that prescribers should be someone with a psychiatric background, whether that’s an actual child psychiatrist, or a psychiatric nurse practitioner. I think it’s best to go with those kinds of doctors because they do get more training about psychiatric medication and specifically how to prescribe those for growing kids and how to change things up as the child continues to grow. 

I know it can be hard to find a prescriber and sometimes the wait lists are really long so first I encourage you to go to your child’s general practitioner or pediatrician and start the conversation. They may be able to get you in somewhere more quickly. They may feel comfortable making those prescriptions themselves and supervising them and then that’s a conversation to have with them. Why they feel comfortable doing that, how they would know if they weren’t comfortable doing that, what are special things you need to look for?  

I think it’s also important to know that all of us who work with anxious kids, anxious families. We are seeing them through the lens of our background. Because I have a clinical, mental health counseling background, I see it through the lens of counseling. How can I support families in shifting those patterns? What kind of psycho-education can I offer what is the longterm treatment plan and bringing those skills to kids? 

However, when you talk to a medical prescriber, they’re going to see it through the context of their medical training and background. So they may recommend meds and maybe that’s the right choice, maybe it isn’t, but that is how they’re going to see it. They’re going to see it from a medication standpoint. 

You get to ultimately make the decision for your kid. You can talk to a therapist and you should, you can talk to a doctor and you should, you can talk to your child’s teacher, their school counselor, but ultimately you’re going to make the decision. So ask yourself, What is the information I am missing that will help me make that decision. What are the questions I have that need to be answered? What are the concerns that I need to have addressed? And I think it’s really important when we’re talking about meds to say. How will we know if it’s not working? What will our plan B be? And how will we get the child off them? If this is going to be a temporary plan? 

I hope this was helpful if you have other questions please post them and I’ll be happy to answer them on a future podcast

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