ADHD AND ANXIETY

1. ADHD AND ANXIETY By Jennifer Simonson

2. DEFINITIONS • Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or activities. (Advameg, 2010) • ADHD is generally first diagnosed during the primary school years. Symptoms are always present before the age of seven, but sometimes continue into adolescence. (NAPSCE, 2007) • Anxiety is defined as a disorder characterized by anxiety, fearfulness, and avoidance of ordinary activities because of anxiety or fear. (Hallahan, Kauffman, & Pullen, 2009)

3. DEFINITIONS • There are different types of anxiety disorders: • Generalized Anxiety Disorder (GAD) • Specific phobias • Social Anxiety • Separation Anxiety Disorder (SAD) • Panic Disorder • Obsessive-Compulsive Disorder (OCD) • Post-Traumatic Stress Disorder (PTSD)

4. ADHD AND ANXIETY • Anxiety is evident in between fifteen to thirty-five percent of children with ADHD and they are especially vulnerable to having multiple anxiety disorders compared with non-disabled children. (Hallahan, Kauffman, & Pullen, 2009) • Children with intense anxiety or depression are particularly likely to have problems that appear similar to ADHD, and evidence also suggests that symptoms of depression-as the child’s self-esteem suffers in the face of continuing social and developmental failures-can complicate ADHD. (Schlozman & Schlozman, 2000) • Misunderstanding students with real anxiety can leave them feeling demoralized and socially unacceptable. (Schlozman, Quit Obsessing, 2002)

5. DIFFERENTIATING ANXIETY AND ADHD SYMPTOMS Anxiety Cause ADHD Cause Symptom: Inattention, easily distracted, doesn’t seem to listen, doesn’t follow through on instructions • Distracted by worries, rituals, and fears; may be afraid of hearing question wrong; may race through assignment, not follow directions, due to nerves. • Distracted by kids and noises, may notice that teacher is saying something, but doesn’t process the instructions; may rush to get unwanted task done quickly and go on to something more fun. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

6. DIFFERENTIATING ANXIETY AND ADHD SYMPTOMS Anxiety Cause ADHD Cause Symptom: Unable to concentrate on work • Afraid that work will be too hard or will have to be done perfectly so avoids; can’t tolerate feeling of not being sure if something is right. • Difficulty sitting still due to boredom. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

7. DIFFERENTIATING ANXIETY AND ADHD SYMPTOMS Anxiety Cause ADHD Cause Symptom: Impulsivity; blurts out answers, interrupts, can’t wait one’s turn • Fear that he will forget answer; needs reassurance that he is right, unable to leave a mistake as is • Not enough processing available between idea and action – no mental breaks; unaware of interrupting Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

8. DIFFERENTIATING ANXIETY AND ADHD SYMPTOMS Anxiety Cause ADHD Cause Symptom: Hyperactivity; fidgety, gets up from seat; talking excessively • Fidgety from anticipation, tension, or worry-can’t sit still, wants to go home, get the day over with • Nervous energy; may be checking compulsions with questions; may be experiencing trauma flashbacks • Physical need to move, keep hands busy. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

9. ARTICLE REVIEWS

10. PERFORMANCE MONITORING AND RESPONSEINHIBITION IN ANXIETY DISORDERSWITH AND WITHOUT COMORBID ADHD • Anxiety disorder is a common, persistent, and impairing condition in the general child population. Affected children face significant impairment in psychosocial development and academic performance (Black, 1995) • The goal of this study was to investigate in anxious children two essential aspects of executive control known to be disturbed in various mental disorders: performance monitoring and response inhibition. • ‘‘Performance monitoring’’ is the online evaluation of the quality of information processing(Logan, 1994) • ‘‘Inhibitory control’’ is defined as the ability to stop a planned or ongoing thought or action suddenly and completely in the presence of changing intentions or external circumstances (Logan, 1994). Korenblum, C. B., Chen, S. X., Manassis, K., & Schachar, R. J. (2007). Performance Monitoring and Response Inhibition in Anxiety Disorders With and Without Comorbid ADHD. Depression and Anxiety , 227-232.

11. PERFORMANCE MONITORING AND RESPONSEINHIBITION IN ANXIETY DISORDERSWITH AND WITHOUT COMORBID ADHD • One hundred thirty-seven participants, ages six to fourteen years, were drawn from referrals to a clinic specializing in children with attention, learning, and behavioral problems in a large urban, pediatric hospital. Korenblum, C. B., Chen, S. X., Manassis, K., & Schachar, R. J. (2007). Performance Monitoring and Response Inhibition in Anxiety Disorders With and Without Comorbid ADHD. Depression and Anxiety , 227-232.

12. CONCLUSIONS • Results fail to confirm any of the hypotheses of specific or generalized cognitive deficit in anxiety. • Once comorbid ADHD was taken into account, researchers did not identify abnormalities in either inhibitory control or performance monitoring in anxious children, contrary to researchers’ predictions. • The presence of ADHD and anxiety resulted in a pattern of cognitive deficits that was similar to that observed in ADHD in the absence of anxiety. • Physicians and psychologists should assess children for the presence of ADHD when diagnosing anxiety. • The anxiety that is observed in children with a disruptive behavior disorder such as ADHD may represent a form of anxiety that is secondary to the social, intrapsychic, and scholastic difficulties that these children experience. Korenblum, C. B., Chen, S. X., Manassis, K., & Schachar, R. J. (2007). Performance Monitoring and Response Inhibition in Anxiety Disorders With and Without Comorbid ADHD. Depression and Anxiety , 227-232.

13. FREEING YOUR CHILD FROM ANXIETY • Anxiety is a tense emotional state that often occurs when you can’t predict the outcome of a situation or guarantee that it will be the desired one. Anxiety becomes a disorder when the child or adult automatically exaggerates risks and underestimates the ability to cope with a situation. • With anxiety, some children appear visibly stressed, others keep their anxiety under control and worry silently, still others are angry-anxious kids, reacting to their limitations with frustration. • An anxiety diagnosis often co-occurs with ADHD. • ADHD generally develops early in childhood whereas anxiety disorders can occur throughout childhood and adulthood. • ADHD medication, psychostimulants, can often increase nervousness in children with anxiety disorders, therefore making the situation worse. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

14. CONCLUSIONS • Anxious children are in all classrooms, knowingly or not. It is estimated that ten percent of students in every classroom deals with some form of anxiety disorder. • When schools attend the needs of anxious children, it can make the difference between a child merely attending school and actually thriving in school or, sadly, not attending school at all. • Teachers should consider the following guidelines when speaking in class: • Emphasize safety precautions as much as, if not more than, risks. • Make sure to put risks in perspective. • Assume that there are anxious ears listening and correct any generic misperceptions or misunderstandings that are likely. • Emphasize above all the appropriate and accurate take-home message. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books.

15. EFFECTIVENESS OF FAMILY THERAPY FOR CHILDREN • Family-based systemic interventions are effective for a proportion of cases with anxiety disorders, depression, and grief. • Emotional problems cause students and their families considerable distress, and in many cases prevent young people from completing developmental tasks such as school attendance and developing peer relationships. • In a review of community surveys, the median prevalence rate for anxiety disorders was 8.1 percent, with a range from 2 to 24 percent. Carr, A. (2009). The Effectiveness of Family Therapy and Systemic Interventions for Child-Focused Problems. Journal of Family Therapy , 3-45.

16. CONCLUSIONS • All anxiety disorders are characterized by excessive fear of particular internal experiences. • Systematic reviews of the effectiveness of family-based treatment for anxiety disorders show that it is at least as effective as individual cognitive behavior therapy (CBT). • FRIENDS is a recommended approach for families and school districts. Carr, A. (2009). The Effectiveness of Family Therapy and Systemic Interventions for Child-Focused Problems. Journal of Family Therapy , 3-45.

17. CONCLUSIONS • The program’s founder, Dr Paula Barrett published the world’s first family treatment randomized control trial for childhood anxiety in 1996. She and her research team have since been credited with publishing more controlled trials for childhood anxiety than any other group in the world. • FRIENDS, a child-focused program, teaches anxiety management skills, such as relaxation, cognitive coping and using social support. This program incorporates students, parents, and teachers. (Barrett, 2009) • Since children spend a the bulk of their time at school, it is imperative that students be encouraged to apply learned coping/resolution techniques at school. Administrative support is key for its success. Carr, A. (2009). The Effectiveness of Family Therapy and Systemic Interventions for Child-Focused Problems. Journal of Family Therapy , 3-45.

18. RECOMMENDATIONS-BASED ON ARTICES-PROS AND CONS OF INCLUSION

19. RECOMMENDATIONS • Do not assume students diagnosed with anxiety will have a cognitive deficit similar to some learners with ADHD. • Learners with anxiety may or may not show similar stereotypical behavioral patterns as ADHD. • For students with anxiety, allow preferential seating for assemblies and large-group activities • Give students advance notices of activities outside of the classroom and allow them a choice of seating, transportation, etc. (Chansky, 2004) • For students with anxiety, allow preferential seating in classroom, especially near door to allow for leaving for “relaxation” breaks. (Souma, Rickerson, & Burgstahler, 2009)

20. RECOMMENDATIONS • For students with anxiety, discuss strategies with student and parents outside of class so that the student understands the teacher’s expectations and the kinds of support the teacher will offer. (Schlozman& Schlozman, 2000) • Family-centered therapy for children with anxiety is extremely effective. The school should also be involved in treatment. • For students with anxiety, determine a “safe place” at school • Allow student access to free pass for brief breaks during class time. (Chansky, 2004) • In an inclusive classroom, incorporate strategies such as PAVES into curriculum-Posture, Attitude, Voice, Eye Contact, and Smile. This strategy teaches effective public speaking and presentations and is helpful for students with generalized anxiety in inclusive classrooms. (Combes, Walker, Harrell, & Tyler-Wood, 2008)

21. WILL INCLUSION WORK? YES NO • Due to higher classroom expectations, students with disabilities learn more in the general education classroom. • Students with ADHD and/or anxiety can learn to manage their behavior among their peers. • All students benefit from social interactions with each other. • Segregating exceptional learners is morally wrong. • Behavioral disruptions from students with ADHD and/or anxiety impacts the learning and social climate of the general education classroom. • Children with disabilities tend not to be liked by their classmates. • The child becomes socially excluded from all social interactions inside and outside of the classroom community. • School districts do not fund inclusion programs appropriately. • Administrators, teachers , and support staff are not trained properly to facilitate the needs of exceptional students in the general education classroom.

22. CLASSROOM APPLICATIONS

23. CLASSROOM APPLICATIONS • Assume that there are always learners with anxiety in my classroom community. Self-monitor conversations and comments to class and others for anxious trigger words or phrases. • Behavioral symptoms of anxiety look similar to those of ADHD. If a student is inattentive, restless, or impulsive do not automatically assume the student has ADHD. • Outside of class, collaborate with specialists, parents, and student to identify best practices to reduce anxiety in and outside of classroom. This can be environmental (classroom set-up) and activity based (assemblies, field trips).

24. CLASSROOM APPLICATIONS • If the student becomes overwhelmed, help them break down the task they are working on or identify the anxiety producing event. For example, during a test or when introducing a new learning topic. • Assign a “study buddy” who can be the in-class contact for questions, missed assignments, and reading partner. This needs to be someone they are comfortable with and can trust. • Differentiate instruction and incorporate various learning strategies to reduce anxiety producing episodes. For example, do not ask child to read out loud in class, if they are not comfortable doing so. Arrange for individual reading time with the student to assess their understanding of reading material.

25. CLASSROOM APPLICATIONS • Encourage student to journal any anxious feelings during the school day. Review journal weekly with student to identify “trouble spots” and brainstorm ways to reduce the anxiety next time that situation occurs. • Organize classroom to keep clutter at a minimum. For personal space, the student should participate in choosing where items are going to go. For classroom space, icons of supplies or color cards can be displayed to help the child know where supplies go. (Swanson, 2005) • Assume competence! Do not assume that every situation will cause an anxious response in your student. Feelings of anxiousness change. One day, going to lunch may be impossible, another day, it may be easily accomplished. • Collaborate with district specialists and other teachers about strategies to include student in the classroom community without causing undue anxiety or stress.

26. REFERENCES

27. REFERENCES Advameg. (2010). Attention-deficit/hyperactivity disorder. Retrieved May 23, 2010, from Encyclopedia of Mental Disorders: http://www.minddisorders.com/A-Br/Attention-deficit-hyperactivity-disorder.html Barrett, P. (2009). FRIENDS Preventing and Treating Anxiety in Children and Youth. Retrieved May 22, 2010, from FRIENDS: http://www.friendsinfo.net/downloads/FRIENDSintrobooklet.pdf Carr, A. (2009). The Effectiveness of Family Therapy and Systemic Interventions for Child-Focused Problems. Journal of Family Therapy , 3-45. Chansky, T. E. (2004). Freeing Your Child From Anxiety. New York: Broadway Books. Combes, B. H., Walker, M., Harrell, P. E., & Tyler-Wood, T. (2008). A Presentation Strategy for Beginning Presenters in Inclusive Environments. Teaching Exceptional Children , 42-47. Hallahan, D. P., Kauffman, J. M., & Pullen, P. C. (2009). Exceptional Learners An Introduction to Special Education. Boston: Pearson Education, Inc.

28. REFERENCES Korenblum, C. B., Chen, S. X., Manassis, K., & Schachar, R. J. (2007). Performance Monitoring and Response Inhibition in Anxiety Disorders With and Without Comorbid ADHD. Depression and Anxiety , 227-232. NAPCSE. (2007). Exceptional Children and Disability Information. Retrieved May 22, 2010, from National Association of Parents with Children in Special Education (NAPCSE): http://www.napcse.org/exceptionalchildren/adhd/adhd-definition.php Schlozman, S. C. (2002). Quit Obsessing. Educational Leadership , 95-97. Schlozman, S. C., & Schlozman, V. R. (2000). Chaos in the Classroom: Looking at ADHD. Educational Leadership , 28-33. Souma, A., Rickerson, N., & Burgstahler, S. (2009). Academic Accommodations for Students with Psychiatric Disabilities. Retrieved May 22, 2010, from DO-IT University of Washington: http://www.washington.edu/doit/Brochures/Academics/psych.html Swanson, T. C. (2005). Provide Structure for Children With Learning and Behavior Problems. Intervention in School and Clinic , 182-187.