Psychological intervention
CBT has been shown effective for child-hood anxiety disorders in randomized controlled trials,12 but even those that included children with comorbid ADHD required that an anxiety disorder be the primary, most impairing diagnosis.13 Thus, little is known about CBT’s effectiveness for children with anxiety plus ADHD. Given the evidence for cognitive deficits in comorbid anxiety and ADHD10 and the challenge of working with highly distractible children, one would expect CBT to be more difficult in this population.
The potential for distraction to adversely affect learning of coping strategies is higher in group than in individual therapy, and children with anxiety and ADHD can be disruptive to other children in CBT groups. Consider individual CBT, and seek a therapist who has experience with this population. Having the child on medication for ADHD symptoms usually helps reduce these symptoms’ impact on sessions.
For children younger than about age 8 or too cognitively impaired to benefit from CBT, behavioral intervention alone may be helpful. The largely behavioral psychosocial intervention in the MTA study of ADHD children age 7 to 9 (Box 2)8,14 helped many of those with comorbid anxiety.
Although programs as intense as that used in the MTA study rarely are provided in community practice, consider behavior modification. For example:
- To reduce anxiety, have the child follow regular, predictable routines, and reward the child for gradually facing previously avoided situations.
- To reduce distractibility in class, have the child sit near the teacher, break work into small chunks, and reward completion of each chunk.
Even small improvements in the child’s home or school behavior may reduce negative interactions with others and the attendant effects on self-esteem.
CASE CONTINUED: Weighing the options
The therapist seeing Aaron’s family listens to their concerns about medication and reassures them that their son will not be denied psychotherapy. She tells them, however, that psychotherapy will not address his urgent school problems and is unlikely to work in the absence of medication, given Aaron’s behavior in the office. The therapist provides accurate information about the risks and benefits of medication and CBT, and the parents agree to think about all treatment options.
By the next office visit, the school has threatened to suspend Aaron. He and his parents agree to combined treatment with a stimulant medication and CBT and to having the therapist provide a behavioral consultation at the school.
Medication + psychosocial treatment
shows best outcomes for ADHD with anxiety
shows best outcomes for ADHD with anxiety
The National Institute of Mental Health’s Multimodal Treatment Study of Children with ADHD—the largest study to date—found that comorbid anxiety did not adversely affect behavioral response to stimulants but did moderate outcomes.
In the parallel group design study, 579 ADHD children age 7 to 9 were enrolled at 6 treatment sites, thoroughly assessed, then randomly assigned to 4 groups: medication treatment alone, intensive psychosocial treatment alone, a combination of both treatments, or usual community care. The first 3 interventions were designed to reflect best practices for each approach, and these children were closely monitored and studied for 14 months. All 4 groups were reassessed periodically for 24 months, evaluating multiple outcomes.
For the total sample, combined and medication treatment were more effective than psychosocial treatment and community care. For ADHD children with comorbid anxiety disorders:
- combined treatment was more effective than either medication treatment alone or psychosocial treatment alone
- both monotherapies were superior to community care.
ADHD: attention-deficit/hyperactivity disorder
Family psychoeducation
With families of children with behavioral challenges, adopt a patient, educational approach rather than acquiescing to their wishes or arguing with them. Either can result in treatment failure. Discuss potential benefits and risks of all treatment options and the impact of comorbidity on treatment.
Parents’ rigid insistence on a particular course of action—such as refusing psychopharmacology—may be caused by anxiety or misinformation. Elicit the source of any anxiety, and provide realistic information and reassurance if possible.
Anxiety in family members may be constitutional—as anxiety is highly heritable15—or relate to aspects of treatment. Families may feel overwhelmed by:
- their child having 2 disorders rather than 1
- your suggestion to start medical and nonmedical intervention together
- hearing about the possibility of multiple medication trials.
Negotiating medication. Discuss with the family the difficulties of a child learning CBT strategies when ADHD is not well-controlled and the cognitive difficulties in many of these children that may necessitate individualized CBT. If the family remains reluctant to consider combining medication with CBT, try contracting for a limited number of CBT sessions (perhaps 3 or 4) before re-evaluating the need for medication.