The ADD Treatment and Research Center was established in 1993 in order to provide low cost services for individuals seeking diagnosis and treatment of ADD. Since we began, we have been privileged to evaluate several hundred adults, and numerous adolescents and children. We are also gathering a research data base which some students currently seeking thesis and dissertation data have found useful. Our hope is that valuable information regarding ADD will be uncovered and disseminated through our efforts.
Let's take a moment to introduce you to our authors and part of our staff. Cindy Taylor, M.A., our Clinical Director, received her Master's degree in Clinical Psychology in 1993 and is currently completing her dissertation for her Ph.D.. She is published in the area of ADD and has been doing research on this subject since 1989. , M.S., LPC is our Director of Treatment Services. In addition to Jan's extensive professional training and experience, she has ADD, as do her husband and three adult daughters!
Our intent is to have a fun and informative place we can share ideas about ADD and tell you what's going on with us here at the ADDTRC. We'd love to hear your stories. If you would like to contribute to the newsletter, please send your stories to ADDTRC, 4230 LBJ Freeway, Suite 525, Dallas, TX 75244 Attn: Newsletter! Or send us an email message!
Many disorders in our current classification system, the DSM-IV, subsume enough of the symptoms of ADHD to meet diagnostic criteria. For this reason, it is sometimes difficult to determine whether the individual is actually experiencing ADD or another disorder. Another factor is that ADD adults have often times developed other psychiatric symptoms and dual diagnoses are very common among this population. Each newsletter will examine disorders which can either mimic or co-occur with ADD. In this issue we will be discussing the symptoms of ADHD and Generalized Anxiety Disorder and reviewing the literature on this topic.
Procrastinate? Don't miss the Procrastinator's Workshop on America Online. Debette, your host and head procrastinator, appears online every Tuesday and Thursday morning at 10:30 Central time. (Use Keyword PEN and go to the IMH chat room). This is a great room for ADDers who have trouble starting, organizing and finishing tasks. OK, while you're on AOL, check out the ADD free-for-all in Better Health on Sunday nights at 10:00 Central. Stay tuned for more from the online critic.
What's the difference between ADD and ADHD? ADD is now called ADHD, whether you have the "H" or not. According to the DSM-IV, our new flavors of ADD are ADHD, Predominantly Inattentive Type, ADHD, Predominantly Hyperactive-Impulsive Type, ADHD Combined Type, and ADD, NOS which means Not Otherwise Specified. In order to be diagnosed with ADD as an adult, you have to have experienced symptoms in childhood before 7 years of age. And you also have to still be having enough of the symptoms in adulthood to meet criteria for diagnosis. It you had it as a child and don't have all of it anymore, it's said to be "in partial remission." If you've got some of the symptoms now, but it's not clear if you had them as a child, then you've got ADD, NOS. OK, now the tricky part.....not only do you have to have the symptoms, but the symptoms have to be causing "significant impairment" in at least two areas of your life. If you're a kid - that's at home and at school; if you're an adult, that can be work, home, interpersonal relationships, or school. And one more thing....those symptoms cannot be better accounted for by another disorder.
What's New??
Strategies for the Workplace: For individuals who are having difficulties in the workplace, we offer individualized strategy planning to examine problem areas and to explore options which might enable successful performance. If ADHD is in the picture, the effort required to be in control of one's workload can be enormous and exhausting, resulting in fatigue, irritability, hyperarousal, and potential negative impact on income, self-esteem and social and interpersonal relationships.
Couples Help: , M.S., LPC is currently working with couples and examining the effects of ADD on relationships. This is partly educational and partly therapeutic. Issues commonly addressed are communication, trust, identifying and expressing feelings, how to pay attention to your partner - and partners...understanding when they can't! You love each other, but you get so exasperated, hurt, shamed, frustrated, bewildered, disconnected, confused, just plain tired of dealing with the effects of untreated ADHD. It can be hard to be in relationship with someone who has ADHD. It can also be very wonderful when understanding about each person's issues and options for dealing with those issues can be explored and developed. Your relationship can get better! You can find ways to have intimacy and connection. You can learn how to value your differences and build on strengths that you have together as a couple. You can learn how to communicate and handle conflicts -- how to hear and be heard when you are troubled. ADHD does not have to be a deficit in your relationship. Both of you together can learn new coping skills to build for yourselves a positive one.
Parenting strategies for parents of adult ADDers. When is it enabling and when is it real help? There's also help for parents who want to become more skilled in dealing with their children in ways that build self-esteem, competency, and good relationships. Families with ADHD children have special needs and stresses that many families do not experience, and there can be enormous strain on energy level, coping skills, marital relationships, and self esteem for parents.
Children diagnosed with ADHD sometimes need extra help in school. However, having a diagnosis does not automatically qualify them for receiving services. In order to receive additional services in the public schools, the diagnosis must impair the child's school performance. Some children with ADHD are able to perform well in school, and thus, they do not need extra services. When a child does need added support, he or she may qualify under one of two federal laws: IDEA (Individuals with Disabilities Education Act), or Section 504 of the Rehab Act. An ARD (admission, review and dismissal) committee is held to determine eligibility, placement, and program changes.
A brief comparison between IDEA and Section 504 is outlined below:
Whether or not a child qualifies for special services, it is always beneficial to establish good communication between the parents and the teacher. Common suggestions are provided below:
While discriminating between disorders within a category of the Diagnostic and Statistical Manual-fourth edition (DSM-IV) can be challenging, generally the child's symptoms will match one disorder more than another, and selection of a single disorder can be determined. However, it is often more difficult to distinguish between disorders of two different categories than within a category since many of the disorders have similar symptoms which may occur for differing reasons. Determining whether symptoms are more reflective of one disorder than another, if meeting criteria for one disorder is the result of another disorder, or if comorbidity exists of the two disorders can be a humbling experience.
Two disorders in which such questions often arise are Attention Deficit Hyperactivity Disorder and Generalized Anxiety Disorder, or overanxious Disorder, (GAD). The term ADHD may also be referred to as ADD-H (Hyperactive-Impulsive Type) and/or ADD-WO (Inattentive Type) throughout this article when referring to research using the terms. According to several research investigations, children with ADHD and children with anxiety disorders often exhibit similar behaviors. However, since parents and teachers appear to have a greater awareness of ADHD, they generally refer the child to a psychologist in order to evaluate for ADHD who in turn requests them to complete rating scales. With the symptoms characteristic of ADHD in mind, the parents and teachers may inadvertently skew behavioral ratings toward a diagnosis of ADHD; thus, children with anxiety may be misdiagnosed as ADHD or children with both disorders may only be treated for ADHD. The distinction between the two disorders is important as the treatment modalities implemented are typically quite different. Currently, common interventions for children with ADHD include behavior management and stimulant medication; whereas, interventions for Generalized Anxiety Disorders consist of relaxation techniques, counseling services, and anti-anxiety medication such as benzodiazepine.
Using the DSM-IV criteria, some symptoms are listed under both disorders, including restlessness and difficulty concentrating; moreover, a child need exhibit only one of the symptoms in order to meet criteria for a generalized anxiety disorder (see Table). While not listed as criteria under anxiety, several of the ADHD symptoms may be seen in children who are anxious, such as fidgeting, talking excessively, and making careless mistakes. Thus, children with anxiety disorders may present as a child with ADHD. The presence of externalizing symptoms are often viewed as characteristic of ADHD-Hyperactive/Impulsive Type; however, children with anxiety may interrupt or move about excessively because they are anxious. The distinction is even more vague between ADHD-Inattentive Type and anxiety since a child may be distracted due to his/her worries, or a child may worry because he/she have difficulty attending. Furthermore, the presence of internalizing symptoms, including anxiety, are often viewed as characteristic of ADHD-Inattentive Type, although the DSM-IV states that it must be determined that the symptoms are not better accounted for by an Anxiety Disorder.
Current research in identifying characteristics of the two disorders indicates a high incidence of comorbidity, but does not clearly address how the two disorders may be distinguished from one another. In fact, questions have been raised regarding the validity of ADHD-Inattentive Type and whether or not the majority of children meeting criteria for this type can be accounted for by an anxiety disorder (Lahey & Carlson, 1991). A study of 119 children who were referred for an evaluation of ADHD confirmed that only 45 children had the disorder, while a large number of cases had anxiety disorders, suggesting an overinclusion of children being referred for ADHD (Desgranges, Desgranges & Karsky, 1995).
The validity of ADD without hyperactivity has been questioned since its appearance in the DSM-III, and its diagnosis can be difficult and controversial (Lahey & Carlson, 1991). As mentioned previously, evidence from a number of studies has shown anxiety to be a common characteristic of children diagnosed with ADHD-Inattentive Type, along with other internalizing symptoms, such as depression and social withdrawal, as compared to the Hyperactive/Impulsive Type. Thus, the question is raised of whether these children are presenting as ADHD due to their anxiety or if the anxiety is a result of having ADHD or if the two disorders simply co-occur. While several studies have distinguished differences between the two subtypes of ADHD, few have distinguished between ADHD (of either type) and anxiety. One study found that children with ADHD showed significant differences in inattention and impulsivity as compared to children with anxiety or disruptive disorders other than ADHD; however, activity levels were indistinguishable across all three groups (Halperin, Newcorn, Matier, & Sharma, 1993). Another study of 47 children with ADD-H found significantly higher anxiety levels than normal children (Jensen, Shervette, Xenakis & Richters, 1993). This group of children exhibited more externalizing symptoms as compared to a clinical population with a variety of other disorders; however, on self and parent ratings, the group was indistinguishable on depressive and internalizing symptoms such as anxiety.
Due to the high rates of comorbidity, a subtype of ADHD with anxiety has been proposed; however, few studies have addressed whether one disorder may be the result of the other. Many studies have compared children with only ADHD to children with ADHD and anxiety. Children diagnosed as ADHD with anxiety were found to be less impulsive and/or hyperactive than those with only ADHD, indicating they are more likely to parallel the ADHD-Inattentive group (Pliszka, 1992). Biederman & Steingard (1989) proposed three symptoms of ADHD found among adolescents: those with conduct disorder, those with depression, and those with anxiety. The authors found that subjects in the ADHD with anxiety group had higher levels of life stresses and parental symptoms than subjects with only ADHD. The authors also recommended prescribing clonidine, a medication prescribed to anxiety patients, to subjects in the ADHD with anxiety group rather than methylphenidate (MPH) because the effectiveness of MPH tends to decline with this group. This suggests that a different area or pathway in the brain may be affected in children with ADHD with anxiety as compared to children with ADHD only, and that the affected area may be more closely linked to that of children with anxiety only.
In a study of 73 males between 6 and 17 years of age diagnosed with ADD/WO or ADD/H, 30% also met criteria for an anxiety disorder, with 60% of those children diagnosed with an overanxious disorder (Biederman, Faraone, Keenan, Steingard & Tsuang, 1991). The same study compared familial risks of children diagnosed with ADHD only and those diagnosed with both ADHD and an anxiety disorder. Questions were raised as to whether or not children who had an anxiety disorder were misdiagnosed as ADHD with anxiety; however, family members of both groups were equally at risk for developing ADHD. Both groups had a higher familial risk for anxiety disorders than the control group, but only the ADHD with anxiety group reached a level of significant difference from controls. The risk for one or more anxiety disorders, but not ADHD, among relatives was higher in the ADHD with anxiety group than the ADHD only group. For both groups, the presence of ADHD in a relative increased the risk for an anxiety disorder in that relative from 11 to 33 percent. No differences were found across SES groups for the risk of anxiety among relatives. In summary, the risk of ADHD was similar for both groups, and significantly higher than controls, the risk of anxiety was higher for the ADHD only group than controls, but relatives of the ADHD with anxiety group were at twice the risk of anxiety disorders than the ADHD only group.
In comparing children with only ADHD to those with ADHD with anxiety with regard to treatment, methylphenidate (MPH) seems to decrease activity levels in both groups; however, the medication increases working memory in the ADHD only group, but not in the group with anxiety (Tannock, Ickowicz & Schachar, 1995). Additionally, MPH increases heart rate, systolic blood pressure, and diastolic blood pressure in both groups, although the diastolic blood pressure is significantly increased further in the ADHD with anxiety group (Urman, Ickowicz, Fulford & Tannock, 1995). This finding further suggests physiological differences between the two groups, supporting evidence of this group representing either a subtype or having a different disorder (i.e. anxiety). Additionally, Buspirone was found to not only improve worry and anxiety in a group of children diagnosed with an anxiety disorder, but also to improve behavior and decrease hyperactivity in children with both ADHD and anxiety, suggesting a physiological link between the two diagnostic groups (Simeon, Knott, Dubois & Wiggins, 1994).
In the diagnosis of either ADHD or anxiety, using a battery of a variety of measures is recommended which includes primarily direct observation, behavior checklists, and parent, teacher, and self rating scales. Some instruments are designed to aid in differential or dual diagnosis, while others are designed to further analyze a specific disorder. In addition, several standardized cognitive and neurological instruments have been used to aid in the diagnosis of ADHD.
Direct observation in a variety of settings, either formally or informally, allows the examiner to note specific behaviors that occurred or did not occur and in what context. For example, when trying to differentiate between the two disorders or determine whether one, both, or neither disorder is present, it is helpful to note behaviors such as whether the child was squirming in his/her seat throughout the entire class period or only when s/he anticipated being called on, whether or not the child had difficulty maintaining attention during both structured and unstructured tasks, and whether the child often missed instructions because of external influences such as the child sitting beside him/her was constantly talking.
Common rating scales used to help differentiate between anxiety and ADHD, among other disorders, include the Behavioral Assessment Scale for Children (BASC) and the Child Behavior Checklist (CBCL). Both measures include a parent and teacher report which can be compared to one another, as well as a self report. However, caution is given with regard to administration of the CBCL for differential diagnostic purposes since it does not clearly define behaviors between disorders, but rather the scale clusters together similar behaviors which can be seen in a number of disorders (Reynolds & Kamphaus, 1990). For example, the scale does not separate behaviors related to anxiety and those related to depression; it also does not provide a distinct scale for hyperactivity. In addition, caution was raised regarding the insensitivity of the CBCL scale for diagnosing ADHD-Inattentive Type since such children may appear within normal limits due to items not reflective of attention difficulties which are included in the Attentional dimension, such as cannot sit still, clumsy, and acts young (Dumas & Guevremont, 1994). On the other hand, the BASC provides a more accurate scale for differentiating between anxiety and ADHD because it includes more distinct behaviors related to a specific disorder, as well as distinguishes among the disorders so that there is a separate scale for anxiety, a scale for attention problems, and a scale for hyperactivity (scales for other disorders are also included). Another benefit of the BASC is the inclusion of a lie scale to detect invalid responses.
Specific behavior rating scales which are used to gain additional insight regarding each disorder include the Attention Deficit Disorders Evaluation Scale (ADDES) and the Reynolds manifest Anxiety Scale (RMAS). Such scales are generally administered following the more comprehensive behavioral scales, such as the BASC, when significant areas of concern have been detected. With regard to ADHD, the ADDES presents a list of behaviors linked to the DSM-IV criteria and provides both a Home Version and a School Version to determine if the child meets criteria and if so, to pinpoint for which subtype. A number of other scales such as the ACTers, the CAAS-H, and the Conners are also used to aid in diagnosing ADHD. However, the ADDES was rated as one of the most favorable tools because it uses specific descriptors and observable behaviors; whereas, other scales tend to be vague, require the rater to draw conclusions, and/or include items unrelated to ADHD (Sharp, 1993). With regard to anxiety disorders, the RMAS provides an overall score which is derived from three subscales: Physiological, Worry/Oversensitivity, and Social Concerns/Concentration. Thus, critical areas can be determined from the subscales with regard to the nature of the anxiety. A lie scale is incorporated to indicate the validity of responses.
Several cognitive and neurological tests are often used in the evaluation of ADHD; however, there are minimal reports regarding the performance of children with anxiety disorders on these measures. Among the most common measures are the Processing Speed subtests on both the Wechsler Intelligence Scale for Children - III and the Woodcock Johnson Tests of Cognitive Abilities, the Stroop Color-Word Test, Continuous Performance Tests (CPT), and the Wisconsin Card Sorting Test. A number of studies have shown that children with ADHD generally perform more poorly on all the above measures in comparison to normal control groups. The small number of studies that have analyzed the performance of individuals with anxiety disorders on selective attention tasks indicate that these individuals also have difficulty maintaining focus and may perform similarly to the ADHD group (Fox, 1993; Mattia, 1993). Thus, such objective measures may not distinguish between the two disorders, although further research is needed.
Although many measurement tools exist to aid in diagnostic decision-making, discriminating between diagnoses or proposing dual or multiple diagnoses remains a challenge. Many symptoms are common to both ADHD and generalized anxiety disorders, making it difficult to determine which disorder a child may have or if multiple disorders are present. Therefore, further information is needed to aid in differentially diagnosing ADHD and anxiety, to determine whether or not subtypes of the disorders exist, or if the disorders are part of a spectrum of related disorders.
Suggestions for additional research include further comparisons between groups of children diagnosed with ADHD-Inattentive Type, ADHD-Hyperactive/Impulsive Type, ADHD-Inattentive Type with anxiety, ADHD-Hyperactivity/Impulsive Type with anxiety, and anxiety only. Comparison studies may include treatment effects of various medications, including MPH and Buspirone as previously mentioned, as well as Benzodiazepine and Clonazepam which are generally used in treating anxiety disorders (Biederman, 1990). With an increasing number of dual and multiple diagnoses, research is needed on the effectiveness of prescribing a combination of medication and to examine interaction effects (Wilens, Spencer, Biederman & Wozniak, 1995).
Other areas of research should include investigation of gender and age differences with regard to comorbidity of ADHD and anxiety. For example, it would be of interest to determine if comorbidity increases with age since one disorder may result from the other, as well as if comorbidity rates are higher among females since anxiety disorders are more prevalent among females.
There are currently over a thousand references for ADD in the psychological literature. Each issue we will pick a topic and provide you with a list of references. The topic for this issue is ADD and Anxiety:
Biederman, J., Newcorn, J. & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564-577.
Biedernan, J. & Steingard, R. (1989). Attention deficit hyperactivity disorder in adolescents. Psychiatric Annals, 19(11), 587-596.
Biederman, J. (1990). The diagnosis and treatment of adolescent anxiety disorders. Journal of Clinical Psychiatry, 51(5), 20-26.
Biederman, J., Faraone, S. V., Keenan, K., Steingard, R.; & Tsuang, M. T. (1991). Association between attention deficit disorder and anxiety disorder. American Journal of Psychiatry, 148(2), 251-256.
Desgranges, K., Desgranges, OL., & Karsky, K. (1995). Attention deficit disorder: Problems with preconceived diagnosis. Child and Adolescent Social Work Journal, 12(1), 3-17.
Duman, M. C. & Guevremont, D. C. (1994). Undifferentiated attention deficit disorder. ADHD Report, 2(1), 4-5.
Halperin, J. M., Newcorn, J. H., Matier, K., & Sharma, V. (1993). Discriminant validity of attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 32(5), 1038-1043.
Jensen, P. S., Shervette, R. E., Xenakis, S. N. & Richters, J. (1993). Anxiety and depressive disorders in attention deficit disorder with hyperactivity: New findings. American Journal of Psychiatry, 150(8), 1203-1209.
Lahey, B. B. & Carlson, C. L. (1991). Validity of the diagnostic category of attention deficit disorder without hyperactivity: A review of the literature. Journal of Learning Disabilities, 24(2), 110-120.
Pliszka, S. R. (1992). Comorbidity of attention deficit hyperactivity disorder and overanxious disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31(2), 197-203.
Reynolds, C. R. & Kamphaus, R. W. (1990). Handbook of psychological and educational assessment of children: Personality, behavior, and context. New York: Guilford Press.
Sharp, K. B. (1993). Comparing the technical aspects of attention deficit disorders rating scale. Columbia, MO: Hawthorne Educational Services.
Simeon, J. G., Knott, V. J., Dubois, C., & Wiggins, D. (1994). Buspirone therapy of mixed anxiety disorders in childhood and adolescence: A Pilot study. Journal of Child and Adolescent Psychopharmacology, 4(3), 159-170.
Tannock, R., Ickowicz, A. & Shachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 34(7), 886-896.
Urman, R., Ickowicz, A. & Fulford, P. (1995). An exaggerated cardiovasculoar response to methylphenidate in ADHD children with anxiety. Journal of Child and Adolescent Psychopharmacology, 5(1), 29-37.
Wilens, T. E., Spencer, T., Biederman, J., & Wozniak, J. (1995). Combined pharmacotherapy: An emerging trend in pediatric psychopharmacology. Journal of the American Academy of Child and Adolescent Psychiatry, 34(1), 110-112.
Of the most recent 136 children referred for evaluation of ADHD, 28 received a diagnosis of ADHD alone (roughly 20 percent). Another 60 had ADHD but also received at least one other diagnosis. Of the sixty children with ADHD, thirty-two had ADHD and learning disabilities; twelve had ADHD and depression; three had ADHD and Oppositional Defiant Disorder. Some of the children represented single cases of another disorder such as mental retardation, conduct disorder, adjustment disorders, etc. The following is a breakdown of diagnoses received.
| ADHD Subjects | |||||
| ADHD only | 28 | ||||
| ADHD | 15 | ||||
| ADHD, Inattentive type | 13 | ||||
| ADHD + Another Disorder | 60 | ||||
| ADHD + Learning Disabilities | 31 | ||||
| ADD + LD + Depression | 5 | ||||
| ADHD + Depression | 12 | ||||
| ADHD + Depression + Another Problem | 2 | ||||
| ADHD + Adjustment Disorder | 4 | ||||
| ADHD + Mental Retardation | 1 | ||||
| ADHD + Autism | 1 | ||||
| ADHD + Oppositional Defiant Disorder | 3 | ||||
| ADHD + Anxiety | 1 | ||||
| ADHD + Anxiety and Depression | 2 | ||||
| ADHD + Obsessive Compulsive | 2 | ||||
| ADHD/Organic Problems | 1 | ||||
| ADHD + Phonological Disorder + Borderline IQ | 1 | ||||
| ADHD + Enuresis | 1 | ||||
| NON-ADHD Subjects | |||||
| Learning Disabled | 11 | ||||
| LD + Adjustment Disorder | 2 | ||||
| LD + OC | 1 | ||||
| LD + Anxiety | 1 | ||||
| LD + Depression | 3 | ||||
| LD + PTSD | 1 | ||||
| Borderline Intellectual Functioning | 2 | ||||
| Mental Retardation | 2 | ||||
| Organic | 4 | ||||
| Auditory Processing | 5 | ||||
| Auditory Proc + Depression | 3 | ||||
| Anxiety + Depression | 3 | ||||
| Depression | 4 | ||||
| Adjustment Disorder | 3 | ||||
| Separation Anxiety/Social Phobia | 1 | ||||
| Conduct Disorder | 2 | ||||
| Enuresis | 2 | ||||
| PTSD | 1 | ||||
| Bipolar Disorder | 1 | ||||
| No diagnosis | 7 |
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