ADHD, Anxiety and Children

One of the co-morbid disorders we often find in children with ADHD is anxiety. Sometimes this anxiety can be so strong it makes all of ADHD intervention attempts hopeless. For years I have been using Cognitive Behaviour Therapy in combination with ADHD therapies with children. Many therapists, teachers, school counsellors and others have been unsure about the use of Cognitive Behaviour Therapy because they feel a child of six or seven doesn't have the capacity to make use of the CBT techniques. As with many emotional issues with children we are able to circumvent that problem by using visual supports. I make use of two visual support systems, one is called "Give Me aHand" which uses the five fingers on your hand to differentiate between different levels of emotions, and the other is a popular system used within the schools called "The Incredible Five Point Scale." These visual supports help students understand the differences between minor feelings of anxiety, situations in which it is OK to have anxiety (like in a scary movie or when playing a game), situations that they feel moderately uncomfortable in, all the way up to situations they feel they must get out of soon, and those they simply can't deal with and feel like they will "explode" in, or melt down. I highly recommend these books and games from the authors of The Incredible Five Point Scale. You can find many of the books I recommend at my web site's resource page here.

REcently there has been some research to support the use of Cognitive Behaviour Therapy with anxiety and, I am sure, ADHD (Attention Deficit Hyperactivity Disorder). Cognitive Behaviour Therapy is also a basis for treatment of both child and adult ADHD, so the treatment fits in well. What's important is we are training our brains how to think rationally, and that can include thinking rationally about ADHD, procrastination, anxiety or depression. It's teaching a way of thinking that avoids many of the thought distortions we find in people diagnosed with ADHD, anxiety, depression and related disorders.

I wanted to provide a little information about the recent research into using Cognitive Behaviour Therapy with children for anxiety.

The authors are Dina R. Hirshfeld-Becker , Bruce Masek, Aude Henin, Lauren Raezer Blakely, Rachel A. Pollock-Wurman, Julia McQuade, Lillian DePetrillo, Jacquelyn Briesch, Thomas H. Ollendick, Jerrold F. Rosenbaum, & Joseph Biederman.

Here's how the article starts: [excerpts]
Anxiety disorders represent one of the most common categories of childhood disorders (Costello et al., 1996; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Studies suggest that childhood anxiety disorders are associated with social, familial, and academic impairment (Essau, Conradt, & Petermann, 2000; Ezpeleta, Keeler, Erkanli, Costello, & Angold, 2001; Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1995; Strauss, Frame, & Forehand, 1987), are likely to persist if untreated, and tend to predispose children to develop anxiety disorders later in adolescence and adulthood (Costello et al., 2003; Hirshfeld, Micco, Simoes, & Henin, 2008; Newman et al., 1996; Weissman, 1999). Clearly, the ability to intervene early to treat these disorders
would be beneficial.

Over the last two decades, promising cognitive behavioral therapies (CBT) have been developed to treat childhood anxiety disorders, including social phobia, separation anxiety disorder, and generalized anxiety disorder (GAD; James, Soler, & Weatherall, 2005; Ollendick & King, 1998; Silverman, Pina, & Viswesvaran, 2008). Such studies have suggested that CBT can be efficacious for these disorders when offered individually or as a family treatment (Kendall, Hudson, Gosch, Flannery- Schroeder, & Suveg, 2008) and when offered alone or in combination with sertraline (Walkup et al., 2008). However, despite at least eight early studies showing the efficacy of approaches such as in vivo desensitization; filmed, live, and participant modeling; graded exposure; reinforced practice; and verbal self-instruction to treat fears or specific phobias in preschool- and kindergarten-age children (see Ollendick & King, 1998), the protocols addressing the other major childhood anxiety disorders have been evaluated mainly among school-age children and adolescents. Although some studies extended their inclusion age downward to age 5 or 6? (e.g., King et al., 1998; Shortt, Barrett, & Fox, 2001), they generally included relatively small numbers of the youngest children (with mean sample ages of 11.03 and 7.8 years, respectively) and did not examine results separately for the youngest age group.

The underrepresentation of younger children in studies of CBT protocols for major childhood anxiety disorders may have derived from beliefs about the transience of anxiety disorders in this age group or from the assumption that younger children were not developmentally mature enough to benefit from cognitive behavioral interventions. However, recent studies have challenged these assumptions. First, studies have demonstrated that preschoolers present with persistent anxiety disorders at rates almost as high as older children (Egger & Angold, 2006; Lavigne et al., 1998), and factor-analytic studies have shown that the symptom presentations in preschoolers closely parallel those found in older children (Eley et al., 2003; Spence, Rapee, McDonald, & Ingram, 2001). In addition, several groups have recently begun testing the use of CBT protocols for a variety of anxiety disorders in younger children.

So anxiety is as common among younger children as any other group. It is an area of concern, and it appears CBT is a helpful intervention. The anxiety these children experience often comes from the same cognitive distortions that teens and adults experience. And we have ways to work on those distortions. And training in relaxation, thought stopping and breathing techniques work with children as well. This goes for adults as well.

Information about my programs for children with ADHD (Attention Deficit Hyperactivity Disorder) can be found at my web site There is also specific information there about adult ADHD assessments and treatment. For that information click here. More general information on my practice can be found by clicking here or here.

Dr. Jim Roche, Registered Psychologist