Nature of anxiety comorbid with attention deficit hyperactivity disorder in children from a pediatric primary care setting
Introduction
Anxiety disorders and attention deficit/hyperactivity disorder (ADHD) are the two most common psychiatric disorders of childhood and are also comorbid with each other in approximately 25% of cases (Pliszka et al., 1999, Tannock, 2000). The rate of comorbidity is greater than would be expected by chance, and is still present after controlling for overlapping symptoms such as restlessness and difficulty concentrating (Milberger et al., 1996, Angold et al., 1999, Tannock, 2000). Children with both these conditions are described as “worriers” about competence and future events and they show a great need for reassurance (Tannock, 2000).
Comorbid conditions such as anxiety and conduct disorder are important given that they may affect the functioning and treatment outcome of children with ADHD (Biederman et al., 1993, Biederman et al., 1996, Greene et al., 2001, Jensen et al., 2001, Newcorn et al., 2004). A few studies have found that children with comorbid ADHD and anxiety respond less well to stimulant medication and get more unpleasant arousal side-effects, but the findings are inconsistent and may be more relevant to girls (Pliszka, 1989, DuPaul et al., 1994, Tannock et al., 1995, Newcorn et al., 2001, Gadow et al., 2002). The Multimodal Treatment Study of Children with ADHD (MTA study) did not find that children with comorbid anxiety (32% of the sample) did worse with stimulant medication, but did find that these children did better with combined medication and behavior therapy (March et al., 2000, Jensen et al., 2001).
This report is based on the second phase of a larger project in which we studied a representative sample of children from a primary care pediatric practice. The Human Research Protection Program at our University approved both phases of the study. Parents provided written consent to the interview and questionnaires, and children and adolescents provided written assent. This study sought to examine clinical differences between children with comorbid ADHD and ADHD or anxiety alone; it was expected that the comorbid ADHD group would have more severe symptoms and impairment than either condition alone.
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Procedures
In the first phase, 1430 families with children between the ages of 8 and 17 years were randomly selected from families that were seen in a pediatric primary care setting within the last year (Chavira et al., 2004). Within each family, one child was randomly selected. Questionnaire packets were mailed by the primary care clinic and received by 1173 families (219 packages were ineligible because of wrong address or children outside of the age range). Of the 1173 families that comprised the
Results
The social demographic characteristics of the children in the four groups are presented in Table 2. Of the children with an anxiety disorder (n = 68), 14 had ADHD (20.6%) and of those with ADHD (n = 29), 14 had an anxiety disorder (48.3%). In the ADHD-only and comorbid groups combined, there were 22 children with the inattentive type of ADHD, three with the hyperactive type, and four with the combined type; there were no demographic differences between the three ADHD groups. As shown in Table 3,
Discussion
Using a moderate level of impairment, approximately 25% of children had an anxiety disorder (including specific phobias) and 15% had ADHD. While the rates of disorders are high, this is not uncommon. Rates of child anxiety disorders often range from 6 to 22% (Kashani and Orvaschel, 1988, Costello, 1989, Reinherz et al., 1993, Briggs-Gowan et al., 2000) while rates of ADHD usually are in the range from 4 to 12% (Brown et al., 2001). In smaller studies, however, rates of ADHD have been much
Conclusions
In our study population, 50% of children with ADHD also had an anxiety disorder. Accompanying this comorbidity were higher levels of impairment when compared to both the ADHD-only group and the anxiety-only group. Specifically, the children with a comorbid ADHD/anxiety diagnosis had more anxiety and depressive symptoms, more attention problems, and were also less socially competent than the comparison groups. Since child anxiety is often a precursor to later anxiety, mood, and substance abuse
References (44)
- et al.
Social Adjustment Inventory for children and adolescents: concurrent validity in ADHD children
Journal of the American Academy of Child and Adolescent Psychiatry
(1993) - et al.
The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics
Journal of the American Academy of Child and Adolescent Psychiatry
(1997) - et al.
Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study
Journal of the American Academy of Child and Adolescent Psychiatry
(1999) - et al.
Mental health in pediatric settings: distribution of disorders and factors related to service use
Journal of the American Academy of Child and Adolescent Psychiatry
(2000) - et al.
Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample
Journal of Affective Disorders
(2004) Child psychiatric disorders and their correlates: a primary care pediatric sample
Journal of the American Academy of Child and Adolescent Psychiatry
(1989)- et al.
Response of children with ADHD to methylphenidate: interaction with internalizing symptoms
Journal of the American Academy of Child and Adolescent Psychiatry
(1994) - et al.
Social impairment in girls with ADHD: patterns, gender comparisons, and correlates
Journal of the American Academy of Child and Adolescent Psychiatry
(2001) - et al.
Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?
Journal of the American Academy of Child and Adolescent Psychiatry
(1999) - et al.
ADHD comorbidity findings from the MTA study: comparing comorbid subgroups
Journal of the American Academy of Child and Adolescent Psychiatry
(2001)
Three traditional and three new childhood anxiety questionnaires: their reliability and validity in a normal adolescent sample
Behaviour Research and Therapy
Symptom profiles in children with ADHD: effects of comorbidity and gender
Journal of the American Academy of Child and Adolescent Psychiatry
Effect of anxiety on cognition, behavior, and stimulant response in ADHD
Journal of the American Academy of Child and Adolescent Psychiatry
Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder
Journal of the American Academy of Child and Adolescent Psychiatry
Prevalence of psychiatric disorders in a community population of older adolescents
Journal of the American Academy of Child and Adolescent Psychiatry
Age differences in the reliability of parent and child reports of child anxious symptomatology using a structured interview
Journal of the American Academy of Child and Adolescent Psychiatry
The Anxiety Disorders Interview Schedule for Children
Journal of the American Academy of Child and Adolescent Psychiatry
Test–retest reliability of the DSM-III-R childhood anxiety disorders symptoms using the Anxiety Disorders Interview Schedule for Children
Journal of Anxiety Disorders
Test–retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions
Journal of the American Academy of Child and Adolescent Psychiatry
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
Diagnostic and Statistical Manual of Mental Disorders
Comorbidity
Journal of Child Psychology and Psychiatry
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