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My 8-year-old son with ADHD is anxious. Should we add to or change his medication?

Medication isn't the first choice for treating anxiety 

Steven G. Dickstein, MD

Pediatric Psychopharmacologist, formerly with the ADHD and Disruptive Behavior Disorders Center
Child Mind Institute

Q: My son is eight years old and in second grade. He was diagnosed with ADHD during 1st grade. He has been on just about every stimulant, except for the patch. The best fit for him has been Vyvanse with a Ritalin booster in the morning and after school. This medicine works great for his ADHD symptoms, but we feel that he has become more anxious while taking this medicine, especially nervous about insects. Without the medication he does not appear anxious but his behavior is challenging for everyone and it has affected him socially.  

Is it possible to add a drug to the Vyvanse to help with his anxiety? I know that there are nonstimulants that may not increase his anxiety, but I'm afraid that they won't help as much with his ADHD symptoms.

A: It is actually very common for kids with ADHD to have problems with anxiety. Sometimes this is because kids feel anxious as a result of their ADHD symptoms—they can't attend to things in class so they're always missing information and getting into trouble, which makes them feel bad. But when kids get effective treatment for ADHD, so that they're able to focus and pay attention and actually hear reassurance from the adults in their life, this kind of anxiety can actually fall away.

For some children, who have both an anxiety disorder and ADHD, the child's anxiety doesn't "leave" when the ADHD symptoms get better. In a situation like this I think it is important to work with a physician who is trained and comfortable treating kids who have the combination of ADHD and an anxiety disorder. In most cases, the best-trained specialist for this type of work is a child psychiatrist. While primary care pediatricians often have tremendous experience in treating ADHD, the residency training program in pediatrics does not fully prepare a doctor to treat severe anxiety with the combination of cognitive behavioral therapy and psychopharmacology that is considered the most efective treatment.

By carefully evaluating all of a child's behaviors and emotional symptoms, a child psychiatrist can help parents identify the right combination of interventions for the complexity of the behaviors. For example, in some more rare cases (1 out of 25 kids) stimulant medications for ADHD make a child more irritable after they are started. However, it takes a lot of careful observation to learn if the anxiety is a side effect of the medication or if it is something else. A psychiatrist needs to determine how anxious your son was before starting the medication. When he's off the medication is he still anxious? Does he get more anxious? Teasing out every factor can be complicated, so you want a doctor who has the time and experience to really figure out what's going on with your son.

It is essential to get a really good diagnostic evaluation and find out if your son has an anxiety disorder co-occurring with ADHD. If he does, anxiety disorders are treated very differently from ADHD. The goal in treating an anxiety disorder is to help kids learn how to tolerate the things that make them anxious. That's why the first line treatment for anxiety is psychotherapy, not medication. When I see a child with ADHD and an anxiety disorder, the first thing I'll do is treat the ADHD with an effective dose of stimulant medication. Once the child's focus and impulsivity have improved, then I work with the family to start treating his anxiety disorder with some good cognitive-behavioral therapy. It happens in this order because kids who are really affected by their ADHD symptoms will need some help before they're able to pay attention to therapy and experience the benefit of it. Then, after the ADHD symptoms are under control and you're doing cognitive-behavioral therapy, you might find that a child is still too anxious. At that point, the child has demonstrated that he has more intense symptoms and his doctor should discuss using an SSRI medication, like Sertraline or Fluoxetine, to target the anxiety disorder. Research has shown repeatedly that the combination of medication treatments with effective psychotherapy (like CBT for anxiety) is more effective than either treatment alone. However, in order to figure out what is working, you want a doctor to work carefully with you to introduce one intervention at a time and develop a strategy that will be both safe and effective to help your child be able to function and reach his full potential.

Published: April 30, 2013

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