I promised in my last post that I would discuss the issue of anxiety and Inattentive ADHD. Some researchers have speculated that Inattentive ADHD is really anxiety disguised as inattention or distraction. I would discount this idea right of the bat except I think that there may be something to it and that it is worth looking at.
The very best reason to not (incorrectly) diagnose anxiety as ADD has to do with treatment. Treating inattention with stimulants will often make the anxiety worse and will likely not help the inattention at all. Another consideration is the difficulty of understanding emotional symptoms in children. I have observed in my clinical practice and in my work in classrooms that children who are in crisis (death of a parent/grand-parent, house fire, sudden relocation) and depressed children often do not act sad. Instead they act angry and frustrated. Anxious children often do not act stressed, instead they just act as if the are "out of it".
I have personal reasons for examining this idea too. I was anxious as a child and I came by it honestly. My family left Cuba when I was four. We lived in three states before I reached the age of six, I was introverted and not fluent in English until third grade, my father died when I was eight, I had terrible separation anxiety .. you get the picture. So getting back to the original question from my last post. Was I just an anxious child that developed inattention as a primary symptoms? Maybe, but the real question is how do you best treat inattention even when it is coupled or caused by depression or anxiety.
We know that anxiety and depression are more common in people with all types of ADHD, including inattentive ADHD. Trying to figure out the chicken and egg question, what came first the inattention or the anxiety/depression is an exercise in futility and might be besides the point. Researchers are finding that there are neurological reasons why people with ADHD, depression and anxiety have the symptoms they have.
The brain areas and processes that are effected (neurotransmitter response, stress response, frontal cortex activity, etc) in these conditions are similar. Given this knowledge, it should not surprise anyone that the rates of suicide in people with ADHD is similar to the rates of suicide in people with depression or anxiety.
Many pediatricians, psychiatrists and neurologists are coming to the conclusion that ADHD needs to be evaluated more thoroughly and that complete psychological and neurological work-ups must be done before a child or adult is "stamped" with an ADHD diagnosis. I could not agree more. Did you know that psychiatrists are almost half as likely to diagnose symptoms as ADHD as are primary care physicians? It is true, the reference is below this post. The reason for this is thought to be related to the fact that psychiatrists tend to do a more thorough evaluation and may be more likely to consider anxiety,depression or another condition as a possible cause of ADHD symptoms.
ADHD is rarely thoroughly evaluated. Insurance companies often will not reimburse patients and parents for a complete evaluation and this is one of the reasons. Another reason may be that primary care providers do not consider all the possible medical conditions that can cause ADHD-like symptoms and are therefore less likely to refer a patient for a more thorough evaluation.
I would love to know what you think about anxiety and depression. Please leave a comment and let me know! Thanks
Chen CY, Gerhard T, Winterstein AG. Determinants of initial pharmacological treatment for youths with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2009 Apr;19(2):187-95.