The presence of 2 or more comorbid anxiety disorders in children with attention-deficit/hyperactivity disorder (ADHD) impairs functioning, increases problematic behavior, and is associated with a poorer quality of life (QoL) compared with children with ADHD who have 1 or no anxiety disorders, new research shows.
Investigators led by Emma Sciberras, DPsych, from Murdoch Children's Research Institute in Parkville, Australia, found that participants' ability to function in daily life as well as QoL were significantly poorer in children with 2 or more anxiety comorbidities compared with their counterparts with ADHD but who had little or no anxiety.
The same group of children also had significantly more behavioral problems than children without significant anxiety.
"A number of studies have focused on externalizing difficulties such as oppositional defiant disorder or conduct disorder in children with ADHD," Dr. Sciberras told Medscape Medical News.
"However, the impact of anxiety on the lives of children with ADHD has been largely overlooked. Given that we found anxiety is so common in children with ADHD and is associated with poorer functioning, it is important that anxiety be assessed as part of clinical assessments for children with ADHD and be reassessed at each follow-up consultation, as anxiety may develop over time."
The study was published April 21 in Pediatrics.
Significant Impact on QoL
For the study, 392 children with diagnostically confirmed ADHD were recruited through 21 pediatrician practices across Victoria, Australia.
Anxiety was measured by the Anxiety Disorders Interview Schedule for Children/Parent Version IV (ADIS-C). Anxiety comorbidities included separation anxiety disorder, social phobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).
QoL was assessed using the 23-item Pediatric Quality of Life Inventory 4.0 ― a parent proxy report ― and behavior and peer problems were measured using the parent- and teacher-reported Strengths and Difficulties Questionnaire.
Daily functioning was measured with the Daily Parent Rating of Evening and Morning Behavior.
The researchers found that 36% of the cohort had no comorbid anxiety; 26% had 1 anxiety comorbidity; and 39% had 2 or more anxiety comorbidities.
Social phobia was the most common anxiety comorbidity, occurring in 48% of children with 2 or more anxiety comorbidities, the authors note.
This was followed by generalized anxiety disorder (34%); separation anxiety (32%); OCD (8%); PTSD (6%); and panic disorders (2%).
"For the current study, differences in QoL we found for children with ADHD and multiple anxiety comorbidities was large compared to children with no anxiety comorbidities," said Dr. Sciberras.
Differences in behavior between the 2 groups were moderate, she added, and differences in daily functioning were small — "but, we would argue, still clinically meaningful."
Table. Adjusted Standardized Mean Differences for Children With Anxiety Comorbidities Compared With Those Without Comorbid Anxiety (Parent-Reported)
| 0 Cormorbidity (Reference) | 1 Comorbidity | ≥2 Cormorbidities |
| Psychosocial QoL | -0.1 | -0.8 (P < .001) |
| Daily functioning | -0.004 | 0.3 (P = .01) |
| Behavior | -0.02 | 0.4 (P < .001) |
High Prevalence
The prevalence of anxiety comorbidities seen in this cohort was higher than that reported in other studies, the investigators note.
"This is likely due to the fact that we examined a 'real-life' group of children with ADHD and did not exclude participants with common comorbidities, including autism spectrum disorder," she explained.
Dr. Sciberras added that multiple anxiety disorders were associated with poorer QoL and behavior for children with ADHD–combined presentation (ADHD-C) as well as for children with ADHD- inattentive presentation (ADHD-I).
Poorer QoL, behavior, and daily functioning were all observed for children with ADHD-I.
"We suspect that high levels of anxiety make it difficult for children with ADHD to get the most out of life and to fully participate in day-to-day activities," Dr. Sciberras explained.
For example, a child's ability to function at school could be compromised if the child spends much of their time worrying about whether they are able to complete the work or if the child avoids tasks they find worrying.
"More generally," Dr. Sciberras added, "anxiety has an impact on our ability to concentrate on tasks."
This suggests that anxiety may intensify attention difficulties in children with ADHD and make daily functioning more difficult.
Common Comorbidity
Commenting on the study for Medscape Medical News, Matthew Jarrett, PhD, University of Alabama, in Tuscaloosa, said that the study brings to light how common anxiety is in children with ADHD.
"Population-based studies show that about 25% of children with ADHD have an anxiety disorder and about 30% to 40% of children in clinical samples have an anxiety disorder," Dr. Jarrett said.
Because this study was carried out in a "real-world" setting, "the fact that researchers found such a high percentage of children with anxiety really suggests that this is a pretty common comorbidity for children ADHD," he added.
Several years ago, Dr. Jarrett and colleagues carried out small study in a group of children with ADHD and 2 or more anxiety comorbidities ( J Consult Clin Psychol. 2012;80:239-244).
Using a combination of parent management training plus cognitive-behavioral therapy (CBT), the group found that the combined approach improved symptoms of both ADHD after 10 weeks of treatment.
"At 6 months' follow-up, many of the children maintained their gains, and there was even greater improvement in ADHD symptoms 6 months posttreatment," Dr. Jarrett said.
Dr. Sciberras and colleagues are currently conducting a pilot trial to evaluate the feasibility and acceptability of using CBT to treat anxiety in children with ADHD.
Children between the ages of 8 and 12 years will receive 10 sessions of CBT during the pilot study.
Investigators hope that the pilot project will set the stage for a controlled trial in which children with ADHD will be randomly assigned to receive active treatment or control to evaluate whether or not CBT improves not only anxiety but broader child and family well-being.
The study by Dr. Sciberras et al was funded by the Australian National Health and Medical Research Council and by the Royal Children's Hospital and the Murdoch Children's Research Institute. The authors and Dr. Jarrett have reported no relevant financial relationships.
Pediatrics. 2014;133:801-808. Abstract
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Cite this: Comorbid Anxiety Impairs Function, QoL in ADHD Kids - Medscape - Apr 22, 2014.
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