Anxiety in Children With Attention-Deficit/Hyperactivity Disorder

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<ul><li><p>DOI: 10.1542/peds.2013-3686; originally published online April 21, 2014; 2014;133;801Pediatrics</p><p>HiscockEmma Sciberras, Kate Lycett, Daryl Efron, Fiona Mensah, Bibi Gerner and Harriet</p><p>Anxiety in Children With Attention-Deficit/Hyperactivity Disorder </p><p></p><p>located on the World Wide Web at: The online version of this article, along with updated information and services, is</p><p>of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2014 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly</p><p> at Tufts Univ on September 25, 2014pediatrics.aappublications.orgDownloaded from at Tufts Univ on September 25, 2014pediatrics.aappublications.orgDownloaded from </p><p></p></li><li><p>Anxiety in Children With Attention-Deficit/Hyperactivity Disorder</p><p>WHATS KNOWN ON THIS SUBJECT: Up to 50% of children withattention-deficit/hyperactivity disorder (ADHD) meet criteria fora comorbid anxiety disorder. Despite the high prevalence ofanxiety in these children, the impact of anxiety on the lives ofchildren with ADHD has been largely overlooked.</p><p>WHAT THIS STUDY ADDS: Presence of $2 anxiety comorbiditiesin children with ADHD was associated with poorer child quality oflife, daily functioning, and behavior. Multiple anxiety comorbiditieswere associated with poorer functioning for children with bothADHD-Inattentive and ADHD-Combined presentation.</p><p>abstractOBJECTIVES: Although anxiety is common in children with attention-deficit/hyperactivity disorder (ADHD), it is unclear how anxiety influencesthe lives of these children. This study examined the association betweenanxiety comorbidities and functioning by comparing children with ADHDand no, 1, or $2 anxiety comorbidities. Differential associations wereexamined by current ADHD presentation (subtype).</p><p>METHODS: Children with diagnostically confirmed ADHD (N = 392; 513years) were recruited via 21 pediatrician practices across Victoria, Aus-tralia. Anxiety was assessed by using the Anxiety Disorders InterviewSchedule for ChildrenIV. Functional measures included parent-reported: quality of life (QoL; Pediatric Quality of Life Inventory 4.0),behavior and peer problems (Strengths and Difficulties Questionnaire),daily functioning (Daily Parent Rating of Evening and Morning Behavior),and school attendance. Teacher-reported behavior and peer problems(Strengths and Difficulties Questionnaire) were also examined. Linearand logistic regression controlled for ADHD severity, medication use,comorbidities, and demographic factors.</p><p>RESULTS: Children with $2 anxiety comorbidities (n = 143; 39%) hadpoorer QoL (effect size: 0.8) and more difficulties with behavior(effect size: 0.4) and daily functioning (effect size: 0.3) than childrenwithout anxiety (n = 132; 36%). Poorer functioning was not observedfor children with 1 anxiety comorbidity (n = 95; 26%). Two or moreanxiety comorbidities were associated with poorer functioning forchildren with both ADHD-Inattentive and ADHD-Combined presentation.</p><p>CONCLUSIONS: Children with ADHD demonstrate poorer QoL, dailyfunctioning and behavior when $2 anxiety comorbidities are present.Future research should examine whether treating anxiety in childrenwith ADHD improves functional outcomes. Pediatrics 2014;133:801808</p><p>AUTHORS: Emma Sciberras, DPsych,a,b Kate Lycett, BA,GDipPsych,a,c Daryl Efron, FRACP, MD,a,b,c Fiona Mensah,PhD,a,d Bibi Gerner, MPsych,a and Harriet Hiscock, FRACP,MDa,b,c</p><p>aCommunity Child Health, Murdoch Childrens Research Institute,Parkville, Australia; bThe Royal Childrens Hospital, Parkville,Australia; cDepartment of Paediatrics, University of Melbourne,Parkville, Australia; dClinical Epidemiology and Biostatistics Unit,Murdoch Childrens Research Institute, The Royal ChildrensHospital, Parkville, Australia</p><p>KEY WORDSattention-deficit/hyperactivity disorder, child, comorbidity, anxietydisorders, internalizing disorders, quality of life, impairment</p><p>ABBREVIATIONSADHDattention-deficit/hyperactivity disorderADHD-CADHD Combined presentationADHD-IADHD Inattentive presentationADIS-CAnxiety Disorders Interview Schedule for Children/Parent Version IVASDAutism Spectrum DisorderDSM-IVDiagnostic and Statistical Manual of Mental Disorders,Fourth EditionESeffect sizeQoLquality of lifeSEIFASocioeconomic Indexes for Areas</p><p>Dr Sciberras coordinated the study and collected study data,conceptualized and designed the study, carried out the analyses,and drafted the initial manuscript; Ms Lycett coordinated thestudy and collected study data, contributed to the conceptionand design of the study, reviewed and revised the manuscript,and provided critical input; Drs Efron, Mensah, and Hiscockcontributed to the conception and design of the study, reviewedand revised the manuscript, and provided critical input; MsGerner coordinated the study, collected study data, andcontributed to the drafting of the manuscript; and all authorsapproved the final manuscript as submitted.</p><p>(Continued on last page)</p><p>PEDIATRICS Volume 133, Number 5, May 2014 801</p><p>ARTICLE</p><p> at Tufts Univ on September 25, 2014pediatrics.aappublications.orgDownloaded from </p><p></p></li><li><p>At least 60% of children with attention-deficit/hyperactivity disorder (ADHD)meet criteria for$1 comorbiddisorders(eg, externalizing, mood, autism spec-trum [ASD], and learning disorders).1</p><p>Although externalizing comorbiditieshave been widely studied in childrenwith ADHD, anxiety has received less at-tention. Approximately 25% to 50% ofchildren with ADHD suffer from at least 1anxiety disorder, including separation,social, and generalized anxiety.2,3 Yet theimpact of anxiety on the lives of childrenwith ADHD remains poorly understood. Ifanxiety adversely affects functioning,then the management of anxiety shouldbe prioritized in treatment.</p><p>Although previous research has sug-gested that children with ADHD and anx-iety are less impulsive,4,5 studies havedemonstrated that these children havemore attentional4,6 and broader cognitiveand executive functioning difficulties7</p><p>than those with ADHD alone. It is possiblethat exacerbation of executive functioningdifficulties for children with ADHD andanxiety, in combination with the avoid-ance and negative thought patterns as-sociatedwith anxiety,mayhave anegativeimpact on functioning for these children.Research examining the impact of anxietyin ADHD has largely focused on socialfunction. Although anxiety has beenshown to exacerbate social problems forchildren with ADHD,6,811 these findingsare not always supported.1214 Mixedfindings may be due to methodologiclimitations, including single clinical sam-ples,8 broadparticipant age range,6,12 andsmall samples.6,10 Although it is sus-pected that anxiety in children with ADHDwould be associated with poorer qualityof life (QoL) anddaily functioning, researchhas yet to examine this. Furthermore,despite children with ADHD-Combined(ADHD-C) and ADHD-Inattentive (ADHD-I)presentation having similar levels ofanxiety,15 it is unknown whether the as-sociation between anxiety and functionis similar for ADHD-C versus ADHD-I.</p><p>Previous research has not fully accoun-ted for factors that may confound therelationship between anxiety and func-tion including ADHD symptom severity,externalizing and mood disorders, andASD, which is problematic given thatthese comorbidities influence function-ing1 and commonly co-occur with anxi-ety.16,17 Furthermore, studies have notaccounted for the impact of havingmultiple anxiety disorders, a commonoccurrence for children with ADHD.18,19 Itis unknown whether functioning is onlycomprised when more pervasive levelsof anxiety are present. In the generalpopulation, the presence of multipleanxiety disorders, in particular, is asso-ciated withmultiple adverse outcomes.20</p><p>Although parents of children with ADHDand anxiety have increased psychiatricsymptoms,2123 this has not been takeninto account when examining the impactof anxiety in these children.</p><p>Therefore, in a large sample of childrenwith ADHD, we aimed to examine</p><p>1. differences in functioning (QoL, peerfunctioning, behavior, daily function-ing, school attendance) betweenchildren without anxiety and thosewith 1 anxiety comorbidity and $2anxiety comorbidities; and</p><p>2. whether anxiety is associated withpoorer functioning in children withADHD-C and ADHD-I.</p><p>It was hypothesized that children withADHD and anxiety (both 1 or$2 anxietycomorbidities) would have poorer func-tioning across all domains comparedwith those without anxiety. No hypothe-sis was formed for the second aim giventhe paucity of previous research.</p><p>METHODS</p><p>Design and Setting</p><p>Participants were recruited via 21 publicand private pediatric practices acrossVictoria,Australia, for2harmonizedADHDstudies: (1) a randomized controlled trialof a behavioral sleep intervention24 and</p><p>(2) a comparable cohort with no/mildsleep problems.25 This study uses base-line data from these two studies. Ethicsapproval was obtained by the RoyalChildrens Hospital (31193; 30033) andthe Victorian Department of Educa-tion and Early Childhood Development(2011_001307; 2010_000573).</p><p>Eligibility and Recruitment</p><p>Participating pediatricians (N = 50)mailed invitation letters to childrenwith ADHD aged 5 to 12 years seen inthe past year. An opt-out approach wasused in which families contacted theresearch team if they did not want tohear about the study. Parents who didnot opt out were telephoned to assesseligibility and interest in participating.</p><p>To be eligible, children needed to havebeen diagnosed with ADHD by their pe-diatrician and meet full Diagnostic andStatistical Manual of Mental Disorders,Fourth Edition (DSM-IV) criteria forADHD. DSM-IV symptom criteria wasassessed by using the parent-reported18-item ADHD Rating ScaleIV26; itemsdirectly reflect DSM-IV symptom con-tent, and the measure has excellent re-liability and validity.26 Parents reportedon their childs unmedicated behavior.Items are rated on a 4-point scale fromnever (0) to very often (4). Symptomsrated often and very often are scored1 (symptom present), and symptomsrated never and sometimes arescored 0 (symptom absent). Parentsneeded to endorse at least 6 of 9 symp-toms as present in either symptom do-main to be eligible. Study-designedquestions assessed additional DSM-IVcriteria including symptom duration of$6 months, age of onset before 7 years,and cross-situational impairment. Chil-dren were classified as ADHD-C if $6symptoms were endorsed in bothsymptom domains and were classifiedas ADHD-I or ADHD hyperactive/impulsivetype if $6 symptoms were only en-dorsed in 1 of the respective domains.</p><p>802 SCIBERRAS et al at Tufts Univ on September 25, 2014pediatrics.aappublications.orgDownloaded from </p><p></p></li><li><p>Children needed to be aged 5 to 13 yearsat the time of recruitment, and those inthe randomized controlled trial neededto have a parent-reported moderate/severe sleep problem and meet criteriafor $1 sleep disorder27 to be eligible.Children in the cohort study needed tohave no/mild sleep problems.</p><p>Exclusion criteria included (1) insuf-ficientEnglish toparticipate, (2)receivingspecialized sleep assistance from a psy-chologist or sleep clinic, and (3) childhaving a serious medical condition (eg,cerebral palsy), intellectual disability, orsuspected obstructive sleep apnea.</p><p>Eligible families were mailed an infor-mation sheet, consent form, and survey.Families were enrolled upon receipt ofthe completed consent form and survey.Enrolled parents were then telephonedto complete a diagnostic interview, andteachers were mailed a consent formand survey if parental consent wasprovided.</p><p>Measures</p><p>Anxiety was measured by using theAnxiety Disorders Interview Schedulefor Children/Parent Version IV (ADIS-C),a semistructured diagnostic interviewassessing DSM-IV disorders.28 Separa-tion anxiety disorder, social phobia,generalized anxiety disorder, panic dis-order, posttraumatic stress disorder,and obsessive-compulsive disorderwereassessed. To screen positive for ananxiety disorder, children needed tomeet symptom criteria and be experi-encing significant impairment (rating of$4 of 8). Interviewers held a minimumfourth-year degree in psychology, wereextensively trained, and were blind toprevious anxiety diagnosis. Cross-codingindicated good reliability for obsessive-compulsive disorder (k = 0.69; P, .001)and excellent reliability for other cate-gories (k = 0.831.0; P , .001). In theparent survey, we also asked whetherthe child had been previously diagnosedwith an anxiety disorder.</p><p>QoL was assessed by using the 23-itemPediatric Quality of Life Inventory 4.0parent proxy report.29 Items are ratedon a 5-point scale from never (1) toalmost always (5) based on the childsproblems over the past month. We re-port the 15-item psychosocial QoL score(a = 0.80), with scores ranging from0 to100 (higher scores indicate better QoL).</p><p>Behavior and peer problems weremeasured by using the parent- andteacher-reported Strengths and Diffi-culties Questionnaire.30 Items are ratedon a 3-point scale from not true (0) tocertainly true (2). Behavior and peerproblems were assessed by using the20-item total problems scale (a = 0.63)and 5-item peer problems subscale(a = 0.71), respectively.</p><p>Daily functioningwasmeasuredbyusingthe Daily Parent Rating of Evening andMorning Behavior,31 an 11-item parent-reported measure of morning (eg, get-ting up and out of bed) and evening (eg,completing homework) behavior overthe previous 4 weeks (a = 0.83). Itemsare rated on a 4-point scale fromnever (0) to a lot (3), with higherscores indicating worse functioning.</p><p>Child school attendance was measuredby parent-report of the number of daystheir child had missed or been late forschool over the preceding 3 months.32</p><p>Parent mental health was assessed byusing theDepression, Anxiety andStressScales total score,33 a 21-item measureof adult mental health, with higherscores indicating poorer mental health.</p><p>A priori confounders included child ageand gender, ADHD medication use (yes/no), ADHD symptom severity (ADHDRating ScaleIV, total score), mooddisorder (yes/no: ADIS-C), externalizingdisorder (yes/no: ADIS-C), ASD (yes/no:parent-report of a previous diagnosis),parent age, parent high school completion(yes/no), and neighborhood socioeco-nomic disadvantage score measuredby the census-based Socioeconomic</p><p>Indexes for Areas Disadvantage Index(SEIFA) for the childs postcode of res-idence (mean 1000, SD 100; higherscores reflect less disadvantage).34</p><p>Analyses</p><p>Summary statistics were used to de-scribesamplecharacteristics, outcomevariables, and anxiety comorbidities.Children were class...</p></li></ul>


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