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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
I'm your host, Matt Butterman. Today we're diving into part two of a really important topic: When ADHD and Anxiety Overlap in Kids and Teens. And if you listen to part one, you know that these two conditions show up together a lot. Today, we're going deeper, specifically into how medications for ADHD and anxiety can affect each other, why treatment options sometimes feel complicated, and why avoiding treatment can actually be more dangerous than parents realize. And back with me is our trusted guide through the world of pediatric mental health, Doctor.
Matt (host):Gretchen Hoyle. Before we get into our discussion, we want to remind you that the content of this podcast is for informational purposes only and should not be construed as medical advice. Please seek the advice of your pediatrician, therapist, or other mental health professional for any concerns about your child's mental health. Doctor. Hoyle, welcome back.
Dr. Gretchen Hoyle:Thanks, Matt. I'm really glad that we're going to do a part two of this. This is one of the most commonly misunderstood conditions or overlapping of conditions at a seeing clinic. So there's always lots of questions.
Matt (host):Sure. So let's start with a refresher. Just how common is it for ADHD and anxiety to occur together?
Dr. Gretchen Hoyle:It's extremely common. I mean, a national survey, it's about four in ten of kids with ADHD also have an overlapping anxiety disorder. So it's really not a rare overlap and it's actually pretty typical presentation in many school aged kids. And when these two conditions show up together, things get more layered behavior, school performance, social interaction, even sleep. That complexity becomes really important when we talk about what we're doing with medication.
Matt (host):Yeah, so let's talk about meds because this is where a lot of parents get really confused or worried. What happens when we treat ADHD but we don't treat the underlying anxiety?
Dr. Gretchen Hoyle:Right, so let's imagine that you've got a kid whose baseline anxiety is like a seven out of ten. So they're on the anxious side and then their ADHD symptoms are like an eight out of 10. And so this is just like sort of a, like a way to measure these these symptoms, we have lots of ways to actually numerically quantify those. But let's just say for this example, we've got both anxiety and ADHD. The ADHD is a little worse as far as when you compare them to the anxiety symptoms.
Dr. Gretchen Hoyle:But a lot of times what will happen is if we treat the ADHD symptoms, especially if we're using a stimulant, which is of course like a first line of treatment or pharmacotherapy for ADHD, and we're only treating the ADHD, and we're using a stimulant to do that, we may reduce the ADHD symptoms, you know, from like, you know, an eight or nine down to a four, but, and that's great, you know, for school and for behavioral, you know, their behavior in public and all that. The catch is that sometimes the stimulant actually pushes up on the anxiety. So now the anxiety is up at a nine when it had been seven. Kids actually, when you do that when they have anxiety and ADHD and you're only treating the ADHD, they may actually feel a little worse internally, anxiety wise, because we haven't really addressed the anxiety piece. Some of that is like, the way to think of that is like, we're sort of creating this additional anxiety layer iatrogenically.
Dr. Gretchen Hoyle:So that word iatrogenic is just means something that we are creating from the therapy that we are providing. So, you know, we need, we really want to be cognizant of that. Like, one of the main tenets of medicine is to first do no harm, and so we don't want to create, more of a problem when we're trying to fix one thing. But that is a common scenario in, you know, in all of medicine, but particularly when we're talking about these kinds of conditions and these kind of medicines.
Matt (host):And pushing the scientific illusion further, It's like a seesaw, right? One, one goes up, the other goes down. So the child might look like they're behaving better, but they're really feeling worse on the inside. Right?
Dr. Gretchen Hoyle:Yeah, exactly. And parents, it's easy to miss that because ADHD meds have like clear immediate effects on behavior, but anxiety meds don't work that way. It takes longer for those to sort of start to work. And so sometimes it's hard for parents to see, especially given the age of the child. And if they're getting a lot of praise for controlling their executive functioning, that anxiety is creeping up on the inside and it's hard for parents to really tell.
Matt (host):So let's talk about the opposite situation when a child starts on an anxiety medication, like an SSRI, but then their ADHD isn't treated.
Dr. Gretchen Hoyle:Right. So that happens too. And so sometimes we'll treat the anxiety first and we might bring that like seven of anxiety down to a four. And so again, great. But in some kids, SRIs can actually activate their ADHD symptoms.
Dr. Gretchen Hoyle:And so suddenly a child is a little more restless, little more distractible, a little more impulsive, and so then their ADHD symptoms actually go up to a nine or a 10. And what's happening there, it's, there's, there's a lot of different interaction between the actual, like, like the chemistry that's happening in the brain and how those, medications interact with each other. But a lot of times what'll happen is when kids are really anxious, sometimes that is what's putting the brakes on their sort of impulsive behavior because they're worried about getting in trouble. And so if we, we don't want them to feel bad like that. We don't want them to be constantly hyper vigilant and like over focused on, you know, worries and that be the way that they're controlling their impulses.
Dr. Gretchen Hoyle:But sometimes when we help like relax some of that anxiety, then those impulses will really push through and they are like, they feel more if they're having less sort of embarrassment or being ashamed, which is good, but it also makes it harder for them sometimes to control those impulsive behaviors. And pretty quickly the anxiety, you know, improvement disappears because their troubles with executive functioning and then sort of getting in trouble more as, you know, environment like responds to their behavior and you can kind of lose ground.
Matt (host):So the benefit gets just gets erased by the environment responding to the worsening ADHD, right?
Dr. Gretchen Hoyle:Yeah. To some extent. I mean, there's obviously huge like balances. This is a back and forth thing. That analogy of the seesaw is one that we use a lot when I try to describe and like, you know, the idea of using the SSRI and using a stimulant and we're just gonna kind of go up a little bit like this back and forth so that we're keeping them in line with each other and in balance.
Dr. Gretchen Hoyle:But yeah, I mean, we definitely don't want to lose ground. And so that is why, you know, I think it's an important topic to talk about because it happens a lot in clinic.
Matt (host):And so you've said that historically pediatricians were taught to aim for monotherapy using one medication when possible, but why doesn't that always work here?
Dr. Gretchen Hoyle:So yeah, monotherapy, especially when you're just looking at ADHD in isolation, that was always the idea is to try to be on one thing because you're trying to, you know, just simplify the regimen and, you know, try to reduce the number of, you know, medications that people are taking and have less potential side effects. But the problem is that a lot of these kids, you know, they just their anxiety component really makes it hard to get it right with just one medicine. There are certainly kids out there who are, you what we call, like, happy hyper, and so they're typically young, typically male, and they are just, you know, a lot of impulsive behavior, but they're super happy and excited and stuff, and really, we're really just wanting to make it so that they are a little more functional. And a lot of times for them, monotherapy with a stimulant is fine. So they'll be on a, you know, sometimes relatively low or even mid dose of stimulant medication, and it improves their behavior.
Dr. Gretchen Hoyle:And so they're getting positive feedback from that. Their baseline is that they're basically pretty happy little folks. And so they're good on monotherapy. But my experience has been that, you know, a lot more of the time or kids who have had, you know, who who meet criteria for an ADHD diagnosis have, you know, at least some component of anxiety. So we're having to look at potentially considering more than one medicine.
Matt (host):Right. Right. And so you've mentioned that some parents are actually more comfortable treating ADHD than anxiety. And so why is that?
Dr. Gretchen Hoyle:Right. So, yeah, so that, this is a bit of a struggle. So, yes. So I think a lot of the reasons that people are kind of on board, it's easier to get them on board with, with treating the ADHD is that, you know, first of all, stimulants like work and they work pretty immediately. And so, you know, we're going to start low.
Dr. Gretchen Hoyle:And so a lot of the times the first day or two, when you're on the really low dose, you may not see a whole lot of improvement. Then as we slowly go up, you know, the hope is that we're going hit a therapeutic level. And then people are like, Oh, that's way better. And this kid can do the things that, you know, we know that we always knew he was capable of doing, but just didn't have the executive functioning to do that. And so people are usually pretty happy with that.
Dr. Gretchen Hoyle:And then the other thing about, like, and so that's really reinforcing to parents. Stimulant medicines, I also, most parents, depending on the reason, you know, we're treating the child, there are definitely some kids where they absolutely need to be on it every day whether they're in school or not. This is for kids who, you know, tend to be doing really impulsive stuff that's dangerous and that, you know, we need to be able to control every day. But there are definitely kids where, you know, they're more, the core issue is the inattention and we need to be able to help them and that we use their medicine as a tool for school and so you don't have to give them every day, whereas with the anxiety medicines, really do need to give those every day in order for them to work properly. And then there's also a stigma, more of a stigma, I feel like with anxiety or SSRI medicines or antidepressants.
Dr. Gretchen Hoyle:So, you know, medicines that we use to treat anxiety and depression are both, I mean, they're in the same category. So they're all antidepressants and they work on modulating serotonin activity in the brain. And so there are folks who, when I hear, you know, when they, when I'm like, well, I'm going treat your child's anxiety. I'd like to do that. These are the medications that I would consider.
Dr. Gretchen Hoyle:And, I'm listing off things like Lexapro and Prozac and Zoloft and some people have to get the generic names of those, but people will recognize those as antidepressants and get a little concern that we're going to be using those types of medicines in kids for their child, or that we're going to be considering that. And so there's just a stigma in our society about like, you know, being able to sort of bootstrap your own like mental health and being able to learn how to deal with those feelings and emotions. And that, that, that is all certainly, you know, an important skill to learn. It's a life skill to learn. But I'm also wary that sometimes like I'm actually piling on a little bit with their anxiety.
Dr. Gretchen Hoyle:If I'm adding a stimulant to help them control their executive functioning, it may also make it so that we're elevating their anxiety to a point where it's, that's not really all internal. I mean, that's, you know, some of that's coming from their treatment. And so, not all that fair to expect that they're going to be able to manage all that and regulate that entirely internally. This is just part of the balance of trying to figure out like, where do we land in a place where everybody's comfortable with what we're doing and we're having minimal side effects, but we're getting benefits both sides of that equation. And it can be really transformative for kids who are having trouble.
Dr. Gretchen Hoyle:And it just makes a big difference. And so it is important to really try to get it right.
Matt (host):Yeah. And as you said before, you really can't grit your way through generalized anxiety disorders, kind of like telling a child with asthma to breathe harder, a child with diabetes to try to regulate their insulin without medication, without medicine. And I know from personal experience, that works real well. Yeah. Anyway, so some parents might wonder those of us without your training in pharmacology and biochemistry, some parents might wonder, well, are we just treating the side effects of one medication with another medication?
Matt (host):And how do you address that?
Dr. Gretchen Hoyle:Yeah. And I mean, I validate that concern. I get it. I totally understand that. Does like, you know, it does matter that we're going to need to do this in, you know, in a controlled fashion that, you know, that sometimes that helps, like their concerns helped me make a decision or help make me make a treatment plan as far as like how to approach this and what sequence to go in and what medicines to try and which ones to try first.
Dr. Gretchen Hoyle:We have, when we have this combination of overlapping conditions, we have options as to, you know, how to start with managing it. On the ADHD side, there are stimulants. There's also medicines for ADHD that can be helpful. Sometimes we'll try that fairly quickly. There are the SSRI medications that we use, the selective serotonin reuptake inhibitor medicines, which are classic antidepressant medicines, and then there are also some medicines that help, like, increase serotonin activity in the brain or that effect, and those are non SSRI medicines that can have real benefits and they may work a little bit faster as well.
Dr. Gretchen Hoyle:And of course, you know, there's always a role for therapy and parent coaching and also, you know, help with getting the school involved. These are all things that we are doing in our collaborative care program at our practice where, you know, having those environmental supports are often, you know, as important as what we're doing, you know, chemically.
Matt (host):And you're tired of applying, you're applying Occam's razor here, right? The lowest effective dose and the simplest regimen that produces the results.
Dr. Gretchen Hoyle:That's exactly what I'm going for. So I tell people if I could wake up in a world where no one needed medicine, I would love that. But we just don't live in that world. And I do think that there is a lot of benefit for a lot of folks in managing these conditions. And of course, you know, the trajectory of your, of their, of these children's lives, managing it early is extremely helpful because, you know, things have a way of, you know, piling up in sequence.
Matt (host):And so you get Snowballing down the road, right?
Dr. Gretchen Hoyle:Correct. Yeah. Yeah. You're wanting to make sure that we're putting that child in his best position to be successful as possible. And that's in school and in life and in general.
Dr. Gretchen Hoyle:And certainly lots of people, you know, where the natural history is that get better with their executive functioning as they get older, they may or may not be able to get better at regulating their emotions, but there is some natural changes that are already built in, but giving folks the tools early to get in as good a place as possible is really what, you know, I've found to be the most helpful.
Matt (host):And in moving on from that sort of resistance that some parents might have to medication, let's get, let's talk about something that's really important and why is it so risky to not treat these conditions, especially when they're concomitant or when they're occurring together? Comorbid, I guess you would call it, right?
Dr. Gretchen Hoyle:Correct. Yeah. Untreated ADHD is associated with, you know, like significant academic trouble, including academic failure and dropping out of school. Untreated ADHD is connected to higher rates of antisocial behavior and trouble with the legal system. So you can imagine we're having difficulty controlling your impulses, especially if you're having trouble regulating your emotions in addition to that, it is easy to get into trouble that would then trigger interaction with the legal system.
Dr. Gretchen Hoyle:There's an increased risk of substance abuse. We think a lot of times folks are trying to figure out ways that they can regulate what's going on for them internally and they'll turn to other substances that are, you know, that are not being managed by a physician. And so they'll, that, that a lot of times, especially when you're looking at, it's true for ADHD, but also for anxiety and depression, that a lot of times folks will turn to substances to help like manage those symptoms. And so then you get into more like difficulties with substance abuse. Substance use disorder.
Dr. Gretchen Hoyle:There is an increased risk of accidental injuries in folks who have untreated ADHD. They are more likely to, as we're talking about with the legal system, end up incarcerated and we're really wanting to keep that from happening as an outcome. There is very, you know, like pretty stunning evidence that untreated ADHD can shorten your life expectancy. And so there are large population studies that can show that usually it's, you know, it's not in isolation. It's that they also, untreated ADHD is also associated with more accidents and substance use and secondary mental health issues.
Dr. Gretchen Hoyle:A lot of times the first thing that we get a crack at treating is the ADHD. And so I think it's important to try to address that as soon as possible. And then there's, you know, for folks who have untreated ADHD and depression, they're having an increased risk of not wanting to go to school and not wanting to be socially engaged. Social anxiety is a huge problem in kids, you know, from early on all the way through all, you know, in through into adult life.
Matt (host):Well, Doctor. Hoyle, thanks once again for helping us understand these, these tough, but crucial topics. And thank you to our listeners. If you found this episode helpful, please share it with a friend, subscribe and stay tuned for more Nimble Youth in your feed. You can now visit us on YouTube at NimbleYouthPodcast and you can find our audio versions on all major podcast platforms.
Matt (host):For show notes and additional information, please visit our website. We'll see you next time. Until then, please take care of the young ones in your lives and yourselves. Bye now.