It is common for children and families to present to their primary care providers with concerns about externalizing behavioral problems and/or wanting to rule out Attention Deficit Hyperactivity Disorder (ADHD) or another disruptive behavioral disorder. A common presenting problem is severe outbursts at home and/or disruptive behavior in school. In some of these cases, the appropriate diagnosis is ADHD or another disruptive behavior disorder and treatment involves medication and/or behavioral therapy and parent management training. But in many of these cases, the underlying diagnosis leading to the externalizing behavioral problems is something else. A not uncommon but often missed reason behind disruptive behavior is underlying anxiety. It is commonly thought that anxiety disorders are underdiagnosed and misdiagnosed in childhood. Are there signs that a child presenting with externalizing behaviors could have underlying anxiety that can be elicited in the primary care office?
A child who appears to be oppositional or aggressive may be reacting to internal anxiety—anxiety he may, depending on his age, not be able to articulate effectively, or not even fully recognize that he’s feeling. Anxiety is based on the body’s physiological response to a threat in the environment, as a response to maximize the body’s ability to either face danger or escape danger. Some children show their anxiety by becoming quiet, shrinking away from situations that make them anxious, and having trouble separating from their parents. These symptoms of anxiety are easy to detect for most providers.
However, the above symptoms are not the only way that anxiety manifests itself. Other children react with an overwhelming need to break out of an uncomfortable situation, which can be misinterpreted as anger or opposition. What people on the outside see is intense anger that is out of proportion to the situation, property destruction, elopement and aggression. In this way, anxiety can be a great masquerader.
Anxiety can present in the school setting as disruptive behavior. A child might find the academic work hard or become frustrated if he can’t do it perfectly. A child might have a hard time taking feedback or criticism from the teacher or peers. A child might be overwhelmed with the noise level in the classroom or a crowded lunch area
When a child presents with disruptive behavior, it is important to ask screening questions in other mental health areas as well, including depression, anxiety, obsessive compulsive disorder and autism. Examples of screening questions for anxiety include: Does your child worry excessively about everyday activities? Does your child have exaggerated or irrational fears? If any of these screening questions are positive, consider asking more detailed questions or obtaining screening questionnaires (for example the GAD7 or SCARED) to elicit more details. Referral for a more thorough diagnostic evaluation with a psychologist could be helpful as well in cases that are diagnostically confusing.
This distinction is important to make sure a child has the right diagnosis, because it impacts treatment. The therapy approach for anxiety is different than the therapy approach for disruptive behavior disorders. Psychotropic medication, if being considered, would be different as well for these diagnoses. The SSRIs would be first line medication treatment for anxiety which the stimulants or non-stimulants like the alpha agonists (guanfacine and clonidine) or atomoxetine would be first line medication treatment for ADHD and other disruptive behavior disorders. If one is considering medication treatment for behavioral dysregulation that can be seen with anxiety, the alpha agonists can be helpful specifically for that. The stimulants can actually make the anxiety worse in these clinical situations.
In summary, it is important to ask what might be underlying the externalizing behavioral problems, because you might uncover anxiety masquerading as a disruptive behavior disorder. As always, SmartCare BHCS Parent Line 858-956-5900 is available to help families find appropriate resources and SmartCare Provider Line 858-880-6405 is available to providers to help with diagnostic clarification and medication treatment questions.
References:
https://childmind.org/article/how-anxiety-leads-to-disruptive-behavior/
Beyond Behaviors by Mona Delahooke PhD: https://monadelahooke.com/beyond-behaviors/
AUTHOR:
Charmi Patel Rao MD, DFAACAP
Co-Medical Director, Vista Hill Foundation
Health Science Clinical Professor, UCSD Department of Psychiatry
President, San Diego Academy of Child and Adolescent Psychiatry