Anxiety and ADHD
Recent estimates from a very large US study (>45,000 participants) with the CDC shows that around 35% of children and 43% of adolescents/teens with ADHD also have an anxiety disorder (Danielson et al., 2024). Next to behavioral/conduct problems, anxiety is the most commonly associated disorder with ADHD. Why and how are anxiety and ADHD related?
A longitudinal study (Gair et al., 2021) that followed young children across time showed that a child with ADHD is at high risk of later developing an anxiety disorder. Possible reasons for this relationship include frequent negative feedback in everyday life, but also the child’s internal experiences and self-evaluation.
If we know that ADHD and anxiety tend to co-occur, you might be wondering if anxiety precedes ADHD. Research suggests the answer is likely no. Although anxiety can contribute to attention problems, evidence does not support that early anxiety is contributing to a later diagnosis of ADHD. But it’s always possible that they both emerge together around the same time.
Why does any of this matter? Because accurate diagnosis(es) and the timing of symptoms inform intervention(s). If you don’t fully understand the problem, it’s hard to figure out what to do. And symptoms can interact with each other, present in different ways, and change across development.
Here are two examples:
A 16-year-old girl tells her parents that she needs a math tutor because she’s overwhelmed and making low grades on quizzes. She shares her worries about how this will impact her ability to take advanced classes next year. She’s also feeling panic about the upcoming PSAT, and a low score could impact an early college scholarship. Her parents believe she’s doing too much because she’s involved in too many sports and hobbies. While she has always made straight A’s, she works very hard for it. She tends to procrastinate and will study until late hours.
After a few months, the tutor reports that she has trouble with multi-step problems and holding things in her working memory – she has to write everything down. The tutor also says that she’s disorganized in her calculations and makes careless errors. When they work in small tutoring groups, she has to repeat information to her but she then catches on well. Her parents reflect and remember hearing some of these things from teachers in 5th and 6th grade. They also know their daughter has test anxiety, and that she hates timed tests. Standardized testing has never been a great reflection of her abilities, even in reading.An 8-year-old boy is showing more behavior problems at home. This includes opposition around morning routines, bedtime, and homework. This is confusing because he’s such a loving, polite, and conscientious child. His parents provide constant reminders and structure to get through the day. He starts to give up easily on homework, saying things like “I’m stupid” or “This is boring”. It seems impossible for him to sit at the table during homework and dinner time.
Despite all this energy, he stopped putting in effort during soccer and tends to follow behind the team without any initiation. All he wants to do is play video games. In the mornings, he gets stomachaches and complains about feeling sick, saying he doesn’t want to go to school. He sleeps with his parents because he has trouble falling asleep on his own and then gets angry when his parents don’t stay with him. At school, his teacher believes he may not be “not trying his best”. He’s also withdrawing from groups during recess and puts his head down during class discussions.
Both of these examples include commonly reported concerns from parents. A lot more information is needed to tease apart concerns and make recommendations for home and school. Both the teen girl and the school-age boy show symptoms of anxiety and/or ADHD. There could be other concerns as well.
Many parents start with their pediatrician when these concerns arise. This makes sense because you have a long-term, trusting relationship. But it’s critical to understand that the pediatrician is not an expert in neurodevelopmental and psychological disorders. They may complete a screening for you (e.g., parent and teacher rating scales), but rating scales about symptoms won’t be enough to fully appreciate your child’s needs.
A screening for possible ADHD or anxiety is just the start. If the findings from a screening suggest elevated symptoms, you still need to pursue a full evaluation. Otherwise, you risk starting a less effective intervention. Both children above would likely be elevated on rating scales that screen for ADHD and/or anxiety. But what should parents do next? They need a plan.
If you have concerns about attention problems, poor self-regulation, executive functioning concerns, worry, avoidance of age typical activities or expectations, or other related symptoms, reach out to us for a free phone consult: [email protected]
Here are the original sources mentioned above if you want to read more:
- Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., … Ghandour, R. (2024). ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment. Journal of Clinical Child & Adolescent Psychology, 53(3), 343–360.
- Gair, S. L., Brown, H. R., Kang, S., Grabell, A. S., & Harvey, E. A. (2021). Early development of comorbidity between symptoms of ADHD and anxiety. Research on child and adolescent psychopathology, 49(3), 311-323.
