As with disruptive behavior disorders, there is a great deal of overlap between anxiety disorders and ADHD. About one fourth of children with ADHD also have an anxiety disorder. Likewise, about one fourth of children with anxiety disorders have ADHD. This includes all types of anxiety disorders—generalized anxiety disorder, obsessive-compulsive disorder, separation anxiety, and phobia (including social anxiety). Younger children with overanxious disorder or separation anxiety are especially likely to also have ADHD.
Anxiety disorders are often more difficult to recognize than disruptive behavior disorders because the former’s symptoms are internalized—that is, they often exist within the mind of the child rather than in such outward behavior as verbal outbursts or pushing others to be first in line. An anxious child may be experiencing guilt, fear, or even irritability and yet escape notice by a parent, teacher, or pediatrician. Only when her symptoms are expressed in actual behavior, such as weight loss, sleeplessness, or refusal to attend school, will she attract the attention she needs. It is important to ask your child’s pediatrician or psychologist to talk with your child directly if you suspect the presence of persistent anxiety in addition to her ADHD.
What to Look For
Identifying an anxiety disorder in your child can be difficult not only because her symptoms may be internal, but because certain signs of anxiety—particularly restlessness and poor concentration—may be misinterpreted as symptoms of ADHD. Children with an anxiety disorder, however, experience more than a general lack of focus or a restless response to boredom. Their anxiety and worry are clear-cut, often focusing on specific situations or thoughts. They may seem tense, irritable, tired, or stressed out. They may not sleep well, and may even experience brief panic attacks—involving pounding heart, difficulty breathing, nausea, shaking, and intense fears—that occur for no apparent reason.While their school performance may be equivalent to that of children with ADHD alone, they tend to experience a wider variety of social difficulties and have more problems at school than children with ADHD alone. At the same time, they may behave in less disruptive ways than children with ADHD alone because their anxiety inhibits spontaneous or impulsive behavior. Instead they may tend to seem inefficient or distracted—having a great deal of difficulty remembering facts or processing concepts or ideas.
Your child can be an important source of information that may lead to a diagnosis of anxiety disorder, although some children are reluctant to admit to any symptoms even if they are quite significant. If the possibility of an anxiety disorder concerns you, be sure to discuss any fears or worries she has and listen carefully to her response. Report her comments to her pediatrician and/or psychologist, and encourage her to speak directly with these professionals.
In the meantime, ask yourself
- Does she seem excessively worried or anxious about a number of situations or activities (such as peer relationships or school performance)? Are her fears largely irrational—that is, overly exaggerated or unrealistic—rather than realistic worries about punishment for negative behavior? Does she find it difficult to control her worrying?
- Does her anxiety lead to restlessness, fatigue, difficulty concentrating, irritability,muscle tension, and/or sleep disturbance?
- Does her anxiety or its outward symptoms significantly impair her social, academic, or other functioning?
- Does her anxiety occur more days than not, and continue for a significant duration? Have her anxiety symptoms lasted for at least 6 months? Do her bouts of anxiety occur at least 3 to 5 times per week and last for at least an hour?
- Is her anxiety unrelated to another disorder, substance abuse, or other identifiable cause? A child who is distressed over a life event, who is abusing drugs, or whose family is in conflict may exhibit some of the symptoms of anxiety disorder. It is important to consider these other causes as the reason for anxiety instead of a formal anxiety disorder.
- As a young child, did she experience developmental delays or severe anxiety at being separated froma parent, express frequent or numerous fears, or experience unusual stress? Children with ADHD and a coexisting anxiety disorder are more likely to have experienced developmental delays in early childhood and more stressful life events such as parental divorce or separation.
- Have others in her family been diagnosed with anxiety disorders? Anxiety disorders tend to run in families. A careful review of your family’s medical history may provide insight into your child’s condition. These are some symptoms of anxiety disorders, and their presence may indicate a need to have your child evaluated by her pediatrician or mental health provider. The sooner your child is properly treated for anxiety, the sooner she can improve her functioning and balance in her daily life.
Treatment for children with ADHD and an anxiety disorder relies on a combination of approaches geared to each child’s specific situation—including educating the child and her family about the condition, encouraging ongoing input from school personnel, initiating behavior therapy including cognitive behavioral techniques, as well as traditional psychotherapy, family therapy, and medication management.
Behavior therapies are among the most proven and effective non-medication treatments for anxiety disorders. (The effectiveness of traditional psychotherapy has been less well studied.) Behavior therapies target changing the child’s behaviors caused by the anxiety rather than focusing on the child’s internal conflicts. Cognitive-behavioral therapy techniques help children restructure their thoughts into a more positive framework so that they can become more assertive and increase their level of positive functioning. For example, a child can learn to identify anxious feelings and thoughts, recognize how her body responds to anxiety, and devise a plan to cut down on these symptoms when they appear. Other behavioral techniques that can be used for treating anxiety include modeling appropriate behaviors, role-playing, relaxation techniques, and gradual desensitization to the specific experiences that make a given child anxious.
Decisions about medication treatment of ADHD and a coexisting anxiety disorder depend largely on the relative strength of each condition. In the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA) study of large numbers of children with ADHD and various coexisting conditions, behavioral treatments were equally as effective as medication treatment for children with ADHD and parent-reported anxiety symptoms. It was not known, however, how many of these children had true anxiety disorders.
In general, if your child’s ADHD symptoms impede her functioning more than the anxiety does, and a medication approach is recommended, her pediatrician may choose to begin treating her with stimulants first. As he adjusts her dosage for maximal effect, he will monitor her for side effects such as jitteriness or overfocusing—possible responses to stimulants among children with ADHD and an anxiety disorder. If your child’s ADHD symptoms improve with stimulant medication and her anxiety diminishes as well, her pediatrician may want to review her diagnosis to discern whether the anxiety stemmed from the ADHD-related behavior and was not a sign of an anxiety disorder. If the ADHD symptoms improve but your child’s anxiety remains, her pediatrician may decide to add another type of medication. These medications can include a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA).