Anxiety Disorders & Attention Deficit Hyperactivity Disorder (ADHD)

Overview

As many as 25-50% of children with attention-deficit/hyperactivity disorder (ADHD) have a co-occurring anxiety disorder. This is about 3 times higher than in the general population. [Barkley: 2014] Anxiety disorders are characterized by persistent and excessive anxiety that results in a significant disruption of function at home, at school, or in the community. Anxiety disorders include separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder and panic attacks, agoraphobia, and generalized anxiety disorder, as well as anxiety related to medication or substance use, or other medical conditions. Anxiety is also a prominent feature of obsessive-compulsive disorder and post-traumatic stress disorders, although The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2013] characterizes them as separate from the anxiety disorders classification. See the Anxiety Disorders module for more detailed information about diagnosis and treatment of anxiety.

Etiology

Anxiety disorders are thought to be an interaction between biological factors (e.g., genetics), psychological factors (e.g., temperament), and environment. Familial patterns are common.

Distinguishing ADHD from Anxiety

Inattentive symptoms occur in both ADHD and anxiety; however, the inattentiveness from ADHD is due to distraction by external stimuli or other interests; in anxiety, attentiveness is associated with worry and rumination (see ADHD vs. Anxiety Didactic Presentation Recording (MAPP-Net)). Other clues can suggest an anxiety disorder:
  • Family history of anxiety
  • Avoidance (most commonly school, but can also be avoidance of other specific places or situations)
  • Age-inappropriate separation anxiety
  • Excessive worries or fears that cause avoidance, distress, or dysfunction
  • Worry or fear after a transition that does not seem to be improving after a few months
  • Nightmares or sleep problems
  • Rituals and/or obsessions that appear overly rigid or are overly time-consuming
  • Frequent non-specific physical complaints (headaches, stomachaches, muscle pain) without clear etiology

Diagnosis

It can be challenging to differentiate behaviors seen in ADHD from those in anxiety disorders. Untreated anxiety can make it harder to effectively treat ADHD. When diagnosing anxiety, questions in the areas listed below can aid in differentiating acute situational anxieties from chronic anxiety disorders
  • Family history
  • Child's usual affect and temperament and recent changes
  • Worries or fears
  • Rituals and/or obsessions
  • Difficulties with separation (babysitter, school, sleep-overs)
  • Nightmares and sleep problems
  • Impact of symptoms on functioning
  • Information from the child's teacher is also important in sorting out degree of symptomatology.
The Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) (PDF Document 1.1 MB), frequently used to assist in diagnosis and monitoring response to treatment for children and youth with ADHD, include several questions about anxiety in the initial evaluation. A high score on the anxiety-related questions, along with impaired function, should raise concern for anxiety. See the Portal's Anxiety Disorders for further details.
Since somatic complaints and health-related concerns are common manifestations of anxiety disorders, medical history and evaluation should be completed to screen for concerns and reassure the family and the child about general health issues. Some medical conditions can be misdiagnosed as anxiety disorder (e.g., partial complex seizures) or may contribute to an anxiety disorder (e.g., the child's response to a serious medical condition). Examination should also monitor for tics (Tourette syndrome, but can also be a feature of anxiety disorders) and mitral valve prolapse (common in adults with panic disorder). Regardless of etiology, somatic complaints can impair functioning, school attendance, and academic performance in addition to struggles a child with ADHD may already experience at school. Evaluation for comorbid learning problems may be indicated since these may also underlie school anxiety/avoidance in children with ADHD.

Treatment

Treatment will vary depending upon the degree of impairment. In some cases, treatment may involve an explanation to the family/child and simple coping strategies. Online e-training and home workbooks can help some children cope with anxiety. [Creswell: 2014] In more significant scenarios, treatment will include a team approach with a psychologist, school personnel, and the pediatrician. Consultation with a psychiatrist or developmental-behavioral pediatrician may also be helpful. Components of team treatment include:
  • Demystify: Explain to child, family, and school (if indicated) the nature of the underlying conditions.
  • Reassure: Help families understand that their child's fears may not be "rational" and thus are not easily "reassured" away. Helping children to understand bothersome or new situations (e.g., new school) better may allow them to handle fears better. A plan with gradual approaches to targeted goals can be discussed (e.g., helping the child sleep in his own room).
  • Social training: With the child's consent, involve the teacher in helping to structure social situations at school. Training in social skills and coping mechanisms for embarrassing situations may be helpful. Social structuring in extracurricular settings (with adult supervision) may also be helpful.
  • Scheduled return to school: For children with school refusal, create a plan for return to school that includes a timeline, modifications needed at the school to minimize distress, and a contingency plan (e.g., what to do when the child reports illness). Collaboration with the school counselor, principal, and staff may be helpful as these individuals can provide support to the child and family during the transition.
  • Behavior therapy: Therapy may include coping strategies (relaxation techniques, cognitive strategies), programs of stimulus exposure, and psychotherapy. For children with anxiety alone, cognitive behavioral therapy has the strongest evidence basis. [Creswell: 2014] A referral for behavioral therapies by a psychologist is indicated when the anxiety disorder is severe and/or functional impairment does not improve with the interventions discussed above.
  • Mindfulness and mind/body approaches like deep breathing and yoga have also demonstrated benefits in children with anxiety and ADHD; see Apps to Help Kids and Teens with Anxiety for ideas for families and patients to try on their own.
  • Medications may be indicated (see below) for anxiety and/or ADHD symptoms.

Medications

Evidence for effective co-management of ADHD and anxiety is still lacking. Many experts advise treating anxiety before treating ADHD in kids with comorbid conditions; however, some children with ADHD may appear anxious because of their inability to attend to their environment and show improvement in these symptoms with treatment of ADHD. Here is a summary of what is currently known:

Atomoxetine

Use of atomoxetine, an SNRI used to treat ADHD, appears to have positive effects on both ADHD and anxiety symptoms. [Barkley: 2014] [Snircova: 2016] [Villas-Boas: 2019]

SSRIs/SNRIs

Pharmacological agents most commonly used for anxiety in children include the selective serotonin reuptake inhibitors (SSRIs), including sertraline, fluoxetine, and fluvoxamine, and selective norepinephrine reuptake inhibitors (SNRI’s), such as duloxetine. The role of using SSRI and SNRI's in treating anxiety disorders is reviewed in the following article: [Strawn: 2017]. Be aware that initiation of an anti-depressant, such as an SSRI, may cause activation in some children, particularly those with neurodevelopmental disabilities; consider starting at half the usual starting dose, especially in children with anxiety, ADHD, and autism. In this population, it becomes especially important to monitor for signs of agitation/activation and increased sleep difficulties when starting a stimulant.

Stimulants

Literature has conflicting reports about the response of children with ADHD and comorbid anxiety disorder to stimulant medication. [Strawn: 2017] It appears that while stimulants can have a positive effect on the ADHD symptoms, their impact on anxiety symptoms is less clear. A 2015 meta-analysis demonstrated improvement of anxiety symptoms in youth treated with stimulants for ADHD [Coughlin: 2015]; however, earlier studies were less clear. [Barkley: 2014]

Co-treatment with SSRI and stimulants

Limited data suggest that concurrent use of a stimulant and a selective serotonin reuptake inhibitor do not show a clear improvement in anxiety symptoms. [Barkley: 2014]

Alpha-agonists

The alpha-2 agonists, although they do not carry indications to treat anxiety, could provide benefit as an adjunctive treatment or when stimulant medications are not tolerated because they decrease hyperarousal and are less likely to cause activation in the patient. However, there is insufficient evidence to clearly determine the efficacy of using alpha-agonists to treat both anxiety and ADHD. [Fiks: 2015]
More studies are needed to compare single- and multi-drug approaches to treating children with both anxiety and ADHD. The role of behavioral health using recognized interventions, such as cognitive-behavioral therapy, coupled with medications for ADHD and/or anxiety also bears further evaluation. Regardless of which approach is used, the clinician should monitor carefully for improvement or exacerbation of comorbid conditions.
For additional information about treatment of anxiety disorders, see Anxiety Disorders.

The Role of the Medical Home

The medical home team can:
  • Identify the clinical concern for an anxiety disorder in the child with ADHD.
  • Assess for increased family stress and trauma exposures that can masquerade as ADHD or anxiety or make it harder to treat these conditions.
  • Advocate for the parent's effort to access appropriate school services and continued participation in school with appropriate accommodations, when indicated.
  • Recommend evidence-based practices like mindfulness and yoga that can help children and adolescents with anxiety and ADHD.
  • Ensure family-centered team collaboration.
  • Prescribe medication or consult with a psychiatrist when indicated.
  • Monitor for side effects of medications that are prescribed for ADHD and anxiety.
  • Refer and ensure treatment by a therapist if indicated.
Children with both ADHD and an anxiety disorder may be more likely to require referral to psychology and/or psychiatry. Be aware that parent training in behavior management, a first-line intervention for ADHD, is not always offered by mental health professionals adept at cognitive-behavior therapy and other first-line interventions for anxiety. Counsel families to ask prospective therapists about their experience treating both conditions. See Outpatient Mental Health Care (see MT providers [15]).

Resources

Information & Support

For Professionals

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

ADHD vs. Anxiety Didactic Presentation Recording (MAPP-Net)
Project Echo presentation on Overlapping Symptoms, DSM-5, National Comorbidity Studies, ADHD Screening, Stimulant Medication Side Effects, Anxiety Screening, Childhood Traumatic Stress, Risks of ADHD, ACES’s and ADHD, Treating Co-Morbid ADHD & Anxiety. Recorded January 22, 2020. Presenter Adrienne Coopey, DO; Montana Access to Pediatric Psychiatry Network.

ADHD vs. Anxiety Didactic Presentation Slides (MAPP-Net) (PDF Document 217 KB)
Project Echo presentation including Overlapping Symptoms, DSM-5, National Comorbidity Studies, ADHD Screening, Stimulant Medication Side Effects, Anxiety Screening, Childhood Traumatic Stress, Risks of ADHD, ACES’s and ADHD, Treating Co-Morbid ADHD & Anxiety; Montana Access to Pediatric Psychiatry Network.

Advanced ADHD Psychopharm Didactic Presentation Recording (MAPP-Net)
Project Echo presentation on Stimulants, MPH, Long-Acting MPH, AMP, Long-Acting AMP, Stimulants & Tics, Stimulants & Anxiety, Stimulants & Adverse Events and Atomoxetine. Recorded August 28, 2019. Presenter Eric Arzubi, MD; Montana Access to Pediatric Psychiatry Network.

Advanced ADHD Psychopharm Didactic Presentation Slides (MAPP-Net) (PDF Document 372 KB)
Project Echo presentation including Stimulants, MPH, Long-Acting MPH, AMP, Long-Acting AMP, Stimulants & Tics, Stimulants & Anxiety, Stimulants & Adverse Events and Atomoxetine; Montana Access to Pediatric Psychiatry Network.

For Parents and Patients

Support

The Child Anxiety Network
Parent-focused information about phobias, specific anxiety disorders in children, and treatment.

General

Anxiety Disorders and ADHD (HealthyChildren.Org)
Online resource for families about ADHD and anxiety; from the American Academy of Pediatrics.

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

Patient Education

Family Resources (AACAP)
Family education for disorders that include anxiety, autism, depression, conduct disorder, oppositional defiant disorder, and more, Includes facts, videos, and a psychiatrist finder tool; American Academy of Child & Adolescent Psychiatry.

Services for Patients & Families in Montana (MT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

PubMed Search on ADHD and Anxiety Disorders

Strawn JR, Dobson ET, Giles LL.
Primary Pediatric Care Psychopharmacology: Focus on Medications for ADHD, Depression, and Anxiety.
Curr Probl Pediatr Adolesc Health Care. 2017;47(1):3-14. PubMed abstract / Full Text

Villas-Boas CB, Chierrito D, Fernandez-Llimos F, Tonin FS, Sanches ACC.
Pharmacological treatment of attention-deficit hyperactivity disorder comorbid with an anxiety disorder: a systematic review.
Int Clin Psychopharmacol. 2019;34(2):57-64. PubMed abstract
The purpose of this study was to conduct a systematic review of the pharmacological options available to treat patients diagnosed with attention-deficit hyperactivity disorder and anxiety disorder, for generating evidence on the safest, most-effective and tolerable pharmacotherapy.

Coughlin CG, Cohen SC, Mulqueen JM, Ferracioli-Oda E, Stuckelman ZD, Bloch MH.
Meta-Analysis: Reduced Risk of Anxiety with Psychostimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder.
J Child Adolesc Psychopharmacol. 2015;25(8):611-7. PubMed abstract / Full Text
The study's goal was to quantify the risk of anxiety as a side effect of psychostimulant treatment for attention-deficit/hyperactivity disorder (ADHD). Meta-analysis suggests that treatment with psychostimulants significantly reduced the risk of anxiety when compared with placebo.

Authors & Reviewers

Initial publication: September 2008; last update/revision: September 2020
Current Authors and Reviewers:
Author: James Ashworth, MD
Contributing Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Reviewer: Peer review pending
Authoring history
2016: update: Mary Steinmann, MDR
2015: first version: Jennifer Goldman-Luthy, MD, MRP, FAAPSA; Robyn Nolan, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...

Barkley R.
Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.
Fourth ed. New York: Guilford Press; 2014. 9781462517725

Coughlin CG, Cohen SC, Mulqueen JM, Ferracioli-Oda E, Stuckelman ZD, Bloch MH.
Meta-Analysis: Reduced Risk of Anxiety with Psychostimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder.
J Child Adolesc Psychopharmacol. 2015;25(8):611-7. PubMed abstract / Full Text
The study's goal was to quantify the risk of anxiety as a side effect of psychostimulant treatment for attention-deficit/hyperactivity disorder (ADHD). Meta-analysis suggests that treatment with psychostimulants significantly reduced the risk of anxiety when compared with placebo.

Creswell C, Waite P, Cooper PJ.
Assessment and management of anxiety disorders in children and adolescents.
Arch Dis Child. 2014;99(7):674-8. PubMed abstract / Full Text

Fiks AG, Mayne SL, Song L, Steffes J, Liu W, McCarn B, Margolis B, Grimes A, Gotlieb E, Localio R, Ross ME, Grundmeier RW, Wasserman R, Leslie LK.
Changing patterns of alpha agonist medication use in children and adolescents 2009-2011.
J Child Adolesc Psychopharmacol. 2015;25(4):362-7. PubMed abstract / Full Text
The purpose of this study was to describe rates and patterns of long- and short-acting alpha agonist use for behavioral problems in a primary care population following Food and Drug Administration (FDA) approval of the long-acting alpha agonists guanfacine and clonidine.

Snircova E, Marcincakova-Husarova V, Hrtanek I, Kulhan T, Ondrejka I, Nosalova G.
Anxiety reduction on atomoxetine and methylphenidate medication in children with ADHD.
Pediatr Int. 2016;58(6):476-81. PubMed abstract
The aim of this study was to compare the medication effect of methylphenidate and atomoxetine on core and comorbid anxiety symptom dynamics in children with ADHD. Both atomoxetine and methylphenidate reduced the symptoms of ADHD and anxiety. Atomoxetine was more effective in anxiety symptom reduction from the fourth week of treatment.

Strawn JR, Dobson ET, Giles LL.
Primary Pediatric Care Psychopharmacology: Focus on Medications for ADHD, Depression, and Anxiety.
Curr Probl Pediatr Adolesc Health Care. 2017;47(1):3-14. PubMed abstract / Full Text

Villas-Boas CB, Chierrito D, Fernandez-Llimos F, Tonin FS, Sanches ACC.
Pharmacological treatment of attention-deficit hyperactivity disorder comorbid with an anxiety disorder: a systematic review.
Int Clin Psychopharmacol. 2019;34(2):57-64. PubMed abstract
The purpose of this study was to conduct a systematic review of the pharmacological options available to treat patients diagnosed with attention-deficit hyperactivity disorder and anxiety disorder, for generating evidence on the safest, most-effective and tolerable pharmacotherapy.