Mental Health Blog

Untangling ADHD and Anxiety as Comorbidities

Hands holding a cutout of a brain, with tangled string.

 

“ADHD and anxiety presenting together is very common in children and adolescents. But it can be difficult to discern which is the primary condition and which to treat first,” explains Kari Overstreet, DNP, APRN, CPNP-PC, PMHS, a pediatric nurse practitioner focused on child psychiatry and a Patient-Centered Mental Health in Pediatric Primary Care (PPP) faculty member at The REACH Institute. 

Research shows that up to 30% of those with ADHD will also struggle with an anxiety disorder. In treating pediatric patients, it’s worth understanding how a child with ADHD might develop an anxiety disorder and how a child with an anxiety disorder may display ADHD symptoms. 

Here, Overstreet walks us through the process of untangling ADHD and anxiety as symptoms versus root causes, and how to approach treatment decisions. 

 

How Symptoms of ADHD and Anxiety Overlap

The experience of living with untreated ADHD may trigger anxiety in children and adolescents. For example, a child who is inattentive or impulsive in school and at home (symptoms of untreated ADHD) may be reprimanded more frequently by teachers and parents. They may be compared unfavorably to their peers and siblings. This can lead to understandable anxiety, as children worry: “Am I going to remember my homework? Am I going to get in trouble today?”

Similarly, the effects of living with an untreated anxiety disorder can resemble symptoms of ADHD, like inattention or impulsivity. “Children with anxiety are like a balloon so filled with air it’s about to pop,” explains Overstreet. Constant anxiety and dread may affect their sleep and ability to focus. They may struggle to pay attention in class, forget details and assignments, or lash out and behave impulsively. 

When patients have both ADHD and anxiety, the conditions can further exacerbate each other if left untreated. 

 

Identifying a Primary Diagnosis

When children display symptoms of both ADHD and anxiety, Overstreet recommends starting the diagnosis process with patient education. “I help the patient and their family understand how ADHD and anxiety can affect each other. Then I help the patient identify what is causing the most suffering or impairment.” 

Overstreet helps patients connect the two conditions to their daily experiences. For example, she may say the following to a pediatric patient: 

“Some kids in your situation tell me that, when sitting in class, they are so worried about other things in their lives that they miss what the teacher says. These kids might think, ‘If only I weren’t so worried, I could pay attention.’ Other kids tell me they’re trying so hard to pay attention and they think they’re doing everything right, only to make a silly mistake on a test or forget an assignment. These kids might say, ‘If only I could just focus, I wouldn’t be so worried.’”

Then she asks the patient, “What about you? What is your experience?”

Clinicians can also use screening tools, like the Vanderbilt assessment scales for ADHD and the SCARED children’s anxiety assessment, to track the severity of symptoms for the comorbid conditions. One benefit of a tool like the SCARED is that it gives insight into different types of anxiety disorders beyond just Generalized Anxiety Disorder. For example, it can help clinicians in diagnosing Separation Anxiety Disorder, Social Anxiety Disorder, Panic Disorder, and School Avoidance. 

 

Deciding What to Treat First and How

In cases of comorbid ADHD and anxiety, general guidelines are to start with stimulant medication. Stimulant medication works faster than anxiety medications like SSRIs and, once the ADHD is treated, children and adolescents often find their anxiety improves too. 

However, many parents and providers still worry that stimulant medication for ADHD may worsen anxiety. In these cases, clinicians can reassure families about the efficacy of stimulant medications and prepare patients for how such medications may affect them. “For kids with a lot of anxiety, sometimes the anxiety comes from not understanding why they are feeling a certain way or experiencing different sensations in their bodies, such as when their heart is beating fast,” explains Overstreet. Clinicians can also reassure patients that they will work together on other treatments if they don’t like how the first medication makes them feel. 

If feeling anxious and panicked is causing the most difficulties for a child, Overstreet shares that it may be worth treating the anxiety first. In these cases, the first-line treatment for anxiety – Cognitive Behavioral Therapy (CBT), SSRIs, or a combination of both – can be very effective. 

Regardless of whether ADHD or anxiety is treated first, clinicians should monitor both disorders to ensure the impairments the patient is experiencing are fully addressed. 

 

How Anxiety May Complicate School Accommodations

Finally, Overstreet reminds clinicians that anxiety may prevent children and adolescents from asking for or utilizing accommodations at school. For example, a teenager with ADHD may be eligible for extended testing time. However, due to social anxiety about how this appears to peers, they may not use this accommodation. In these cases, clinicians should ask patients what they need to feel comfortable using the accommodations available and make a plan to address those factors.

 

RESOURCES
  • Read more about ADHD and anxiety as comorbidities at ADDitude Magazine
  • Two screening tools that Overstreet recommends clinicians consider are the SCARED Screen for Child Anxiety Related Disorders (available online here) and the Vanderbilt Assessment Scale for diagnosing ADHD (available online here).
  • REACH’s one-day CBT for Anxiety in Pediatric Primary Care program helps primary care providers learn CBT techniques they can immediately incorporate into their practice to support children and adolescents with anxiety.

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