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Mental Health: Is it Anxiety or ADHD?

Column Author: Sara Anderson, MD, MPH | Child and Adolescent Psychiatry

Column Editor: Trenton Myers, MD | Child and Adolescent Psychiatry

…Maybe both!

Attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders frequently co-occur in children, presenting a complex diagnostic challenge for clinicians. Studies indicate that up to 50% of children with ADHD also meet criteria for an anxiety disorder, highlighting the need for careful assessment and differentiation. Although ADHD and anxiety often appear together in children, their symptoms can be quite similar, making it challenging for clinicians to distinguish between the two in practice.

ADHD and anxiety share mental symptoms like trouble concentrating, restlessness, sleep problems and racing thoughts, but their underlying characteristics differ. For example, children with ADHD often experience a persistent mental chatter with thoughts jumping from topic to topic, reflecting difficulty in maintaining focus. In contrast, anxious children tend to have specific worries or fears dominating their thoughts, often centered on specific themes or situations.

Additionally, both conditions can manifest physical symptoms such as hyperactivity and fidgeting. Aggression may occur in either condition: in ADHD, it often stems from impulsivity and frustration, while in anxiety, it may be a response to feeling overwhelmed or threatened. Understanding these distinctions is crucial for accurate diagnosis and effective treatment.

While ADHD and anxiety disorders share these overlapping symptoms key differences exist in their clinical presentation:

ADHD

Anxiety Disorders

·         Children typically exhibit impulsivity, disorganization and consistent inattention across most or all settings.

·         Often avoid tasks that require sustained mental effort.

·         Difficulty concentrating even when calm.

·         Anxiety is typically related to problems caused by ADHD, like poor academic performance or inability to focus.

·         Children often display excessive worry, perfectionism and situational avoidance.

·         Often avoid tasks that may be anxiety-provoking, like novel situations.

·         Difficulty concentrating in anxiety-inducing situations or because of the anxious thoughts.

·         Anxiety is typically related to general worries about several different things.

 

Accurate diagnosis requires a comprehensive assessment, including a thorough clinical history, observations in multiple settings, standardized rating scales, and, potentially, psychological testing. Clinicians must focus on persistent patterns of inattention, hyperactivity and impulsivity when evaluating for ADHD, while anxiety assessments should emphasize excessive worry, physical symptoms and avoidance behaviors.

The Vanderbilt rating scale is one of the most commonly used for ADHD, which is freely available online at the following link:
https://upa.wustl.edu/wp-content/uploads/2015/09/ADHD_Assessment_NICHQ.pdf

The SCARED rating scale is one of the most commonly used scales to assess childhood anxiety, and is freely available online at the following link:
https://www.ohsu.edu/sites/default/files/2019-06/SCARED-form-Parent-and-Child-version.pdf

Treatment:

Treatment approaches for comorbid ADHD and anxiety require careful consideration. Addressing ADHD symptoms first can often lead to a reduction in anxiety symptoms. Stimulant medications, the first-line pharmacological treatment for ADHD, have shown efficacy in improving core ADHD symptoms. However, they should be used cautiously in comorbid cases, as they may exacerbate anxiety symptoms in some individuals. However, if the anxiety stems from the core issue of inattention, most children with ADHD see an improvement in their anxiety after the ADHD is treated, even with stimulants.

Non-pharmacological interventions, such as cognitive behavioral therapy (CBT), can be beneficial for both conditions and should be considered as part of a comprehensive treatment plan. Parent training and school accommodations can provide additional support. More resources on the diagnosis and treatment of ADHD can be found in the Children’s Mercy ADHD Clinical Pathway. As treatment progresses, clinicians should closely monitor both ADHD and anxiety symptoms, adjusting the treatment plan as needed to address the comorbidity effectively. This nuanced approach to differential diagnosis and treatment is crucial for developing effective strategies and ensuring optimal outcomes for affected children.

 

References:

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. https://doi.org/10.1176/appi.books.9780890425596
  2. Jensen PS, Hinshaw SP, Kraemer HC, et al. ADHD comorbidity findings from the MTA Study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry. 2001;40(2):147-158. doi:10.1097/00004583-200102000-00009
  3. Katzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry. 2017;17(1):302. doi:10.1186/s12888-017-1463-3
  4. Pliszka S. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. doi:10.1097/chi.0b013e318054e724
  5. van der Meer D, Hoekstra PJ, van Rooij D, et al. Anxiety modulates the relation between attention-deficit/hyperactivity disorder severity and working memory-related brain activity. World J Biol Psychiatry. 2018;19(6):450-460. doi:10.1080/15622975.2017.1287952
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