Anxiety in ADHD: Comorbidity and Confusion
by Jessica Staniland, Clinical Psychologist - Psychologist BPsych (Hons) MPsych(Clinical)
April 2019
by Jessica Staniland, Clinical Psychologist - Psychologist BPsych (Hons) MPsych(Clinical)
April 2019

Does your child often struggle to pay attention in class? Do they frequently need excessive encouragement to complete homework or assignments? Do they have trouble socialising or get left off birthday party invite lists? Do they have “melt downs” or over-react to the smallest events? Do they have excessive emotional or behavioural outbursts? Do they have trouble “settling down” to sleep at night? These concerns are key for both children with ADHD (Attention Deficit Hyperactivity Disorder) and for those with Anxiety, which is why the two diagnoses are often confused, and why anxiety is sometimes entirely missed in children with ADHD.
ADHD and Anxiety commonly exist together. Research suggests that between 25% and 33% of children with ADHD have a co-existing (or comorbid) Anxiety Disorder. In fact, childhood Anxiety is the 2nd most common condition co-existing with ADHD, coming second only to ODD (Oppositional Defiance Disorder). Unfortunately, however, these statistics are likely to be an under-representation as ADHD and Anxiety may be “misdiagnosed” or a “missed diagnosis.”
Where the Confusion Lies:
The key symptoms in ADHD and Anxiety are inherently similar, and may even be exacerbated by the presence of the second disorder. Both diagnoses can result in children displaying poor concentration, behavioural challenges, social and learning difficulties, sleep difficulties and a poor appetite. Despite this, what actually underlies these symptoms, and even more importantly how they are treated, is different.
“Misdiagnosis” versus “Missed Diagnosis”
One example of when misdiagnosis may occur is when Anxiety symptoms are confused with a physical concern due to a child’s complaints of headaches or tummy aches. When a child struggles to make friends because of their worry, lack of confidence and/or reactive behaviour, anxiety may also be misdiagnosed as a Social Communication Disorder such as Autism.
Where a child displays “explosive behaviour”, as part of the “fight or flight” response to Anxiety, this can be confused with ODD or felt to be due to their ADHD. Hence, Anxiety may also be missed entirely as a comorbid diagnosis where ADHD already exists.
Where a child displays “explosive behaviour”, as part of the “fight or flight” response to Anxiety, this can be confused with ODD or felt to be due to their ADHD. Hence, Anxiety may also be missed entirely as a comorbid diagnosis where ADHD already exists.
So how do we tell the difference?
Unfortunately, there is no magic formula or universally recognised assessment tool for determining whether a child has ADHD, Anxiety or both. Just like with all childhood developmental and emotional health disorders, it takes time, experience and a comprehensive assessment to understand where a child’s difficulties arise from. This requires gathering information in more than one setting and observing the child, sometimes over a few visits.
Some clues that suggest Anxiety:
Some clues that suggest Anxiety:
- Children with Anxiety are sometimes more sensitive to social cues (e.g. they recognise and worry about how they look to others)
- Children with Anxiety want reassurance and preparation for activities
- Children with Anxiety may have physiological symptoms (abdominal pains, nausea, dizziness, racing heart etc.)
- Children with Anxiety tend to show less problem behaviour when they are calm and feel safe
How do we support a child with ADHD and Anxiety?
Although there are similarities in symptoms, what underlies each symptom is different, and each diagnosis requires its own treatment and management plan. As a general rule, it is helpful to trial environmental changes and behavioural strategies before introducing medication.
Cognitive-behaviour Therapy with a Child Psychologist is the gold-standard treatment for Anxiety in Children, however it relies on children being able to sit still and cognitively engage for a period of 50 minutes per week or fortnight which can be challenging for some children with ADHD.
Medication options are available for both conditions if required. It is helpful to remember that stimulant medications for ADHD act quickly (days to weeks) whereas anti-anxiety medications take time (weeks to months) to see effect.
Cognitive-behaviour Therapy with a Child Psychologist is the gold-standard treatment for Anxiety in Children, however it relies on children being able to sit still and cognitively engage for a period of 50 minutes per week or fortnight which can be challenging for some children with ADHD.
Medication options are available for both conditions if required. It is helpful to remember that stimulant medications for ADHD act quickly (days to weeks) whereas anti-anxiety medications take time (weeks to months) to see effect.
Behavioural Strategies for ADHD:
Children with ADHD function best in a structured environment which is free from clutter, and where there is a consistent routine and clear expectations.
- At school and at times that require focus, reduce external distractions for your child by seating them away from windows, close to their teacher and in a clear and organised space.
- Provide your child with regular opportunities for movement breaks and sensory regulation activities.
- Warn your child of any changes in their routine in advance so as to ensure predictability.
- Your child may benefit from the use of visual schedules, prompt cards or alarms/timers as reminders of when to start and stop tasks.
- Children with ADHD tend to be “visual and practical learners” and therefore, wherever possible, supplement their learning with visuals and opportunities to physically engage in activities as part of their learning.
- Break down instructions into single steps, and wait until one step is completed before asking the next. Break new learning into “chunks”.
- Children with ADHD tend to have more difficulty with organisation, and may benefit from help to colour code their books, folders, and timetables.
- “Silly” behaviours used as a means of avoidance should be ignored where possible.
Behavioural Strategies for Anxiety:
Children who have anxiety have a heightened stress response system and can be easily triggered into either a “fight” (behavioural outbursts/aggression/defiance) or “flight” (absconding/crying/withdrawing) response to their anxiety. This means that they can become controlling or defiant, or may avoid the things they are worried about.
- Where possible, model and praise non-anxious behavior and reduce attention towards anxious behaviours, as providing excessive reassurance can inadvertently reinforce their worries.
- Always praise and reward children for “having a go” at the things they find challenging, and focus as much as possible on “effort” rather than “successful completion” of tasks.
- Help your child to “gradually face their fears” by taking small steps to become more comfortable with a feared situation (e.g. gradually increasing the amount of time spent away from mum/dad).
- Anxious children often try and gain control over situations as a way of relieving underlying anxiety. Where possible, give your child some limited choices, as this allows them some control over their environment and may reduce their need to try and gain control in other ways.
- Just like children with ADHD, children with Anxiety benefit from structure and routine. They like to know what is expected of them as this enables them to ensure control over their own environment.
- All children experience some level of anxiety, but when it starts getting in the way of them doing things that they would otherwise enjoy, it may be beneficial for them to see a Psychologist for some one-on-one counselling.
Sources
https://www.heysigmund.com/anxiety-and-adhd/
https://www.additudemag.com/anxiety-disorder-diagnosis/
https://www.psychologytoday.com/au/blog/here-there-and-everywhere/201706/the-overlap-adhd-and-gad
Schatz, D. B., & Rostain, A. L. (2006). ADHD with comorbid anxiety: A review of the current literature. Journal of Attention Disorders, 10, 141−149
Jarrett M.A., & Ollendick T.H. (2008). A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: Implications for future research and practice. Clin Psychol Rev 28, 1266 –1280.
Sciberras, E., Lycett, K., Efron, F., Mensah, B., Gerner, B., & Hiscock, H. (2014). Anxiety in Children with Attention Deficit Hyperactivity Disorder. Pediatrics, 133, 801-808.
https://www.heysigmund.com/anxiety-and-adhd/
https://www.additudemag.com/anxiety-disorder-diagnosis/
https://www.psychologytoday.com/au/blog/here-there-and-everywhere/201706/the-overlap-adhd-and-gad
Schatz, D. B., & Rostain, A. L. (2006). ADHD with comorbid anxiety: A review of the current literature. Journal of Attention Disorders, 10, 141−149
Jarrett M.A., & Ollendick T.H. (2008). A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: Implications for future research and practice. Clin Psychol Rev 28, 1266 –1280.
Sciberras, E., Lycett, K., Efron, F., Mensah, B., Gerner, B., & Hiscock, H. (2014). Anxiety in Children with Attention Deficit Hyperactivity Disorder. Pediatrics, 133, 801-808.