ADHD Anxiety Symptom Checklist for Children
Why your child’s inattentive or hyperactive symptoms may actually be symptoms of anxiety. Or why her worry and trouble sleeping may point to ADHD. And how to ensure an accurate diagnosis.
Analyzing a child’s symptoms to make a diagnosis of ADHD or another brain-based condition isn’t always straightforward.
About half of all children with attention deficit disorder (ADHD) also have a learning disability, mood disorder, obsessive-compulsive disorder (OCD), anger-control difficulties, a motor tic disorder, bipolar disorder, or an anxiety disorder. Symptoms may also look similar.
A child who seems to have ADHD — she’s hyperactive, impulsive, and inattentive — may have an anxiety disorder instead. Children who display classic symptoms of anxiety disorder may have ADHD. Distinguishing between ADHD and anxiety in children requires a full evaluation by a professional who is willing to dig deep for clues.
Still, even professionals can misinterpret symptoms. If a child can’t sit still, doesn’t stay on task, calls out in class, or shouts out inappropriate comments, they think it must be ADHD. If a child has excessive fears or worries, it must be an anxiety disorder.
The problem is that we sometimes see the smoke and miss the fire. Or we see the smoke and conclude incorrectly what is causing the fire. Behaviors are messages, they are not diagnoses. It is the task of the professional to clarify reasons for behaviors.
Focus and Fear Problems
Take Monica, a third-grader, for example. Her restlessness in class and her inability to focus on classwork led her teacher to believe she had ADHD. Her pediatrician started Monica on a stimulant medication for ADHD, but her symptoms didn’t improve.
Recently, she started showing signs of anxiety: She had trouble falling asleep by herself, and she was afraid to be alone anywhere in the house.
My informal assessment showed that her reading and written-language skills were at the early second-grade level. Monica told me that, if she did not know what to write or had trouble reading in class, she was afraid that the teacher would be mad at her.
Formal studies confirmed that she didn’t have ADHD, but she actually had a learning disability that caused her to be anxious at home and in school.
Easily Distracted and Intimidated
Joseph was 16 when he visited my office. His parents described him as quiet, shy, and “afraid of his shadow.” He had no friends, and he avoided sports or other group activities.
Joseph was nervous around people he did not know or when he had to speak in front of the class. He was also afraid of elevators and other small, enclosed spaces.
His parents said that Joseph showed signs of anxiety since early childhood. His mother admitted that she had similar behaviors as a child — and that she still had them. I learned that Joseph did poorly in school.
He was distracted by objects and noises in the classroom. He daydreamed and lost track of what was going on. I also found that he had problems with organization. I diagnosed him with anxiety disorder and untreated ADHD.
Mrs. Garcia, a college graduate who held a prominent position in a consulting firm, took anxiety medication for three years. But it didn’t help: She still needed a quiet space in order to stay focused. It seemed to me that her anxiety and stress in college and at work stemmed from inattention.
I took her off anxiety medication and started her on ADHD meds. Within a week, she could focus on and complete her projects at the job. Her anxiety ceased.
Anxiety: The Cause or Effect?
Stress and anxiety are a normal part of life for children and adults. Moderate anxiety helps children push themselves to succeed at home, with peers, and in school.
It is normal to be anxious when taking a test or performing in the school play. We expect children and adolescents to be nervous at the doctor’s or dentist’s office or when faced with a new situation. When the level of anxiety is greater than expected, we suspect that there is an anxiety disorder.
Yet merely ticking off prominent symptoms can lead parents and professionals down the wrong path. Anxiety may cause restlessness that can be interpreted as hyperactivity. Or it may bring worries or concerns that cause a child to be inattentive. As anxiety levels increase, the child may appear to be acting quickly or irrationally in order to minimize stress. A parent might label him as impulsive. A superficial assessment might suggest that the child has ADHD, when he really has an anxiety disorder.
An accurate diagnosis is critical to developing an appropriate treatment plan. A doctor or professional should determine whether the anxiety is primary or secondary.
If a child has had difficulty regulating stress and anxiety since early childhood, and his anxiety is pervasive, it is primary. If one or both parents remember being anxious in early childhood, or they still are, a diagnosis of anxiety is almost certain. Anxiety disorders are often genetic.
On the other hand, an anxiety disorder may be secondary to difficulties experienced by a child who has ADHD or a learning disability. Secondary anxiety occurs in certain circumstances.
Monica became anxious over anything related to school. Her anxiety disappeared on weekends. Some children become anxious after they experience a stressful event, such as moving to a new city or their parents going through a divorce. With secondary anxiety, there is no family history of the disorder.
Which Do You Treat First?
The answer lies in discovering the causes of observed behaviors. When a child shows signs of anxiety, a parent or professional must not assume he’s suffering from an anxiety disorder.
They must try to get to the root of that anxious behavior. Maybe the child (or adult) has ADHD, and his anxiety is secondary to the frustrations, failures, and negative feedback he experiences in school or at work, at home, and with peers. In such a case, a professional should treat the ADHD while working to address the social, emotional, and family problems associated with the anxiety disorder.
Another possibility is that the child has ADHD and an anxiety disorder. If so, a professional must treat both disorders to maximize success. If the child is receiving treatment for anxiety, but his symptoms persist and the doctor begins to suspect that they’re caused by undiagnosed ADHD, he should treat the ADHD and see whether the symptoms of anxiety cease.
Treatment might include medication, behavioral therapy, individual therapy, social skills groups, and/or family counseling. Parents should remember that an effective treatment plan always flows from an accurate diagnosis.
A Diagnosis Wrinkle
Parents need to understand that the diagnostic process can be further complicated during the treatment phase. It was for 10-year-old Robert.
He was diagnosed with ADHD and was put on a stimulant. Two days later, his mother called, saying that her son had become anxious. He would not sleep alone, and he would call his mother from school to make sure she was OK. I took him off the medication, and his anxiety disappeared.
While some children with ADHD may also have an anxiety disorder or another comorbid condition, sometimes the disorder is so minimal that there are no symptoms. We call this subclinical. Taking a stimulant, however, may exacerbate a low-level condition. When this happens, it is important to deal with the anxiety disorder first. Once that is treated, it is generally safe to reintroduce the stimulant without causing a flare-up of anxiety.