Which Came First: The Anxiety or the ADHD?

About three in ten children with ADHD also suffer from an anxiety disorder. The inverse is also true. These conditions, which look very much alike in some circumstances, often overlap. While scientists research the genesis and manifestation of the comorbidity, parents can take action now to relieve their kids’ anxiety. Here, learn how.

Anxiety in Children with ADHD: Which Came First?
A child with separation anxiety clings to their parent.

Anxiety — from mild to crippling — is common in children diagnosed with an array of mental disorders, including developmental differences and learning challenges. Anxiety in children with ADHD is also quite common — about 3 in 10 children with ADHD experience it. But don’t mistake its ubiquity for inevitability. Parents and professionals can deploy specific strategies to help ease — and not exacerbate — anxiety in their kids.

This is the hopeful message of Perri Klass, M.D., and Eileen Costello, M.D., coauthors of the book Quirky Kids: Understanding and Helping Your Child Who Doesn’t Fit In. Their message is an important one: Never dismiss or play down your child’s anxiety. When they complain of a stomachache or headache in the morning before school, they’re not faking. The pain they feel is real, and may require clinical treatment.

Anxiety disorder is the most common mental health condition in children,” says Klass, professor of pediatrics and journalism at New York University, who points out that anxiety rates are higher among children who already feel different and who struggle with tasks that their classmates seemingly find easy. “It’s true that everybody feels anxious sometimes. Maybe performing makes you anxious. Or social situations make you anxious. As a result, people don’t understand how big a problem anxiety disorder actually is — how much it is getting in the way and preventing these children from doing what they need to do.”

At what point should a parent seek a diagnosis and treatment for an anxious child? “When the fear or the worry is severe, and not appropriate for the child’s stage of development,” says Costello, clinical professor of pediatrics at the Boston University School of Medicine and Chief of Ambulatory Pediatrics at Boston Medical Center. “If the anxiety is causing them to perseverate about something when they ought to be thinking about other things, or it’s making it difficult for them to access the curriculum at school or engage with their peers, then it reaches a level that we would call clinical anxiety disorder.”

Anxiety disorder is a broad term that applies to various specific manifestations of anxiety.

Common Types of Anxiety and Their Symptoms

[Self-Test: Does My Child Have Generalized Anxiety Disorder?]

  • Generalized anxiety disorder Children with generalized anxiety disorder worry about frightening scenarios such as a family member dying suddenly or a bomb falling on their house. When severe, it becomes a constant feeling of doom and the child can’t stop thinking about terrible events.
  • Social anxiety disorder is a severe, paralyzing fear about being embarrassed in public. “This could mean that a child is so anxious about making a mistake while playing the piano in front of friends that she can’t do it — the anxiety paralyzes her,” explains Dr. Costello.
  • Separation anxiety disorder “This is common in the very young child, but we also see it in older children who are afraid to go to school because they can’t separate from their parents,” Costello says. “Sometimes, they’re afraid to be independent or they’re worried about something happening to their parents while they’re not there.”
  • Phobias can inhibit a child from doing everyday activities. “I have an 11-year-old patient who has terrible fear of airplanes and elevators,” Costello says. “My office is on the sixth floor and he always takes the stairs because he can’t get into an elevator. His phobia about being in an enclosed space is very real.”
  • Panic disorder Panic attacks, which are highly heritable, often occur out of the blue. “A child could be eating dinner and the next moment she’s hyperventilating, sweating, and having palpitations. It’s traumatic and frightening,” Costello says.
  • Selective mutism Some children talk happily at home but outside the house they’re too anxious to speak. “It’s important to recognize that this is not a behavior problem; it’s an anxiety disorder,” Costello says. “It’s not that a child is being oppositional or uncooperative — anxiety is driving it.”
  • Obsessive-compulsive disorder (OCD) is common in children on the spectrum. “Obsessions are thoughts that you can’t get rid of, and ‘compulsion’ means you’re being compelled to repeatedly wash your hands, line up your shoes, or touch every surface of the room,” Costello explains. “The compulsion causes a lot of distress if you can’t do it.”
  • Agoraphobia Kids with agoraphobia are afraid of particular environments. They may be in a mall or at a baseball game and suddenly cannot tolerate how they feel and need to leave immediately.
  • Post-traumatic stress disorder is usually a feeling of anxiety or panic that is triggered by past experience. “That could be any number things that the child experienced as traumatic,” says Costello. “For example, say a child got lost in a shopping mall in the past. That child could experience terrible separation anxiety and much greater stress than a typical child.”

[Read This: What Does Anxiety Look Like In Children?]

Anxiety Disorders and ADHD

The pediatric anxiety disorder triad — which includes generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder — is particularly common among children with ADHD.

“The question that we often get is what comes first, the anxiety or the ADHD?” says Costello. “It’s a great question and we don’t know the answer to it. We just know that these things are associated with each other and it’s very, very difficult to tease it out.”

Some signs of anxiety — restlessness, lack of focus, outbursts, and defiance, for example — are commonly mistaken for symptoms of ADHD. Other times, the perfectionism or social challenges associated with ADHD are wrongly attributed to anxiety. And then there are those children who experience both conditions, and perhaps a learning disability as well.

“A lot of kids will develop poor self-esteem related to the social skills and academic underachievement that comes with the symptoms of ADD or ADHD,” Costello says. “It’s hard on kids and it’s hard on their families. It doesn’t feel good to have ADHD. As professionals, our job is to help the child understand that it’s not their fault and that lots of other kids have this too and we’re going to help you.”

Strategies to Help the Anxious Child

Cognitive Behavior Therapy to Help Anxiety

Cognitive behavior therapy (CBT) is the gold standard treatment for children whose anxiety interferes with their ability to go school or do everyday activities such as ride an escalator, Klass says. It’s time-limited and goal-oriented.

“With the help of a therapist, kids are cognitively trained to react differently to situations that provoke their anxiety,” Costello explains. The idea is to expose the child to a little bit of the thing that she’s anxious about and then talk about it afterward.

Scripting to Help Anxiety

Talking through an upcoming event can be especially useful for kids with social anxiety. The parent of a child who is afraid of loud noises might say, “We’re going to a party where there will be a lot of people and balloons. Some of them might pop and make a really big sound, so let’s figure out what we can do.”

“The night before the birthday party, say to your child, ‘The last time you went to a birthday party you had a hard time, but I know you really want to go,’” Costello says. “So, we’re going to just talk about this in advance.’” Some people also use things like the dream catcher or worry box to contain the worries in a visual way, saying ‘All right, we’re putting that in the box.’”

Visual Aids to Help Anxiety

Visual aids such as a Feelings Thermometer can help kids identify where they are on a scale of mild to severe anxiety without requiring them to use their words in a time of distress. They might realize ‘Oh, actually, I don’t feel so bad right now at all,’ or they may express to themselves, and you, with “I can’t cope.”

Pairing Therapy with Medication for Anxiety

Kids who are severely impaired by anxiety often benefit from a multi-pronged approach that includes both family and individual therapy, along with CBT and medication. Selective Serotonin Reuptake Inhibitors (SSRIs) such as Prozac are considered first-line therapies for anxiety.

Unlike stimulant medications or antibiotics, SSRIs don’t take effect immediately. They build up in the system for weeks or even months before patients begin to notice a difference. “It takes time to titrate to get their effective dose and then it will take time for that effective dose to kick in,” Costello says. “I usually say, ‘Let’s try this maybe for a year, maybe for nine months, maybe for the school year. And if things are going well, we can take a break.’”

SSRIs also carry with them the warning for a small increased risk of suicidal ideation and behavior in kids with depression. “It’s best to start at the lowest possible dose to make sure you’re not seeing a side effect, because that side effect is not dose-related,” Costello says.

“Evidence shows that CBT and medications are equally effective but if you use them together, the effectiveness is superior to either one of them alone, which I think is important,” Costello says. “If the child is really suffering and the people in their environment are really suffering, and the child is not moving forward and other modalities have not been effective enough, meds can help a lot of kids. Medication can turn down the volume on the symptoms to a degree that makes the child able to access the other strategies that we’re trying to put in place to help them.”

[Read This: Why Anxiety Disorder Is So Often Misdiagnosed]

This content came from the ADDitude webinar by Eileen Costello, M.D., and Perri Klass, M.D., titled “Worry Less: Managing Anxiety in Children and Adolescents with ADHD and Learning Differences”, which is available for free replay.