ADHD
Maybe It's Not ADHD—Maybe It's Anxiety
Anxiety can look like an attention problem, so how can you tell the difference?
Posted June 17, 2025 Reviewed by Margaret Foley
Key points
- Struggling to pay attention can be a symptom of ADHD, but not always.
- Anxiety is a common childhood disorder that can disrupt focus and concentration.
- Determining whether the correct diagnosis is anxiety or ADHD requires careful evaluation.
Kendra, a high school freshman, came to see me with her mother, Suzanne, after their pediatrician referred them. She was a freshman in high school who was referred to me by her pediatrician with concerns about ADHD. Before this year, Kendra had always gotten straight A's and had worked diligently to get them. But three months into 9th grade, Kendra was dangerously behind in all her classes, no matter how many hours she spent studying. She was even overwhelmed in Spanish, despite having been in a bilingual program since kindergarten and already being proficient.
ADHD had not come up before this year. But, Suzanne noted, Kendra had always taken a long time to complete her homework—longer than her friends did. Kendra and her mother attributed this to her tendency to be a perfectionist. But now Kendra couldn’t seem to get any work done at all, in or out of class. She spent hours in her room every night, but she couldn’t seem to get anything done.
The pediatrician had mentioned to Mom, correctly, that girls with ADHD may be missed in the early school years because they are often more inattentive than hyperactive or impulsive. Kendra’s parents wondered if she had gone under the radar and they were only now noticing it, in high school, which is also not an uncommon pattern. There was also a family history—Kendra’s father had been diagnosed with ADHD just a few years ago, and he wanted to make sure Kendra was identified early if she had it.
Symptoms First, Diagnosis Second
Central to the diagnosis of ADHD is a checklist of symptoms related to inattention, hyperactivity, and impulsivity. To meet criteria for the diagnosis, someone must have enough of the symptoms, enough of the time, at enough severity to cause problems in functioning.
So we dug into the details. Kendra told me that in school, her brain was buzzing with thoughts, and she couldn’t focus on what the teacher was saying. She would try to focus on the teacher, but she kept getting drawn back into her thoughts. Suzanne noted that Kendra was also making errors on simple questions, and she couldn’t bring herself to review her work, even though she had always done so before. As we were talking, Kendra pulled a notebook out of her backpack to show me the empty pages. She and Mom told me Kendra had previously been a great note-taker and an excellent organizer. She loved her color-coded folders and notebooks, but these too were now hardly used.
As we reviewed the symptoms, it was clear that ADHD might explain them, but we had to consider other reasons for her struggles. Many conditions can lead to trouble concentrating, ranging from physical illnesses to sleep problems to a range of psychiatric conditions, including common ones such as anxiety and depression. With this in mind, I needed to know more about Kendra’s history and current symptoms.
Tell Me More
It turned out that even before this year, Kendra constantly worried about making any mistakes, no matter how small. This led her to spend hours on every assignment, no matter its size or importance to her grade. This pattern suggested that anxiety might be part of the picture, so I asked her for more details about the thoughts that distracted her. She let out a big sigh and then rattled off an impressive and painful list of fears and worries. She told me that she couldn’t stop thinking about “What if?” What if she gets a bad grade? What if the teacher or her parents get upset? What if she failed 9th grade and couldn’t go to college, get a job, or make money? She started to cry. Suzanne said that when Kendra was overwhelmed with the questions, she would try to offer reassurance that everything would be OK. Kendra shot her a look and said, “But you don’t know that, do you”?
Thinking more about anxiety, I asked about sleep, and it was not good. Kendra often stayed up for hours trying to make her brain focus, but she would stare at her computer, unable to understand the words in front of her, panicking about the work not getting done, and how much work she was falling behind on. Her parents would eventually convince her to turn off the laptop and climb into bed, but once there, the thoughts about schoolwork poured in, and she would lie awake for hours before falling asleep. Kendra often felt her heart racing and felt like she couldn’t catch her breath. A trip to the pediatrician had shown no problems with Kendra’s heart or lungs.
Correct Diagnosis to Get the Correct Treatment
With this story in mind, and after reviewing other medical and psychiatric histories, I determined that while the presenting problem was inattention, an anxiety disorder was the primary driver of the symptoms, rather than ADHD. Kendra might also have ADHD, but I couldn’t determine that until we addressed her anxiety so her brain could quiet. As it turned out, there was also a family history of anxiety—Kendra’s mother had been treated for it. The developmental picture was also consistent. The onset of puberty is a common time for anxiety disorders to appear in a child’s life.
Once we had the diagnosis, we built a treatment plan to address it. The first step was a referral to a therapist with expertise in anxiety and cognitive behavioral therapy (CBT) with children and adolescents. That work included coaching and support for parents as well, to help them understand more about the anxiety and the process of treating it. Kendra and her family found CBT helpful, and Kendra’s symptoms improved steadily over the next few months.
Trouble focusing is a symptom of various medical and psychiatric conditions. Anxiety that looks like ADHD is one frequent example, and there are others. It’s critical not to stop too soon in the diagnostic process. Listening to a child’s whole story is a psychiatrist’s way of teasing out the problems so we can choose the right solutions.
