Untangling Anxiety and ADHD Symptoms in Children
Understanding your child's behavior helps to make (or break) an ADHD diagnosis
Posted Sep 01, 2019
When parents take their child to go see a psychologist or therapist, performance in school is one of the most common complaints that they want to address.
For mental health and medical providers, there's nothing as fun as a parent who brings in their child pre-diagnosed. When search engines were first invented, providers everywhere rejoiced—knowing how much time they would no longer have to spend on a thorough diagnostic process. Kidding.
The reality is, academic concerns are a valid reason for seeking psychological treatment and/or testing from a qualified professional. Well-intentioned parents everywhere have high expectations for their child's work in school.
But it's time to consider that Attention-Deficit/Hyperactivity Disorder (ADHD) may not be the perpetrator in all these cases. It's important to understand how anxiety can look like ADHD—especially in kids.
One of the faults of the Diagnostic and Statistical Manual (DSM) is the greatly limited extent to which it incorporates developmental considerations into its diagnostic criteria. In other words, the DSM provides a fairly comprehensive compendium of mental health diagnoses and their respective features, but it does not spend adequate time examining the variations possible for kids—whose brains, bodies, and personalities are evolving on a daily basis.
The DSM's diagnostic criteria section for ADHD is one of its longest, weighing in at a hearty two pages. These criteria (below) are summarized nicely here:
9 Inattention Symptoms (Six or more symptoms present for 6 months or more)
- Consistently disorganized
- Problems organizing activities
- Cannot focus or pay attention to tasks or instruction
- Frequently loses personal items (arrives at class unprepared, loses toys and tools)
- Begins tasks or assignments, but frequently does not follow through and leaves them uncompleted
- Appears not to listen, even when directly addressed
- Makes careless mistakes in schoolwork, professional work, and other activities
- Avoids taking on tasks that require sustained mental effort for long periods
9 Hyperactivity-Impulsivity Symptoms (Six or more symptoms present for 6 months or more)
- Talks excessively at home, in class, at work, and other places
- Has difficulty remaining seated in situations where sitting still is expected
- Children may move about a room, climb, or run where inappropriate to do so—teens and adults feel restless
- Cannot sit still when seated and frequently squirms, fidgets, or moves around
- Difficulty playing quietly (children) or quietly engaging in leisure activities (teens and adults)
- Seems constantly moving and driven, as if by a motor
- Impatient and has trouble waiting for his or her turn
- Interrupts others’ conversations or games
- Blurts out answers to questions before the speaker has completed the question
Most parents can probably identify a number of these traits in their child—that's why there's the six-symptom threshold for diagnosis. Plus, the inattentive or hyperactive symptoms must be present in and interfere with two or more settings in the child's life. Here's where the diagnostic process gets sticky.
From a clinical perspective, many of these symptoms can be explained by anxiety. Imagine you're preparing for a big job interview in a few hours. In the meantime, would you be able to focus well on a task? Might you be more forgetful than normal? Are you a pacer or a fidgeter? Do you find your mind drifting off to your talking points instead of whatever the task at hand is?
For any number of reasons, some children are more anxious than others; imagine they feel that pre-job interview nervousness all the time!
With that in mind, there are some ways to explore the possibility that your child's ADHD-like symptoms are anxiety. For example, if your child's teachers report these symptoms, but you don't see them in the home, your child may have school-specific anxiety.
Is your child able to sit down at home and read a book they're interested in without getting distracted, but the school says their reading attention span is poor? Does your child report more than their fair share of headaches and stomachaches? Do these seem to coincide with the beginning of the fall and spring semesters?
Perhaps most commonly of all, the anxious child looks like the angry child. Parents frequently complain that their child's anger is "out of control" or that it "seems to come out of nowhere." For kids, when you see anger, consider anxiety as a possible root cause.
There are many feasible explanations for this connection, but one that seems most straightforward is that children have not yet learned the rules of social acceptability of emotions that adults have. Well, most adults, that is.
For children, throwing a chair in class is grounds for a trip to the principal's office—a minor punishment in the grand scheme of things. For adults, throwing a chair in the workplace is grounds for dismissal and possibly legal charges if anyone was endangered. While we can all think of the occasional adult who, unfortunately, has not yet learned how to properly express their emotions, this skill in young children is almost universally just beginning to develop.
Children are learning machines. And they're great at their job! Sometimes we wish their learning abilities could be applied more in the classroom and less in the car when we let a choice four-letter word slip after the rude driver in a Mustang cuts us off (it's always a Mustang, isn't it?).
One of the first lessons learned in a newborn's life is that crying is a great way to get immediate care. That distinctive wail that has been the nighttime terror of parents since the beginning of time is a hard habit to unlearn. In childhood, many little ones find themselves in need of care for their emotions. While your child has likely become very proficient at asking for food, toys, and more playtime, they haven't yet learned how to elicit emotional caretaking.
Enter the anger. Outrageous behaviors like chair-throwing, hair-pulling, punching, and head-banging often prompt the "That doesn't sound like little Johnny!" response from parents. This sort of uncharacteristic behavior from your child may be evidence of their attempt to engender emotional caretaking.
Let me prove my point. Ask yourself how you would question your child if they failed to finish a class assignment. The parent's main concern would likely be a practical explanation: "Don't you care about getting good grades?!" The academically faltering child is met by questions that ascertain their ability to plan, complete work, or perform up to the standards of their academic year.
But the parent of the child who is sent to the principal for throwing a chair in class intuitively wonders about their child's emotional state. "What was little Johnny thinking?!" Or, perhaps more accurately, what was he feeling? The angry child is questioned about their emotions and their psychological experiences that could explain the choice to behave in an unacceptable manner.
Remember that children are learning machines. For the child who (even without knowing it) desires care for and attention to their emotional state, only certain types of behavior will elicit emotional caretaking. There is a high degree of co-occurrence between ADHD-symptoms and undesirable behaviors both in the home and at school. In order to arrive at an accurate diagnosis of ADHD, it's important to consider the role that anxiety—which often appears as anger—could be playing.
In a treatment study of Cognitive Behavioral Therapy (CBT) for anxiety in children who had been diagnosed with ADHD, "children’s ADHD symptoms improved significantly after CBT for anxiety, with most gains retained by 6-month follow-up. Improvements were modest, with the average participant improving by approximately 1 to 1.5 points on the ADIS-IV-C/P severity scale; however, in the mild-to-moderate ADHD sample, this was sufficient for approximately one third of children to score below the cutoff for a diagnosable disorder" (Gould, Porter, Lyneham, & Hudson, 2018).
It's possible that the increasing prevalence of ADHD diagnoses for U.S. children comes as a result of the complex comorbidity of anxiety and ADHD along with the difficulty associated with teasing the two apart.
For parents who are concerned about their child's behavior, the best course of action is to take them in to see a qualified mental health professional. ADHD should be diagnosed after a thorough psychodiagnostic testing process—not after a screener at a primary care provider's office.
This post sought to explain how ADHD symptoms might, at times, be better explained as anxiety symptoms. But a comprehensive psychological testing process can help to rule out a learning disability, an intellectual disability, or another relevant diagnosis that might otherwise be missed in a quick doctor's office checkup.
To find a therapist near you, visit the Psychology Today Therapy Directory.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Gould, K. L., Porter, M., Lyneham, H. J., & Hudson, J. L. (2018). Cognitive-behavioral therapy for children with anxiety and comorbid attention-Deficit/Hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 57(7), 481-490.e2. doi:10.1016/j.jaac.2018.03.021
Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young people: Prevalence, care pathways, and service provision. The Lancet Psychiatry, 5(2), 175-186. doi:10.1016/S2215-0366(17)30167-0