As many as 25-50% of children with attention-deficit/hyperactivity disorder (ADHD) have a co-occurring anxiety disorder. This is about 3 times higher than in the general population. [Barkley: 2014] Anxiety disorders are characterized by persistent and excessive anxiety that results in a significant disruption of function at home, at school, or in the community. Anxiety disorders include separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder and panic attacks, agoraphobia, and generalized anxiety disorder, as well as anxiety related to medication or substance use, or other medical conditions. Anxiety is also a prominent feature of obsessive-compulsive disorder and post-traumatic stress disorders, although The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2013] characterizes them as separate from the anxiety disorders classification. See the Anxiety Disorders module for more detailed information about diagnosis and treatment of anxiety.

Anxiety disorders are thought to be an interaction between biological factors (e.g., genetics), psychological factors (e.g., temperament), and environment. Familial patterns are common.

Inattentive symptoms occur in both ADHD and anxiety; however, the inattentiveness from ADHD is due to distraction by external stimuli or other interests; in anxiety, inattentiveness is associated with worry or rumination (see ADHD vs. Anxiety Didactic Presentation Recording (MAPP-Net)). Other clues can suggest an anxiety disorder:

• Family history of anxiety
• Avoidance (most commonly school, but can also be avoidance of other specific places or situations)
• Age-inappropriate separation anxiety
• Excessive worries or fears that cause avoidance, distress, or dysfunction
• Worry or fear after a transition that does not seem to be improving after several months
• Nightmares or sleep problems
• Rituals and/or obsessions that appear overly rigid or are overly time-consuming
• Frequent non-specific physical complaints (headaches, stomachaches, muscle pain) without clear etiology
• Meltdowns or tantrums that are not age appropriate
• Irritability or anger reactions

It can be challenging to differentiate behaviors seen in ADHD from those in anxiety disorders. Untreated anxiety can make it harder to effectively treat ADHD. When diagnosing anxiety, questions in the areas listed below can aid in differentiating acute situational anxieties from chronic anxiety disorders:

• Family history
• Child's usual affect and temperament and recent changes
• Worries or fears
• Rituals and/or obsessions
• Difficulties with separation (babysitter, school, sleep-overs)
• Nightmares and sleep problems
• Impact of symptoms on functioning
• Information from the child's teacher is also important in sorting out degree of symptomatology.
• Differences in behavior across settings (e.g., does really well at school but is struggling at home)

The Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB), frequently used to assist in diagnosis and monitoring response to treatment for children and youth with ADHD, include several questions about anxiety in the initial evaluation. A high score on the anxiety-related questions, along with impaired function, should raise concern for anxiety. See the Portal's Anxiety Disorders for further details.

Since somatic complaints and health-related concerns are common manifestations of anxiety disorders, medical history and evaluation should be completed to screen for concerns and reassure the family and the child about general health issues. Some medical conditions can be misdiagnosed as anxiety disorder (e.g., partial complex seizures) or may contribute to an anxiety disorder (e.g., the child's response to a serious medical condition). Examination should also monitor for tics, which is a common comorbidity of ADHD but can also be a feature of anxiety disorders and mitral valve prolapse (common in adults with panic disorder). Regardless of etiology, somatic symptoms can impair functioning, school attendance, and academic performance. Evaluation for comorbid learning problems may be indicated since these also may contribute to school anxiety/avoidance in children with ADHD.

Treatment will vary depending upon the degree of impairment. In some cases, treatment may involve an explanation to the family/child and simple coping strategies. Online e-training and home workbooks can help some children cope with anxiety. [Creswell: 2014] In more significant scenarios, treatment will include a team approach with a psychologist, school personnel, and the pediatrician. Consultation with a psychiatrist or developmental-behavioral pediatrician may also be helpful. Components of team treatment include:

• Demystify: Explain to child, family, and school (if indicated) the nature of the underlying conditions.
• Reassure: Help families understand that their child's fears may not be "rational" and thus are not easily "reassured" away. Helping children to understand common triggers for anxiety, such as a new school, may allow them to handle fears better. A plan with gradual approaches to targeted goals can be discussed (e.g., helping the child sleep in his own room).
• Social training: With the child's consent, involve the teacher in helping to structure social situations at school. Training in social skills and coping mechanisms for embarrassing situations may be helpful. Social structuring in extracurricular settings (with adult supervision) may also be helpful.
• Scheduled return to school: For children with school refusal, create a plan for return to school that includes a timeline, modifications needed at the school to minimize distress, and a contingency plan (e.g., what to do when the child reports illness). Collaboration with the school counselor, principal, and staff may be helpful as these individuals can provide support to the child and family during the transition.
• Behavior therapy: Therapy may include coping strategies (e.g., relaxation techniques, grounding exercises,), exposure response therapy, and cognitive behavior therapy. Cognitive behavioral therapy has the strongest evidence for children with an anxiety disorder [Creswell: 2014], but these other strategies may be useful as well depending on the individual. A referral for therapy by a licensed counselor or psychologist is indicated for mild to moderate anxiety causing dysfunction in one or more aspects of the child’s life.
• Mindfulness and mind/body approaches like deep breathing and yoga have also demonstrated benefits in children with anxiety and ADHD; see Apps to Help Kids and Teens with Anxiety for ideas for families and patients to try on their own.
• Medications may be indicated (see below) for anxiety and/or ADHD symptoms when therapy alone is not effective or for moderate to severe impairment.

Medications

The medical home team can:

• Identify the clinical concern for an anxiety disorder in the child with ADHD.
• Assess for increased family stress and trauma exposures that can masquerade as ADHD or anxiety or make it harder to treat these conditions.
• Advocate for the parent's effort to access appropriate school services and continued participation in school with appropriate accommodations, when indicated.
• Recommend evidence-based practices like mindfulness and yoga that can help children and adolescents with anxiety and ADHD.
• Ensure family-centered team collaboration.
• Prescribe medication or consult with a psychiatrist when indicated.
• Monitor for side effects of medications that are prescribed for ADHD and anxiety.
• Refer and ensure treatment by a therapist if indicated.
• Refer to psychotherapy if indicated.

Children with both ADHD and an anxiety disorder may be more likely to require referral to psychology and/or psychiatry. Be aware that parent training in behavior management, a first-line intervention for ADHD, is not always offered by mental health professionals adept at cognitivebehavior therapy and other first-line interventions for anxiety. Counsel families to ask prospective therapists about their experience treating both conditions. See Outpatient Mental Health Care (see OH providers [0]).