Understanding the Role of Anxiety in Children with ADHD by Nathaly Pesantez, ADDitude
Dec 2 , 2019



The overlap between ADHD and anxiety is well established. According to one study1, a quarter of children and teens with ADHD also suffer from an anxiety disorder. This information is not new. Therapists, parents, and educators know this comorbidity exists, yet few truly understand what it means, how it manifests, and how to respond when it does.

The truth is, we're quick to diagnose kids with ADHD without properly acknowledging the emotional experience of the condition. I wish I had understood earlier in my career as a therapist that anger and opposition can be a cover for shame and the fear of not measuring up. Sadly, kids who exhibit these behaviors push away the people from whom they most need support. Understanding the interplay between ADHD and anxiety allows parents, educators, and therapists to view children more fully and better meet their unique needs.

Can ADHD Look Like Anxiety? And Vice Versa?
Children with ADHD tend to express anxiety in one of two ways: externally or internally. Children who internalize their anxiety tend to display worry, fear, sadness, tearfulness, and a reluctance to engage in activities. Generally speaking, these children and the adults around them are able to pinpoint a reason for their emotional upset ("I'm really nervous about taking my math test."). Internalized anxiety, in my experience, is more readily diagnosed among kids with ADHD, and thus more commonly treated.

Children with externalized anxiety, on the other hand, are frequently misdiagnosed and misunderstood due to their outbursts. They hold their true emotions close to the vest. Instead of tears, their anxiety appears as defiance or anger. I'm talking about the kid who adamantly refuses to do their homework, or who throws a tantrum after getting home from a long day at school. Parents may struggle to identify the source of this kind of behavior because it can be so upsetting and aggravating.

Can ADHD Cause Anxiety?
I like to use an iceberg metaphor when talking to a parent whose child is exhibiting signs of externalized anxiety. Above the surface of the water this parent sees jagged shards of ice that are imposing and even scary. Below the surface, though, lies the fear, shame, and feeling of not being "good enough" that comes with anxiety and ADHD.

Children with ADHD know they're different from their peers. They know that they have to try twice as hard to keep up with neurotypical kids their age. And when they fall short in terms of behavior or academic performance, they can't help but feel bad about themselves.

How Do You Treat Childhood Anxiety?
If you're the parent of a child suffering from the more obvious internalized anxiety, your job is somewhat straightforward: provide reassurance and love, and begin to work on clinical interventions - such as gradual exposure and CBT - that treat the symptoms.

Parents in the other group have a more complex task at hand. First, you have to recognize the symptoms for what they are - deep fears and anxiety masked in anger and defiance. Then, you have to try addressing these symptoms with a child who likely will be reluctant to acknowledge the problem. And then, to top it all off, you have to manage your own feelings and reactions your child's behavior.

After you've spent the whole day at work or tending to household duties, the last thing you want is for your child to yell at you. And if you experience symptoms of ADHD yourself, your child's behavior may be triggering. In these challenging moments, I suggest that take a step back, not take their child's behavior personally, and look for the deeper "why" behind the acting out. The "why" is sometimes situational - tiredness, fatigue, stress at school.

For kids with ADHD, though, the "why" is often linked to anxiety. When you realize your kid isn't simply intent on saying 'no' or making you mad, the dynamic changes completely. You're better able to respond with empathy and compassion because you can look past the power struggle and see your child's vulnerability. As hard as it can be to deal with a kid in the throes of a tantrum, it's much harder for that kid to cope with the fear and discomfort accompanying their condition.

In my profession, we're quick to diagnose kids with ADHD without properly acknowledging the emotional experience of the condition. I wish I had understood earlier in my career that anger and opposition can be a cover for shame and a fear of not measuring up. Sadly, kids who exhibit these behaviors push away the people from whom they most need support. Understanding the interplay between ADHD and anxiety allows parents, educators, and therapists to view children more fully and better meet their unique needs.

Sources
1 Biederman, J., Newcorn, J. Sprich, S. (1991). Comorbidity of Attention Deficit Hyperactivity Disorder With Conduct, Depressive, Anxiety, and Other Disorders. AM J Psychiatry. 148:5. Retrieved from https://pdfs.semanticscholar.org/0a1...29f84baabb.pdf