What's Happening

ADHD and Anxiety – Part One

By Riikka Melartin, Psy.D.

Many children have diagnosed or undiagnosed Attention Deficit Hyperactivity Disorder, or ADHD. Although people often associate ADHD with hyperactive, out of control behavior, it presents in many forms, including an inattentive type that may be easily overlooked. Furthermore, the term “attention deficit” is itself in some ways misleading, as the difficulties fall more broadly in the realm of attention regulation and other executive functions.

Executive functions are the skills that help us execute tasks, such a planning ahead, estimating time, organizing, shifting attention when needed, and so on. Resourceful children in environments that are a good fit for them may not run into difficulty until they’re older, when demands increase— whether that be middle school, high school, or beyond. Given all these factors, it is not surprising that there can be diagnostic confusion and a great deal of overlap between symptoms of ADHD and other issues, especially anxiety.

• ADHD can lead to anxiety. Children (and adults) with executive function issues may often be late or procrastinate, make unintentional mistakes, feel like they’re not doing a good job, and be criticized for being lazy or not caring. Between their internal negative judgement of themselves and criticism from others, children may chronically worry about what they might be overlooking, what mistake they might make next, and when they will next get into trouble. Children with ADHD (especially if undiagnosed) can develop a sense of anxiety and low self-esteem that carries over into adulthood.
• Anxiety often manifests in behaviors similar to those found in ADHD: procrastination, avoidance, inattention, or difficulty with processing. For example, a child worried about failure may paradoxically put off studying because it is too nerve-wracking; or a child preoccupied with social anxiety or separation anxiety may not be able to focus in the classroom. Thus, there can be a feedback loop: executive vulnerabilities can foster anxiety, and anxiety can exacerbate executive deficits.

Because of this complexity, if you suspect your child might have either ADHD or anxiety, it is best to have neuropsychological testing to help determine the underlying factors for their behaviors. While questionnaires are important in identifying behavioral patterns and while they may suggest certain conditions, they do not investigate underlying causes the way neuropsychological testing does. Other contributors may include things like learning disabilities, an uneven pattern of cognitive strengths and weaknesses, or depression.

I will end with a case example that hopefully illustrates all of these points. A high school girl had started therapy for anxiety. However, her parents wanted to make sure they were not overlooking anything. In particular, the daughter had mentioned that her friends seemed “smarter” that her because they were quicker with homework than she was (though she was getting good grades.) After full neuropsychological testing, the parents were surprised when their daughter turned out to have ADHD and slow processing speed (the ability to take in and produce information quickly.) Her ADHD was of the inattentive kind. As a perfectionistic, anxious child, she had simply doubled down and spent an excessive number of hours on her homework to compensate, not complaining to anyone. Neither parents nor teachers picked up on her executive function difficulties. The first observable symptoms that lead to her initially going to therapy were her attendant anxiety and insecurity. As a result of the testing, she received accommodations in school. The relief of a diagnosis, the provision of accommodations such as extra time on exams, and continued therapy helped reduce the student’s overlapping symptoms of both ADHD and anxiety.

Stay tuned for Part Two which will address ways you can help support your child with ADHD.

Riikka Melartin, Psy.D. is a licensed psychologist who provides individual therapy, counseling, and consultation for clients who are diverse in age, ethnicity, and sexual orientation. Until recently, she also worked as a school psychologist.