Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD)


As many as 25-50% of children with ADHD have a co-occurring anxiety disorder. This is about three times higher than in the general population. [Barkley: 2014] Anxiety disorders are characterized by persistent and excessive anxiety that results in significant disruption in 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 these are now characterized separate from the anxiety disorders classification in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). [American: 2013]

When to suspect 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 doesn’t seem to be improving after a few 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


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.


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.
See the Portal's Anxiety Disorders, Ongoing Assessment for further details.

Additional evaluation

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 to 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 (Tourette syndrome, but can also be a feature of anxiety disorders) and mitral valve prolapse (common in adults with panic disorder). Regardless of etiology, somatic complaints can impair functioning, school attendance, and academic performance in addition to struggles a child with ADHD may already experience at school. Evaluation for co-morbid learning problems may be indicated since these may also underlie school anxiety/avoidance in children with ADHD.

Medical home provider roles:

  • Identify the clinical concern for an anxiety disorder in the child with ADHD.
  • Ensure referral to, and treatment by, a therapist if indicated.
  • Advocate for the parent's ability to access appropriate school services and continued participation in school.
  • Ensure family-centered team collaboration.
  • Support parents in advocating for needed supports.
  • Prescribe medication or consult with a psychiatrist when indicated.
  • Monitor for side effects to medications that are prescribed for ADHD and anxiety.
Children with both ADHD and an anxiety disorder may be more likely to require referral to psychology and/or psychiatry.


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 bothersome or new situations (e.g., new school) better may allow them to better handle fears. 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 be 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 school counselor, principal, and staff may be helpful as these individuals can provide support to the child and family during the transition.
  • Behavior programming: Therapy may include coping strategies (relaxation techniques, cognitive strategies), programs of stimulus exposure, and psychotherapy. For children with anxiety alone, cognitive behavioral therapy has the strongest evidence basis. [Creswell: 2014] A referral for behavioral therapies by a psychologist is indicated when the anxiety disorder is severe and/or functional impairment does not improve with the interventions discussed above.
  • Pharmacological agents may be indicated (see below) for anxiety and/or ADHD symptoms.

Pharmacological agents most commonly used for anxiety in children include the selective serotonin reuptake inhibitors (SSRI’s), such as fluoxetine or sertraline. The role of using SSRI's in treating anxiety disorders is reviewed in the following articles: [Strawn: 2014] [Ipser: 2009] [Creswell: 2014] For additional information about treatment of anxiety disorders, review of the Anxiety Disorders, Treatment & Management may be helpful.

Evidence for effective co-management of ADHD and anxiety is still lacking. Literature has conflicting reports about the response of children with ADHD and co-morbid anxiety disorder to stimulant medication. It appears that while stimulants can have a positive effect on the ADHD symptoms, they do not have a consistent impact on the anxiety disorder [Barkley: 2014] [Golubchik: 2014], or worsen the anxiety symptoms. [Barkley: 2014] In this population, it becomes especially important to monitor for signs of agitation/activation and increased sleep difficulties when starting a stimulant. However, some children with ADHD can appear anxious because of their inability to attend to their environment, and may show improvement in these symptoms with treatment of ADHD.

Limited data suggests that concurrent use of a stimulant and a selective serotonin reuptake inhibitor do not show a clear improvement in anxiety symptoms. [Barkley: 2014] Use of atomoxetine appears to have positive effects on both ADHD and anxiety symptoms. [Barkley: 2014] The alpha-2 agonists, although they do not carry indications to treat anxiety, may also provide benefit as adjunctive treatment or when stimulant medications are not tolerated as they decrease hyperarousal and are less likely to cause activation in the patient. More studies are needed to compare single- and multi-drug approaches to treating children with both anxiety and ADHD. The role of behavioral health using recognized interventions such as cognitive behavioral therapy coupled with medications for ADHD and/or anxiety also bears further evaluation. Regardless of which approach is used, the clinician should monitor carefully for improvement or exacerbation of comorbid conditions.


Information & Support

For Professionals

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

Congenital Heart Defects (AHA)
Diagnosis and care information, printable information sheets, and resources for specific congenital heart defects; American Heart Association.

For Parents and Patients


The Child Anxiety Network
Parent-focused information about phobias, specific anxiety disorders in children, and treatment.


Anxiety Disorders and ADHD (HealthyChildren.Org)
Online resource for families about ADHD and anxiety; from the American Academy of Pediatrics.

Anxiety and Depression Association of America
A national nonprofit organization providing information and resources for families and professionals.

Patient Education

Information for Families (AACAP)
Family education for disorders that include anxiety, autism, depression, conduct disorder, oppositional defiant disorder, and more; American Academy of Child & Adolescent Psychiatry.

Helpful Articles

PubMed Search on ADHD and Anxiety Disorders

Ipser JC, Stein DJ, Hawkridge S, Hoppe L.
Pharmacotherapy for anxiety disorders in children and adolescents.
Cochrane Database Syst Rev. 2009(3):CD005170. PubMed abstract

Southammakosane C, Schmitz K.
Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety.
Pediatrics. 2015;136(2):351-9. PubMed abstract

Authors & Reviewers

Initial publication: September 2008; last update/revision: November 2016
Current Authors and Reviewers:
Author: James Ashworth, MD
Reviewer: Mary Steinmann, MD
Authoring history
2015: first version: Jennifer Goldman-Luthy, MD, MRP, FAAPSA; Robyn Nolan, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013.

Barkley R.
Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment.
Fourth ed. New York: Guilford Press; 2014. 9781462517725

Creswell C, Waite P, Cooper PJ.
Assessment and management of anxiety disorders in children and adolescents.
Arch Dis Child. 2014;99(7):674-8. PubMed abstract / Full Text

Golubchik P, Sever J, Weizman A.
Methylphenidate treatment in children with attention deficit hyperactivity disorder and comorbid social phobia.
Int Clin Psychopharmacol. 2014;29(4):212-5. PubMed abstract / Full Text

Ipser JC, Stein DJ, Hawkridge S, Hoppe L.
Pharmacotherapy for anxiety disorders in children and adolescents.
Cochrane Database Syst Rev. 2009(3):CD005170. PubMed abstract

Strawn JR, Welge JA, Wehry AM, Keeshin B, Rynn MA.
Efficacy and tolerability of antidepressants in pediatric anxiety disorders: a systematic review and meta-analysis .
Depress Anxiety. 2014. PubMed abstract