- Cynthia Yoo
Anxiety & ADHD - The Big Overlap and How To Tell the Difference
There is an excellent article explaining how anxiety and ADHD overlap in terms of symptoms. It explains how they can look the same and how to tell them apart. I have copied the article Anxiety or ADHD? Why They Sometimes Look the Same and How to Tell the Difference here for your easy reference. All credit for the article is owed to Karen Young.
Anxiety and ADHD are very different, but sometimes the symptoms can look similar. The correct diagnosis is critical to guide treatment and to make sense of things when kids seem to be struggling or when something doesn’t feel quite right. As much as the right diagnosis can heal, the wrong one can also harm. Understanding how anxiety might look like ADHD, and the telltale differences between the two, can make an important difference in avoiding a misdiagnosis, and helping kids deal with the symptoms that might be getting in their way.
ADHD is one of the most diagnosed childhood conditions, and it seems to be increasing. The Centre for Disease Control reports that 11% of children between 4-17 have been diagnosed with ADHD at some point in their lives. Reports suggest that about 8% currently have ADHD and about 6% are taking medication. The prescription of medications for ADHD has increased by 800% in the last two decades.
ADHD has been the firestarter for plenty of hearty debate, with some questioning whether or not it actually exists. Let’s start by putting that argument to bed, or somewhere less cosy and far away so it won’t find its way back. ADHD absolutely does exist, and there are pictures to prove it. Brain imaging shows definite differences between a brain with ADHD and a brain without.
Researchers don’t know exactly what causes ADHD, but they know for certain that it’s is a neurobiological condition. It has nothing to do with bad behaviour, bad parenting, too much sugar, not enough sleep, fairy dust, wearing too much yellow – or whatever other crazy theories are out there. Fortunately, these theories have been debunked, which means now researchers can get on with finding out what’s really going on, which they are.
Perhaps something that has given buoyancy to the ‘does it exist or doesn’t it’ debate is the overdiagnosis of ADHD, or the misdiagnosis of symptoms that look like ADHD. A major problem facing doctors and clinicians is that there is currently no widely available objective physiological assessment for the presence of ADHD. At the moment, brain imaging can’t be used for diagnosis, but researchers are working on developing a more accurate and objective diagnosis tool.
In the meantime, diagnosis relies on reports of the child’s behaviour from two different environments, typically school (from teachers) and home (from parents). If your child seems to struggle at school but seems fine at home, it’s not ADHD, and vice versa. Diagnosis of ADHD is based on a list of 18 possible symptoms, all of which exist on a spectrum, and all of which could apply to any child at some point in time. The 18 symptoms are divided into two clusters with nine symptoms in each cluster (‘inattentive’ and ‘hyperactivity/impulsivity’ cluster). A formal diagnosis of ADHD comes down to a question of degree. To be diagnosed, a child has to have most of the symptoms from both clusters (combined inattentive and hyperactivity/impulsivity) or one of the clusters (predominantly inattentive or predominantly hyperactive) most of the time, and they have to intrude significantly into day-to-day life.
Studies that have looked at the way ADHD is assessed by clinicians have found that a large majority of practicing clinicians did not regularly follow assessment procedures that are in line with best practice guidelines. One of these guidelines is to use multiple methods to diagnose but only 15% of clinicians reported doing this.
Research has also found that the youngest children in a year level are more likely to be diagnosed with ADHD and medicated than older children in the year level. Interestingly, this trend is only found with preschool and primary school (elementary) age children, not adolescents. Researchers suggest this may be because younger children, because of their age and stage of development, don’t quite yet have the neurocognitive development of their older classmates and may wrongly be diagnosed with ADHD.
Without a reliable objective measure of ADHD, there will inevitably be times when a cluster of behaviours in a child is labeled as ADHD, but isn’t. The key symptoms of ADHD – inattention, distraction, fidgeting, problems at school, problems focusing – don’t automatically mean ADHD. They can indicate several other conditions, one of which is anxiety.
The problem with misdiagnosis.
No parents wants their child to be diagnosed with ADHD. Understandably though, it can be a massive relief when there is finally an explanation for behaviours that don’t seem to make sense, or which are causing problems at school, at home and with friendships.
Having a correct diagnosis is vital. It can bring clarity and guide the management of symptoms in ways that see important parts of a child’s life (relationships, academics, behaviour, self-esteem) improving significantly. But as much as a diagnosis can heal, it can also harm. When a child is misdiagnosed, the fallout can be immense. Not only might the child be exposed to unnecessary medication, but the wrong diagnosis can mean that the child isn’t receiving the support or treatment that actually would help their symptoms.
Misdiagnosis can set a path for treatment that is unhelpful or detrimental, and it runs the risk of overlooking the true cause of any difficulties the child is having. Labeling a child with the wrong diagnosis also has the potential to shrink the expectations of teachers or other adults as to what that child is capable of. Children will live up to expectations or down to them. They’ll look to the important adults in their lives for clues about how hard they should try, and whether the reach is in them.
But then there’s the overlap.
The overlap between the symptoms of ADHD and other conditions can also add to the potential for misdiagnosis. As many as 75% of children with ADHD meet the criteria for another diagnosis. About a third of children who have ADHD will also have clinical levels of anxiety. The presence of anxiety seems to be related to more severe ADHD, so it’s massively important that the diagnostic process is open to this. If anxiety is present, it’s vital that it is given the attention it needs, and not overlooked or treated as part of the ADHD.
The Masquerade – When anxiety looks like ADHD.
Anxiety and ADHD are very different, but the symptoms can sometimes look similar. This is because both have symptoms are driven by changes in the pre-frontal cortex BUT the nature of those changes and the processes behind those changes are different. With anxiety, the symptoms are brought about by the fight or flight response. This response can be enduring and intense, and it can happen even when there is no threat and no real need for fight or flight. With ADHD, the symptoms are brought about by structural, functional and chemical changes in the brain.
When there are changes in activity in the prefrontal cortex, as happens during anxiety and ADHD, symptoms can include inattention and distraction; impulsivity and hyperactivity; and difficulty controlling emotions, impulses and habits.
But if the symptoms are the same, does it matter how it’s treated?
Yes. Yes. Yes. It matters. The symptoms aren’t the problem. The condition driving the symptoms is the problem. Understanding whether it’s ADHD, anxiety, or both is the first and most important step in making sure your little person is getting what he or she needs to move forward. Although both anxiety and ADHD are manageable, they need different types of support to improve.
ADHD is generally treated with medication that boosts the necessary neurochemicals and stimulates the parts of the brain that need to work a little harder. This may be effective for ADHD, but if the symptoms are being driven by anxiety, the use of ADHD medication is massively heavy-handed and fails miserably to give the child the skills or resources needed to best manage the symptoms. Even if anxiety and ADHD are happening together, it’s important to also treat the anxiety as a separate condition. A growing body of highly regarded research is showing that mindfulness and exercise are both powerful ways to do this.
If the symptoms are from ADHD, what’s driving them?
An ever-increasing body of research has found that there are widespread structural and functional, electrical and neurochemical differences in the brains of children with ADHD. Researchers aren’t exactly sure what causes these changes, but there’s a lot of research happening in the area to get us closer to the answers.
The changes are particularly in the areas of executive functioning (planning, organising, concentration, impulse control, focusing attention, remembering instructions, inhibition, self-control) and sensorimotor processing (using the information that we receive through our senses, to produce an effective motor response).
The frontal cortex and other parts of the brain are smaller in children with ADHD. Size makes no difference at all when it comes to intelligence, and many kids with ADHD will have above average IQ’s. What it does affect is behaviour. An ADHD brain is powerful, intelligent, and very capable, but it’s not able to filter the ‘noise’ from the relevant information coming in. A brain with ADHD is like a beautiful, high-powered, high performing sports car, but without any brakes.
In any brain, the different parts interact with each to form different networks that control processes such as behaviour, movement and attention. These networks are like a symphony – they increase in activity or decrease in activity depending on what we are doing. For a brain to do what it needs to do effectively, the networks need to work together and increase activity or decrease activity just enough to make things happen. When we are trying to learn something, for example, the networks that process information increase in activity, while at the same time the networks involved in daydreaming decrease in activity. In a child with ADHD, some networks switch on too much and some don’t switch on enough. When this happens, they may struggle with tasks or behaviour.
Many people seem to grow out of ADHD, and there seems to be a good reason for this. Research suggests that with ADHD, the brain is delayed in some areas by about three years. It still develops in a normal pattern, but some areas will take a little longer. Eventually, the functioning in these areas catches up, which is when the symptoms of ADHD seem to lessen or disappear.
And if the symptoms are from anxiety?
Anxiety comes from a part of the brain called the amygdala. It’s a tiny almond-shaped part at the back of the brain and its job is to keep us safe by warning us when there might be danger. When the amygdala senses threat, the brain immediately switches to auto-pilot and initiates the fight or flight response. It hands the bulk of the workload to the more primitive, instinctive, impulsive lower brain (at the back of the brain). At the same time it organises for the pre-frontal cortex to sit out for a while until the threat has passed. When this happens, behaviour becomes less planned, more instinctive, and more impulsive.
There’s a very good reason for sending the pre-frontal cortex offline when there’s an immediate threat. The amygdala doesn’t want the pre-frontal cortex to use valuable survival time thinking, planning, deciding – it just wants to get you safe. If there’s a wild dog with gnarly teeth running at you, there’s no time to think about whether it might be lost, angry, hungry or misunderstood, or to imagine how cute it would be if it was wearing one of those cute dog jackets that all the cool dogs are wearing. Your brain just wants you out of there – fast.
It’s important to remember that the fight or flight response doesn’t only happen when there’s a threat. For kids with anxiety, it can feel constant. Sometimes, the amygdala gets a little too overprotective and initiates the fight or flight response too many times, too unnecessarily – just in case. It’s evidence of a strong, healthy brain switching into survival mode, but just a little more than it needs to. That’s evolution for you … sometimes it gives us opposing thumbs, and sometimes it gives us anxiety.
Anxiety, ADHD and the look-alike symptoms.
Even though the symptoms of ADHD and anxiety might look the same, they will be driven by different processes. It’s also important to remember that not all ADHD looks the same and not all anxiety looks the same, but there are versions of both that can look similar. Let’s go through the symptoms:
Difficulty in class, makes careless mistakes, distraction, inattentiveness, restless, difficulty focusing/ planning.
If it’s caused by anxiety: When anxiety hits in class, it can shut down the pre-frontal cortex, the part of the brain that is important for thinking, learning and remembering. Anxiety is all about protecting you from threat, so the brain shuts down to detail. Instead, it becomes focussed on staying safe. Anxiety can make kids so distracted by worrying thoughts, that they are unable to apply themselves to whatever they are working on. This can make kids appear restless, distracted and make it difficult to focus, retain information or pay attention. When kids are highly anxious, their thoughts are consumed with their worries. They might have trouble writing, sitting still, staying focussed or copying from the board. They might also be reluctant to ask questions or ask for guidance.
If it’s caused by ADHD: With ADHD, the symptoms are thought to be because in the prefrontal cortex, the levels of the neurotransmitters norepinephrine and dopamine, aren’t quite what they need to be. Neurotransmitters are the chemicals in the brain that help brain cells communicate with each other. Everything we do depends on the levels of these neurotransmitters being at the right levels. Even the smallest changes in norepinephrine and dopamine levels can have a big effect on the capacity of the prefrontal cortex to do its job effectively. Norepinephrine increases the signals for appropriate response. Dopamine decreases any irrelevant ‘noise’ that might get in the way. When the levels of these neurotransmitters are out, kids can have difficulty ignoring irrelevant stimuli. It’s not that they are unable to pay attention, it’s that they are paying it to different things, or too many things at once.
Hyperactivity, fidgeting, squirming, talking or moving too much, extra movement when doing simple tasks.
If it’s anxiety: When the brain feels there might be a threat, it surges the body with neurochemicals to ready the body for fight or flight. The idea is to get the body faster, stronger and more powerful so it can fight or flee the danger. If there is no need for fight or flight, these neurochemicals build up. The energy created has to go somewhere. Sometimes this can look like ‘too much movement’, such as fidgeting, foot tapping, wringing hands, or pacing.
If it’s ADHD: The part of the brain that puts the brakes on behaviour is a little slower to activate, meaning there aren’t enough messages instructing the body to stop or slow down.
If it’s anxiety: When the sensations of fear or anxiety are strong, the surging of fight or flight chemicals sends the pre-frontal cortex (the seat of self-control) offline. The impulsive, instinctive amygdala takes charge. When this happens, the prefrontal cortex isn’t available to help calm big feelings or plan a more considered, less impulsive response. When the anxiety passes, the pre-frontal cortex will take charge again and guide healthier responses. Impulsive behaviour can also look like aggression, which is the ‘fight’ part of the fight or flight response. Anxiety and big emotions come from the same part of the brain so when anxiety is on full volume, other emotions, such as anger might also be switched up to high. Something else to be mindful of is that being silly, which can sometimes look like impulsive behaviour, might be used as a mask by kids to cover up their anxiety or nervousness.
If it’s ADHD: Differences in the parts of the brain that manage self-control mean that behaviour might be more impulsive. This isn’t because of bad behaviour, but because of a brain that’s not quite doing what it needs to.
Not able to finish schoolwork, poor time management.
If it’s anxiety: Kids with anxiety might have trouble completing their schoolwork. Anxiety can cause kids to worry about making mistakes. Because of this, they might do things over and over, or take plenty of time to make sure their work is right or as close to perfect as it can be. It’s more about the need to produce perfect, mistake-free work than about ability, failure to focus or failure to plan.
If it’s ADHD: Kids with ADHD are unable to keep their attention on a task, most likely because of an ability to manage impulses or to shut out irrelevant distractions. Because of the regular shifts in focus, the work doesn’t get completed.
Difficulty organising tasks and activities and managing sequential tasks, disorganised work.
If it’s anxiety: The left brain loves logic and sequences, and it helps to give structure and order to our experiences (‘this, then this, then this …’). The right brain is more concerned with emotion and the big picture of ‘what does this mean for me?’. It’s heavily directed by sensations in the body and messages from the lower brain, which is the major player in anxiety. We need both sides of the brain to work well together, but sometimes in all of us, one side will become dominant for a little while. If a child is feeling anxious in class or in relation to a specific task, the right ’emotional’ brain can take over and temporarily disconnect from the left side. While the anxiety is high, there will be higher emotion and a greater focus on ‘what does this situation mean for me’, and less concern for order or logic.
If it’s ADHD: Insufficient levels of neurochemicals make it difficult for the brain to screen out irrelevant stimuli. There’s too much irrelevant information coming in and creating noise. This means that however hard kids with ADHD try to organise their work and do what’s expected, their busy brains will make organisation difficult.
Anxiety or ADHD? How can I tell the difference?
If you suspect ADHD, it’s really important to get a proper assessment from someone who is qualified to diagnose. Be mindful that many of the symptoms we’ve discussed might always point louder to ADHD than anxiety. In some instances, it may be that both anxiety and ADHD are driving behaviour. Whatever’s happening, getting to the bottom of it is the most important step in getting your child the support they need to push forward.
Because a diagnosis of ADHD depends on observation and interpretation of the behaviours, be open to the possibility that if you go to an ‘ADHD specialist’ or a doctor who specialises in ADHD, they may be more likely to read the symptoms as ADHD. Certainly they can be an important and wonderful support for kids with ADHD, but always be ready to seek a second opinion if that’s what you need for clarity. Ask as many questions as you need to ask and remember, you are the expert on your child. If something doesn’t feel right, keep chasing it down until things make sense to you.
Here are some clues that the symptoms might be more indicative of anxiety (or perhaps anxiety and ADHD) than ADHD.
Kids with anxiety are generally more sensitive to social cues, and to what other people are thinking and feeling, or what they need.
Anxiety can create physical symptoms such as a racy heart, clamminess, tense muscles, tummy aches, headaches, nausea, or dizziness. This is the physiological basis of anxiety. When the neurochemicals that are there to ready you for fight or flight build up, they lead to physical symptoms. These symptoms feel awful, but if they are driven by anxiety they are all completely safe.
Children with anxiety don’t tend to have as many problems with impulsivity. Their impulsive behaviour generally happens in isolated bursts when they are anxious, and is less likely to happen when they are feeling calm and safe.
Children with anxiety will be unlikely to show problem behaviours when they are feeling calm, safe, and doing things they enjoy. Children with ADHD might struggle even when they are doing the things they want to be doing.
Children with anxiety are more likely to talk about feeling worried, even if they can’t articulate exactly what they are worried about. This is because anxiety comes from a brain that thinks there might be a threat, not necessarily because there actually is one.
And finally …
The importance of a correct diagnosis is so important to make sure that kids with ADHD receive the best possible support to manage the symptoms and limit the intrusion into their day-to-day lives. You will always be the expert on your child, and you’re their voice when something doesn’t feel right. There will be times when you’ll need other experts on your team, but for certain, the glue that will hold it all together will be you – your questions, your questioning, your answers, your second opinions – whatever it takes for things to make sense.
All kids need a support crew, made up of the adults around them who are ready to help lift them to full flight. The support crew will look different for every child, but will likely involve family, teachers, coaches and sometimes therapists, specialists and doctors. ADHD can be tricky to diagnose, but there are many wonderful clinicians out there who, with you by their side, will be able to widen your child’s opportunity to be the very best that he or she can be.
*Again, this article is written by Karen Young and can be found here.