In Children With ADHD, Anxiety Usually Has a Specific Cause

What the research found

Specific phobia is a fear fastened to one definite thing, such as dogs, needles, the dark, or being sick. It has an object, and the child can usually name the object. Among children with ADHD at one Turkish clinic, it was the most common anxiety diagnosis by a wide margin.

Yusuf Yasin Gumus, Nursu Cakin Memik and Belma Agaoglu assessed 170 children and adolescents aged six to sixteen, all newly diagnosed with ADHD and none yet treated, at the child and adolescent psychiatry outpatient clinic of Kocaeli University in Turkey. The interviews ran from January to July 2010, and the results appeared in Archives of Neuropsychiatry in 2015. Thirty-three of the children were girls and 137 were boys, with a mean age of nine.

An anxiety disorder of some kind was present in 47 of the 170, or 27.6 percent. Specific phobia accounted for 24 of those cases, 14.2 percent of the whole sample, and separation anxiety disorder for 13, or 7.6 percent. Generalized anxiety disorder reached only 6 children, 3.6 percent. That is the diffuse kind, the worry that moves from one subject to the next without fastening to any of them.

The remaining diagnoses were sparse. Seven children had an anxiety disorder the clinicians could not place in a category, five had social anxiety disorder, and four had obsessive compulsive disorder. Most of the anxious children carried a single diagnosis; 36 of the 47 had one, 10 had two, and one child had three.

Whether a child was anxious made no visible difference to how severe the ADHD looked. Mothers, fathers and teachers rated every child on a standard DSM-based symptom scale, and the anxious children were indistinguishable from the rest on all three sets of ratings. Mother-rated totals were 44.5 for the anxious group and 43.2 for the others, a gap well inside the range of chance.

Anxiety comorbidity did not differ significantly across the ADHD subtypes, which in this sample were almost half inattentive and almost half combined. The sample came from a single clinic with no comparison group, which means the 27.6 percent describes these children and cannot be read as a rate for children with ADHD in general. Within this clinic, a child with an anxiety disorder and a child without one presented with the same ADHD.

What it means for you and your child

A fear with an object can be described, and a description is what a clinic can act on. The child who will not go upstairs alone, or who stands rigid at the school gate each morning through an entire year, is showing something with a name in the diagnostic manual and a literature behind it. In this sample, that was the usual form the anxiety took.

Parents often arrive expecting the worry to be general, a feature of temperament. These findings point to something narrower and more concrete, which is fortunate, because a fear that can be pointed at can also be asked about directly.

Girls in the sample had anxiety disorders more often than boys, 39.4 percent against 24.8 percent, though with only 33 girls the difference did not reach statistical significance, and it stands as a hint awaiting a larger study. One sex difference did hold. Generalized anxiety disorder was diagnosed in 4 of the 33 girls and in 2 of the 137 boys, a gap wide enough to survive testing.

The authors note that their sample was young, and since anxiety becomes more common through adolescence, the figure for older children stands above this one. What a single assessment at diagnosis cannot supply is an order of arrival, so ADHD giving rise to fear, fear producing the inattention that resembles ADHD, and some third factor driving both all remain open possibilities.

The symptom scales used to assess ADHD ask about attention, activity and impulse, and a child’s fears sit outside their range entirely. This study cannot show that anxiety is being missed in ordinary practice, and to say so would be an inference beyond its evidence, but it does establish that the ADHD ratings ran level whether a child had an anxiety disorder or not.

That gives a parent something exact to say at the next appointment or school meeting. His ADHD scores look like everyone else’s here, and he has not slept in his own room since March. Can we assess separately for a specific anxiety disorder, and record which one? You are the person in that room who has seen the fear.