How Do ADHD and Anxiety Symptoms Influence Each Other During Adolescence?

What you need to know

• ADHD and anxiety symptoms influence each other reciprocally during adolescence
• Higher ADHD symptoms at ages 13 and 15 predicted higher anxiety symptoms at ages 15 and 17
• Higher anxiety symptoms at age 15 predicted higher ADHD symptoms at age 17
• Monitoring and addressing both ADHD and anxiety symptoms in adolescents may help reduce overall symptom burden

The Connection Between ADHD and Anxiety

Attention-deficit/hyperactivity disorder (ADHD) and anxiety frequently occur together, but the reasons for this co-occurrence are not well understood. This study aimed to examine how ADHD and anxiety symptoms influence each other over time during adolescence. Understanding these developmental relationships can provide valuable insights for clinicians and families navigating these commonly co-occurring conditions.

ADHD is characterized by persistent inattention and/or hyperactivity-impulsivity that interferes with functioning. Anxiety involves excessive worry and fear. While they are distinct conditions, about 25% of children and 50% of adults with ADHD also meet criteria for an anxiety disorder. When looking at symptom levels rather than diagnoses, ADHD and anxiety show moderate correlations.

Despite recognition that anxiety commonly co-occurs with ADHD, there has been limited research on explaining the links between them, particularly from a developmental perspective. It has been unclear whether ADHD symptoms tend to lead to anxiety, anxiety leads to ADHD symptoms, or if the relationship is bidirectional. Adolescence may be a particularly important period to examine, as life demands increase and concerns about peer relationships, academic performance, and other outcomes associated with ADHD may intensify.

Examining Developmental Relationships

This study used data from 1,483 community-based adolescents in Zurich, Switzerland, who were assessed at ages 13, 15, and 17. The researchers measured ADHD and anxiety symptoms using brief self-report questionnaires. To examine how the symptoms influenced each other over time, they used a statistical technique called an autoregressive latent trajectory model with structured residuals (ALT-SR).

This approach allowed them to look at within-person effects - how changes in an individual’s symptoms in one domain (e.g. ADHD) related to changes in their symptoms in the other domain (e.g. anxiety). This is different from between-person effects, which compare symptom levels across different individuals. The within-person approach provides clearer information about how symptoms may influence each other at an individual level.

Key Findings on Symptom Relationships

The results revealed reciprocal relationships between ADHD and anxiety symptoms during adolescence:

• Higher ADHD symptoms at age 13 predicted higher anxiety symptoms at age 15
• Higher ADHD symptoms at age 15 predicted higher anxiety symptoms at age 17
• Higher anxiety symptoms at age 15 predicted higher ADHD symptoms at age 17

This suggests that ADHD and anxiety symptoms can mutually influence and reinforce each other over time within individuals. The relationship appears to strengthen in later adolescence, with anxiety symptoms beginning to predict subsequent ADHD symptoms.

Potential Explanations for ADHD Leading to Anxiety

There are several reasons why ADHD symptoms earlier in adolescence may contribute to later anxiety:

• Academic difficulties: Struggles with schoolwork and grades due to ADHD may create stress and worry.
• Social challenges: ADHD can impact peer relationships, potentially leading to social anxiety.
• Negative feedback: Frequent criticism or correction related to ADHD behaviors may erode self-esteem.
• Risky behaviors: Impulsivity in ADHD can lead to dangerous situations that create anxiety.
• Disorganization: Feeling overwhelmed by disorganization and forgetfulness may increase anxiety.

Some research has found that treating ADHD can lead to improvements in anxiety symptoms, lending support to this directional relationship. However, the exact mechanisms require further study.

How Anxiety May Influence ADHD Symptoms

The finding that anxiety symptoms predicted later ADHD symptoms in older adolescents is a newer insight. Some potential explanations include:

• Cognitive interference: Worry and anxious thoughts may further impair attention and concentration.
• Restlessness: Physical tension and agitation from anxiety could manifest as hyperactivity.
• Avoidance: Anxiety may lead to avoidance of challenging tasks, exacerbating attention difficulties.
• Sleep disruption: Anxiety often interferes with sleep, which can worsen ADHD symptoms.

More research is needed to clarify the specific pathways by which anxiety may exacerbate or maintain ADHD symptoms over time.

Implications for Assessment and Treatment

These findings have several important clinical implications:

1. When adolescents present with anxiety, clinicians should assess for underlying ADHD symptoms that may be contributing.

2. For adolescents with ADHD, ongoing monitoring of anxiety symptoms is warranted, with early intervention if anxiety emerges.

3. Treating ADHD symptoms may help prevent the development of secondary anxiety.

4. Addressing anxiety symptoms in adolescents with ADHD may improve overall functioning and reduce ADHD symptom severity.

5. Integrated treatments targeting both ADHD and anxiety concurrently may be beneficial, particularly in later adolescence when the bidirectional relationship appears stronger.

6. Prevention programs could focus on building coping skills for both ADHD and anxiety symptoms in early adolescence.

The reciprocal relationship also highlights that symptom trajectories and severity may fluctuate over time. An adolescent’s primary area of difficulty may shift between ADHD and anxiety symptoms across development.

Gender Considerations

The study found that females showed higher levels of anxiety symptoms and slightly higher levels of ADHD symptoms compared to males. Previous research has suggested that ADHD-anxiety comorbidity may be especially common in females. Clinicians should be aware that ADHD symptoms in females may sometimes be mistaken for or obscured by anxiety. Careful assessment of both symptom domains is important regardless of gender.

Limitations and Future Directions

While this study provides valuable insights into ADHD-anxiety symptom relationships in adolescence, some limitations should be noted:

• The measures of ADHD and anxiety were brief self-report scales rather than comprehensive clinical assessments.
• The sample was from a single geographic region, so findings may not generalize to all populations.
• The study focused on adolescence, but examining these relationships from childhood through adulthood would provide a fuller lifespan picture.

Future research could:

• Use more detailed measures to look at relationships between specific ADHD and anxiety subtypes or symptom clusters
• Explore potential mediators of the ADHD-anxiety relationship, like emotion regulation, peer problems, or academic difficulties
• Examine how other commonly co-occurring issues like depression interact with ADHD and anxiety symptoms over time
• Investigate which treatments are most effective for adolescents experiencing both ADHD and anxiety symptoms

Conclusions

• ADHD and anxiety symptoms show reciprocal developmental relationships during adolescence
• Higher ADHD symptoms predict later increases in anxiety symptoms throughout adolescence
• Higher anxiety symptoms predict increases in ADHD symptoms in later adolescence
• Assessing and monitoring both ADHD and anxiety symptoms is important for comprehensive adolescent mental health care
• Integrated approaches addressing both ADHD and anxiety may be beneficial, especially in mid-to-late adolescence