It is well established that there are increasing numbers of children struggling with attention problems, particularly in the school setting. Approximately 11% of school-age children in the United States are now diagnosed and/or medically treated for attention problems.
When a child is having difficulty paying attention, particularly in school, the assumption is generally that they have attention deficit hyperactivity disorder (ADHD). This diagnosis is often given with very little assessment of the child’s needs and challenges, and medication is often given without thorough evaluation of the root causes of attention problems. One of the common misdiagnosis issues I see in clinical practice is children receiving a diagnosis of ADHD when the real problem is anxiety.
Anxiety is the most common cause of childhood emotional and behavioral issues. Approximately 13% of children experience some type of anxiety disorder. Inattention is a common symptom of children with anxiety, particularly in the school environment. Children with anxiety can appear to be inattentive, distracted, or daydreaming because their minds are so consumed with worry, compulsions, and anxious thoughts that they don’t have any mental concentration capacity left for schoolwork. Anxiety can also cause physical restlessness that can be misinterpreted as hyperactivity. As children become more anxious they may be impulsive or irrational in their thoughts and behaviors.
It can be difficult to tell the difference between attention difficulties driven by anxiety and those that stem from the executive function issues associated with ADHD. Here are some signs that anxiety may be the root cause of attention problems:
• The child’s attention difficulties are situational. Anxiety-driven attention problems tend to show up in a specific environment or in specific types of situations. Children with general inattention tend to exhibit this problem across all environments and situations.
• The child tends to have frequent physical (somatic) complaints such as headaches and stomach pains.
• The child tends to favor familiarity, structure, and routines; and can become upset or shy away from unstructured or unfamiliar situations.
• The child has fears about specific issues such as being separated from a parent, falling asleep alone, what other children think of him/her, or failing an assignment.
• The child hyper-focuses on specific aspects of tasks or assignments, such as making sure penmanship or answers are “perfect” before turning something in.
• There is a recent history of significant family issues such as parental separation/divorce, death of a loved one, a move to a new home/school, etc.
• The child has a history of trauma or abuse.
• There is family history of anxiety symptoms or diagnosed anxiety disorders.
Some children experience symptoms of anxiety and ADHD in combination. It is estimated that up to 25% of children with ADHD also have co-occurring anxiety. Both issues need to be properly evaluated and specific treatments for each issue are necessary to support the child’s functioning. It is important to know that stimulant medications commonly prescribed for attention problems can significantly worsen anxiety symptoms. Therefore, if a child has both ADHD and anxiety disorder care needs to be taken to utilize treatments that do not exacerbate other symptoms.
When a child is inattentive in the classroom, care needs to be taken to fully investigate the underlying reasons for this behavior. Quickly jumping to the conclusion that ADHD is the problem can lead to misdiagnosis and inappropriate treatment. If anxiety is the cause of inattention then no amount of stimulant medication or other traditional ADHD treatment approaches will be successful. Specific treatment for anxiety, such as cognitive behavior therapy, relaxation training, and neurofeedback, is needed in order to reduce the worry and improve focus. Parents should seek out professionals who are able to thoroughly evaluate potential root causes of attention problems in order to ensure appropriate treatment.