ADHD + Anxiety: Recognizing and Managing Dual Diagnoses

Difficulty focusing, racing thoughts, emotional overwhelm, and constant worry are some of the most common reasons families and adults seek mental health care. What makes these symptoms especially challenging is that they can point to more than one diagnosis. Attention-Deficit/Hyperactivity Disorder (ADHD) and anxiety disorders frequently overlap, and when they do, the impact on daily life is often greater than either condition alone.

Research consistently shows that 25-50% of children and adolescents with ADHD also meet criteria for an anxiety disorder, with similar patterns seen in adults [1][2]. This combination is associated with more academic difficulties, greater social stress, and higher emotional burden. Understanding how these conditions interact, and how psychiatric providers approach treatment, is essential for choosing care that actually helps.

Why ADHD and Anxiety Are So Common Together

ADHD is defined by persistent patterns of inattention, hyperactivity, and impulsivity, while anxiety disorders involve excessive fear, worry, and avoidance. Although they are distinct diagnoses, they share several overlapping features, including restlessness, difficulty concentrating, irritability, and sleep disruption. Because of this, one condition can easily obscure the other.

Importantly, the relationship is often bidirectional. Untreated ADHD can create repeated experiences of failure or conflict at school, work, or home, which may lead to chronic anxiety over time. Conversely, untreated anxiety can significantly impair attention and executive functioning, making ADHD symptoms appear more severe. Studies show that individuals with both conditions experience greater functional impairment across home, school, peer, and community settings than those with ADHD or anxiety alone [1][3].

The Importance of Careful Assessment

Accurate diagnosis is the foundation of effective treatment, particularly when symptoms overlap. Clinical guidelines emphasize that evaluation should focus not only on symptom checklists but also on how symptoms interfere with daily functioning across multiple domains [3][4].

Psychiatric providers typically rely on a combination of clinical interviews, standardized rating scales, and collateral information from parents, caregivers, or partners. This comprehensive approach helps determine which condition is currently more impairing, a key step that guides treatment planning. Importantly, the primary target of treatment may shift over time as symptoms improve or change [4].

Deciding What to Treat First

When ADHD and anxiety occur together, treatment is rarely one-size-fits-all. The Society for Developmental and Behavioral Pediatrics recommends a stepwise, parsimonious approach, starting with the condition that causes the greatest functional impairment and avoiding unnecessary polypharmacy whenever possible [3][4].

For some individuals, inattention and impulsivity are the main drivers of distress, even if anxiety is also present. For others, avoidance, excessive worry, or panic symptoms are the primary barriers to functioning. Addressing the most impairing condition first often leads to meaningful improvement in overall symptoms and clarifies what additional treatment is needed.

When ADHD Is the Primary Driver

Stimulant medications remain the first-line treatment for ADHD, including in individuals with comorbid anxiety [4][5]. A common concern among families is that stimulants will worsen anxiety symptoms. However, multiple reviews and clinical guidelines indicate that stimulants generally do not exacerbate anxiety and may actually reduce it by improving attention, emotional regulation, and daily functioning [4][6].

As ADHD symptoms improve, anxiety related to academic performance, work demands, or organizational difficulties often diminishes. This pattern supports the idea that, in many cases, anxiety is secondary to unmanaged ADHD rather than a contraindication to stimulant treatment.

For individuals who do not tolerate stimulants or whose anxiety remains prominent, atomoxetine offers an alternative. Evidence suggests that atomoxetine can improve both ADHD and anxiety symptoms, making it a useful option in select cases [1][5].

Behavioral interventions also play an important supportive role. Research indicates that children with ADHD and comorbid anxiety may respond particularly well to structured behavioral approaches, sometimes even more favorably than children with ADHD alone [4]. While Remedy Psychiatry focuses on medication management, collaboration with behavioral supports can enhance overall outcomes.

When Anxiety Is More Impairing

When anxiety symptoms are the primary source of impairment, cognitive-behavioral therapy (CBT) is generally recommended as the initial treatment [3][4]. CBT, particularly when it includes exposure-based techniques, has strong evidence for reducing anxiety symptoms – even in individuals who also have ADHD.

Importantly, having ADHD does not appear to reduce the effectiveness of CBT for anxiety. Studies show that neither ADHD diagnosis nor subtype predicts poorer response to anxiety-focused CBT [7]. This finding reassures families that anxiety can be effectively treated even when attention difficulties are present.

If anxiety remains moderate to severe despite therapy, selective serotonin reuptake inhibitors (SSRIs) may be introduced while continuing CBT. Reviews of pharmacologic treatment indicate that SSRIs can be safely combined with ADHD medications when clinically indicated, provided careful monitoring is in place [5].

Treating Both Conditions Over Time

In real-world care, many individuals with ADHD and anxiety ultimately benefit from combined or sequential treatment. Evidence suggests that combined behavioral and stimulant treatment may lead to greater improvement in internalizing symptoms than behavioral treatment alone [4]. For individuals with moderate to severe anxiety, SSRIs can be added to stimulant regimens when symptoms persist [5].

Integrated treatment approaches are also emerging. Research on combined protocols that incorporate parent management training for ADHD alongside family-based CBT for anxiety shows promising improvements in both symptom domains [8]. These findings reinforce the idea that treatment focus may evolve over time, shifting from ADHD to anxiety, or vice versa, as impairment changes [4].

When to Seek a Psychiatric Evaluation

A psychiatric evaluation may be helpful if you experience persistent difficulty with focus, organization, or impulse control alongside excessive worry, avoidance, or emotional distress. Symptoms that interfere with school, work, or relationships across multiple settings are especially important to address early. Timely, accurate diagnosis can reduce long-term academic, occupational, and emotional consequences and help families feel more confident about next steps.

Accessing Telepsychiatry in California

Telepsychiatry offers a practical way to access psychiatric care without long wait times or travel. Through secure virtual visits, psychiatric providers can evaluate symptoms, prescribe and adjust medications, and monitor progress over time.

Remedy Psychiatry provides evidence-based medication management via telehealth across California. You can learn more about available treatment services here, review accepted insurance plans here, or explore common questions in the FAQs here.

If you’re ready to take the next step, you can book a same-week telepsychiatry appointment in California here.

Disclaimer: This article is for educational purposes only and does not constitute medical advice. Treatment decisions should always be made in consultation with a qualified psychiatric provider.