The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

April 14, 2023

ADHD increases the likelihood of postpartum depression (PPD) and postpartum anxiety in more significant and impactful ways than do other well-established risks like comorbid psychiatric disorders or sociodemographic factors in women, according to a recent study published in the Journal of Affective Disorders. ¹

The research found that 25% of women with ADHD had postpartum anxiety, compared to 4.61% of women without ADHD. In addition, almost 17% of women with ADHD had PPD, compared to 3.3% without ADHD.

“ADHD is an important risk factor for depression and anxiety disorders postpartum,” the researchers wrote. “Therefore, ADHD needs to be considered in maternal care, regardless of sociodemographic factors and other psychiatric disorders.”

Using population-based registers from Sweden, the researchers identified 773,047 women who gave birth to their first or second child between 2005-2013. Of that number, 3,515 had received an ADHD diagnosis before their pregnancy. They also analyzed data on women’s depression and anxiety diagnoses before pregnancy, maternal age at delivery, highest achieved maternal education at childbirth, cohabitation status with their child’s father, and family history of depression and anxiety disorders.

The study found that the risk of PPD and postpartum anxiety was lower for women diagnosed with a psychiatric disorder before pregnancy and those with a history or family history of depression or anxiety. The researchers suggested that women diagnosed before pregnancy with ADHD and depression or ADHD and anxiety may have received greater support and treatment during and after their pregnancies compared to women diagnosed with ADHD alone.

Women with ADHD Become Pregnant Younger

Women diagnosed with ADHD were more likely to have a lower education level and less likely to live with the father of their child compared to women without ADHD, according to the researchers.

The study also reported that women with ADHD gave birth to their first child at a younger age (15–24 years) than did women without ADHD (25–34 years), supporting previous research. A study published in the Journal of Attention Disorders of more than 7,500 adolescents with ADHD and 30,000 adolescents without ADHD in Taiwan found that participants with ADHD became pregnant younger, more frequently, and had a higher risk of early pregnancy than did their neurotypical peers.² A large Danish study published in the Journal of the American Academy of Child & Adolescent Psychiatry reported that girls with ADHD were more than three and a half times as likely as their peers to become pregnant between the ages of 12 and 15.³

“It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD,” said Ellen Littman, Ph.D., in discussing how hormonal fluctuations impact women in the ADDitude webinar titled Why ADHD is Different for Women: Gender Specific Symptoms & Treatments.

In addition, the Swedish study found that 59% of the women diagnosed with ADHD had an additional psychiatric disorder compared to only 5% of the women without ADHD.

“The combination of being diagnosed with ADHD and being pregnant at a young age could increase the vulnerability and therefore the risk of being diagnosed with a psychiatric disorder postpartum, such as depression and anxiety,” researchers wrote. “However, results from the present study also show that women diagnosed with ADHD have an increased risk of depression and anxiety disorders regardless of age. This highlights the importance of health care providers to evaluate women diagnosed with ADHD across the lifespan.”

Postpartum Depression and ADHD

In a recent ADDitude survey of 2,027 women with ADHD, one-third of mothers reported that they experienced PPD, including the following symptoms:

• crying spells: 76%
• feelings of worthlessness, shame, guilt, or inadequacy: 76%
• mood swings: 66%
• irritability: 62%
• lack of concentration: 58%
• sleep problems: 57%
• withdrawing from friends and family 55%
• restlessness 46%
• appetite changes (increase or decrease) 37%
• thoughts of harm to self or others 31%
• other 24%
• extreme mood disorder or psychosis 13%
• self-harm 6%

“My ADHD got significantly worse postpartum,” said a survey respondent. “I felt overwhelmed and was not supported by my husband. He’d say things like, ‘Sarah next door has four children, and she copes. I don’t understand why you can’t even manage to keep things organized when you only have one!’”

“Something in me definitely changed after giving birth,” said an ADDitude reader from Ontario, Canada. “My doctors told me it was ‘anxiety’ and hormones. Although tired and sleep-deprived from the baby, I could not shut down my racing mind. I was constantly irritable, impatient, and a complete space cadet. I did suffer from postpartum depression after the birth of my second child. That is when I looked deeper into the root of my troubles. I have always wondered if I had PPD after my first child, or was my ADHD so out of control that I didn’t even notice?”

ADDitude survey respondents reported that their PPD symptoms lasted:

• 1-3 months 13.14%
• 4-6 months 18.63%
• 7-13 months 21.63%
• 14-24 months 13.63%
• Longer than two years 14.14%

Women Lack Treatment for Postpartum Depression

Almost half of ADDitude survey respondents said their healthcare providers did not offer treatment for their postpartum depression or anxiety.

“The medical community didn’t take baby blues seriously when my children were born,” said one ADDitude reader. “I just ‘needed to exercise, lose the rest of the baby weight, and focus on my family.’ Then I would be all better.”

“No one talked about it, and my doctor never asked how I was doing. So, I assumed I was weak,” said another survey respondent.

One ADDitude reader found the help she needed on her own. “No doctor cared,” she said. “So I self-treated by researching natural treatments and took several supplements that helped.”

According to the ADDitude survey, 41% of respondents received prescriptions for antidepressants, and 20% received therapy for PPD.

“PPD made it hard to get through anything without going into a guilt-depression spiral,” an ADDitude reader said. “It was awful. Antidepressants changed everything so I could function without spiraling or wanting to disappear.”

Postpartum Depression with Undiagnosed ADHD

Many ADDitude readers who experienced postpartum depression or postpartum anxiety were unaware of their ADHD diagnoses at that time.

“I had depression, anxiety, and just went into full paralysis,” an ADDitude reader said. “I didn’t know I had ADHD. I thought I sucked at everything, so I might as well add motherhood to the list.”

“I lost all sense of myself and pretended to cope,” said an ADDitude reader from Edmonton, Canada. “It wasn’t until I was diagnosed and looked back on my pregnancy that I realized how much ADHD and hormones played a role in my lack of coping. I wish I could go back and talk to that frightened, overwhelmed, and so very sad me and let her know there was a reason for it all.”

ADHD and Maternal Care: Next Steps

The Swedish researchers recommended that primary healthcare providers assess women with ADHD for the risk of PPD and postpartum anxiety beginning with the first prenatal visit. In addition, they said, women with ADHD should receive parental education before conception, psychological surveillance during pregnancy, and social support after childbirth.

According to Littman, women should find a doctor who understands the impact of hormones on ADHD and the interplay with medication. “Finding this professional is perhaps the most important and most difficult thing to do,” she said. “Be sure to ask about their experience treating ADHD in women.”

Sources

¹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

²Hua, M.H., Huang, K.L., Hsu, J.W., Bai, Y.M., Su, T.P., Tsai, S.J., and Chen, M.H. (2020). Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study. Journal of Attention Disorders. https://doi.org/10.1177/1087054719900232

³Østergaard, S.D., Dalsgaard, S., Faraone, S., Munk-Olsen, T., and Laursen, T, (2017). Teenage Parenthood and Birth Rates for Individuals with and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study.  Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2017.05.003

When I was young, I felt little connection or fulfillment when children came over for play dates. Playmates would often not return to my home after the first visit. It was likely due to my silent nature and difficulties with reciprocity. I struggled to read nonverbal cues and to practice give-and-take communication. In adolescence, I had a small group of friends but was often excluded from activities outside of school. I was introverted by nature, but despite my social anxiety, I still wanted bonds. I branched out and started over in college.

One day, sophomore year, I was strolling through the student union when a male student at a booth approached me and said, “Would you like to take a free depression screening?” Caught off guard, I shrugged and said, “sure.”

The student indicated afterward that I showed high anxiety markers. He asked if I wanted to work with a student clinician at the university’s psychology clinic for a low-cost fee. I felt like there was little to lose. After all the years of wondering what was “wrong” with me, perhaps I could get answers. I had dreamt of therapy since I was a teenager; I just thought it was a luxury or for people who struggled more severely.

I felt so wonderful just letting it all out during my intake session. I told my clinician about my insecurities about being labeled mousy and shy and being teased due to my passive nature in middle and early high school. I talked about my difficulties with being assertive. I explained how awkward and silent first-time meetings were for me and how I had been labeled “rude” and “standoffish.” I discussed how I never knew what to say when making small talk and how I felt my heartbeat, got sweaty palms, and froze in social situations.

Diagnosis: Social Anxiety

After multiple sessions, my therapist drew some key conclusions: Many things make me anxious, but most of my triggers are social situations. On a scale that measures social anxiety disorder, I scored a 30, which was considered “severe.”

[Get This Free Download: Social Anxiety Facts and Falsehoods]

I met with this clinician for about a year and a half. During our sessions, we practiced exposure therapy, which included role-playing social situations with other clinicians, recording them, and receiving critiques. She also asked me to look for real-world opportunities to initiate contact with people. Every few months, she evaluated my social anxiety score. Eventually, my score fell to a 10; I still met some criteria, but it was much lower.

She didn’t diagnose me as neurodivergent; that came years later. But every day, I am grateful for my wellness journey that began at age 20. I was never seen as a person who struggled immensely in the world. I could get by day to day. But the start of my journey taught me not to settle; I am worth more than just getting by. I deserve fulfillment. I deserve to thrive. I am in a better place than before.

Exposure Therapy Techniques That Worked

Below are examples of exposure therapy exercises I repeated with my therapist. She would tell me that I don’t have to do these things regularly, but knowing I am capable is important.

Journal Prompts

First, write down the following:

• How anxious are you?
• What are your physiological symptoms?
• What thoughts and emotions do you have (e.g., “This person won’t like me”)?
• How can they be challenged?

[Free Webinar: How to Reduce Social Anxiety and Foster Connections”]

Social Activities

1. Go to a restaurant or cafe alone. Don’t bring work; face the fear of others seeing you alone. Goal: Learn to enjoy your own company and to pursue your own interests.
2. Repeat the above, but this time people watch. Observe those around you — their body language, conversation topics, and other patterns.
3. Talk to a service worker, unfamiliar colleague/classmate, or patron (e.g., at a bar, party, restaurant, store, waiting room, etc.). You can start with a compliment, a friendly statement like “you look familiar,” or a question or comment about a product or service. Build off that and continue to talk about other topics. Roleplay with a counselor or friend to ease into this activity, if necessary.
4. Repeat the above, but approach someone you find attractive (I found this to be the hardest!)

Finally, return to your journaling prompts. Rate your anxiety. Then repeat the activities until your anxiety number goes down.

Disclaimer: I am not a healthcare provider; work with one as needed before attempting these activities.

Social Anxiety: Next Steps

• Free Download: Become a Small-Talk Superstar
• Read: The ADHD Guide to Natural Flowing, ‘Normal’ Conversations
• Q: “My Paralyzing Anxiety Tells Me I’m Not Good Enough”
  
• eBook: The ADHD Guide to Making Social Connections

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help

February 21, 2023

Teen girls in the U.S. are “engulfed in a growing wave of sadness, violence and trauma,” according to a report released last week by the Centers for Disease Control and Prevention (CDC) that found alarming increases in rates of rape, depression, suicidality, and cyberbullying among adolescents.¹ “The numbers are unprecedented,” said Kathleen Ethier, director of the CDC’s Division of Adolescent and School Health. “Our young people are in crisis.”

The CDC report echoes findings from a 2022 ADDitude survey of 1,187 caregivers, which found that an astounding 75% of adolescent girls with ADHD also have anxiety, 54% suffer from depression, more than 14% have a sleep disorder, and nearly 12% report an eating disorder — more than three times the national average for neurotypical women.

“The kids are not alright. Not at all,” wrote one ADDitude reader who works as a youth therapist.

[The ADHD Symptom Test for Teen Girls]

The CDC report, based on the most recent Youth Risk Behavior Survey, included a nationally representative sample of students in public and private high schools, and it found that adolescent health risks have ballooned to levels never seen before—especially for girls. Its findings include the following:

• Nearly 60% of teen girls reported persistent feelings of sadness and hopelessness during the past year, double the rate reported 10 years ago, and twice the rate in boys. For LGBTQ+ teens, this number jumped to a startling 70%.
• 1 in 3 of girls seriously considered attempting suicide during the past year, up nearly 60% from a decade ago.
• At least 1 in 10 girls attempted suicide in the past year. Among LGBTQ+ youth, the number was more than 1 in 5.

Girls with combined type ADHD are 3 to 4 times more likely to attempt suicide than are their neurotypical peers, and they are 2.5 times more likely to engage in non-suicidal self-injuring behavior, said Stephen Hinshaw, Ph.D., in an ADDitude webinar titled, “Girls and Women with ADHD.” The 2022 ADDitude survey found that 18% of girls with ADHD had engaged in self-harm in the past two or three years, as opposed to 9% of boys; it did not specifically ask about suicidality, however anecdotal reports from caregivers are both frequent and frightening.

“A few years ago, I would have been shocked by these numbers,” said one mom of a teen daughter recently diagnosed with ADHD. “But in 2021 my girl was admitted to a clinic for suicidal ideation. She is still here and working on her mental health daily.”

Only 6% of caregivers rated their adolescents’ mental health as “very good” in the ADDitude mental health survey. Contributing to elevated rates of depression, self-harm, and suicidality among teen girls with ADHD are poor response inhibition and peer victimization, as well as a history of maltreatment, such as physical abuse, sexual abuse, or neglect, Hinshaw said.

“I can’t tell you how many mums are holding their girls tight as they self-harm their way through adolescence,” wrote one ADDitude reader in Canada.

[ADHD and Self-Harm: How to Help the Girls Who Suffer Most]

“We are gaslighted, misdiagnosed, or expected to suck it up,” wrote an ADDitude reader on Instagram. “The wait times for help are not OK, and once you finally do get ‘help,’ they barely listen or dismiss your concerns.”

Sexual Violence at an All-Time High

Among the CDC report’s more distressing findings was a stark increase in sexual violence among teen girls. It found the following:

• 1 in 5 girls recently experienced sexual violence
• 14% have been forced to have sex, an increase of 27% over the past 2 years
• For American Indian or Alaska Native girls, that number jumped to 18%, and for LGBTQ+ teens, it was 20%

“For every 10 teenage girls you know, at least one of them, and probably more, has been raped,” Ethier said during a press briefing.

The prevalence of sexual violence causes significant and understandable anxiety. According to the ADDitude survey, 20% of girls expressed anxiety about physical or sexual assault, as opposed to 7% of boys.

The CDC’s study reflects this anxiety, reporting that:

• 10% of girls did not go to school in the past 30 days because of safety concerns, nearly double the rate from 10 years ago; the same was true for 7% of boys.
• School avoidance rates were higher among LGBTQ+ students, at 14%; American Indian and Alaska students, at 13%; and Black students at 12%.

The prefrontal cortex in a developing brain is especially sensitive to the effects of stress and “children with ADHD may be even more sensitive to the effects of traumatic stress,” said Cheryl Chase, Ph.D., in her ADDitude webinar, “How Stress and Trauma Affect Brain Development.” In other words, the trauma of sexual violence leaves lasting scars.

The mother of a girl with ADHD explained the long-term implications of a sexual assault on her daughter’s health and well-being four year after the attack: “When she was a freshman in college this past year, she was re-triggered while in public talking to a boy who touched her inappropriately without her consent.”

Cyberbullying Twice as Likely for Girls

Whether in school or online, girls are more likely to be victims of bullying, according to the CDC report.

• 1 in 5 girls said they were bullied through texting and social media, almost double the percentage of boys who were cyberbullied
• In school, 17% of girls and 13% of boys reported experiencing bullying in school over the past year

Among teens with ADHD, the rates of bullying are much higher. According to ADDitude survey respondents, 60% of girls with ADHD have been bullied at school, 58% on social media and 44% in text messages.

“We know that kids who are neurodiverse are often seen as peculiar and different,” explained Sharon Saline, Ph.D. “You miss social clues, you blurt things out, and chances are you’re more likely to experience bullying and be socially excluded.”

This was the case for the daughter of an ADDitude reader in Wisconsin: “Bullying has been around my daughter’s lack of age-appropriate social insight and her emotional reactivity. Girls exclude her from group texts. Friends screenshot the negative posts others create about her, and she then ruminates until her mood totally plunges.”

Bullying is a widespread problem, and so is the response (or lack thereof) from most schools;  72% of ADDitude survey respondents who reported that their kids were the victims of bullying also said they were dissatisfied with the school’s response.

“The lack of help in the public school system is so disappointing,” wrote an ADDitude reader on Instagram. “They claim to not be tolerant of bullying, yet anytime you seek help you’re met with nothing but rotating doors and promises of help that go undone.”

Substance Use Higher in Girls

Teen girls are more likely to use alcohol, marijuana, vaping, and illicit drugs, according to the CDC.

• Alcohol: 27% of teen girls reported drinking in the last month vs 19% of boys
• Vaping: 21% of girls reported vaping in the last month vs 15% of boys
• Illicit drugs: 15% of girls reported ever using illicit drugs vs 12% of boys
• Misuse of prescription opioids: 15% of girls reporting ever misusing opioids vs 10% of boys

“ADHD affects substance abuse in both children and adults,” explained Walt Karniski, M.D., in a recent ADDitude webinar on ADHD medication. “Children with ADHD are more likely to smoke and to begin smoking at younger ages. They’re more likely to use alcohol at younger ages and more likely to abuse alcohol as adults.”

“A Level of Distress that Calls on Us to Act”

In the introduction to its 89-page report, the CDC authors clearly state its takeaway: “Young people in the U.S. are collectively experiencing a level of distress that calls on us to act.”  The CDC urges schools to act swiftly and thoughtfully for maximum impact.

“Schools play an integral role in promoting wellness and connectedness, and facilitating protective factors among students,” said Anna King, president of the National PTA. Specifically, the report highlights the importance of implementing quality health education, connecting young people to needed services, and making school environments safer and more supportive.

“It’s about time someone noticed, besides all the struggling parents and kids,” wrote one ADDitude reader in New York.

How Can Parents Protect Their Kids?

Keep lines of communication open

“As girls reach the teen years, they naturally want to emancipate from adult control,” Chase says. “But teens’ brains have more ‘accelerators’ than ‘brakes,’ so they need a loving, interested adult to guide them.” This is doubly true for teens with ADHD, whose executive function weaknesses may exacerbate impulse control. So, how do you stay connected with a teen who seems intent on pushing you away?

• Prioritize a positive relationship

Sources for conflict between adolescents and parents abound, but Saline advises that parents pick their battles. “Your Number One agenda item as the parent of a teen is maintaining a positive connection,” Saline says. “So that they will come and talk to you if they need help.”

To build that connection, Chase emphasizes the importance of unstructured time together. “Going for walks, grabbing a smoothie together, playing a game,” she suggests. “Time just to ‘be’ and if they want to talk, they can.” Don’t wait for your teen to reach out to you. Be proactive, and invite them to do something low-key and stress-free every week or two.

• Make communication routine

When teens push back against their parents, seeking autonomy and space, anxious parents often ask a lot of questions, which can make teens feel hounded, Saline says. Keep communication open without putting teens in the hot seat by making conversations routine. Saline suggests instituting a family-wide practice of sharing one “happy” and one “crappy” thing that happened during the day — at dinner or in the car ride home. If it’s a daily practice in which everyone participates, your daughter won’t feel singled out.

• Actively listen, rather than offer unsolicited advice

When your child share experiences with you, practice active listening to ensure the communication continues. Allow your child tell their story, uninterrupted, and follow up with reflective statements, like “I think I’m hearing you say…”  Avoid swooping in with unsolicited advice — that’s the fastest way to get a teen to shut down, according to Chase and Saline.

Help your daughter find treatment

Depression, anxiety, trauma, and self-harm are all treatable, and a mental health professional can help you figure out what avenue of treatment to pursue. If you sense something’s persistently troubling your teen, Chase urges you not to wait to find them a therapist. “It’s like going to the dentist with a toothache,” she explains. “It doesn’t mean they are broken.”

Cognitive behavioral therapy, dialectical behavior therapy, and medication are among the most common interventions. If trauma is involved, consider somatic therapy, which increases awareness of the sensations in the body as a form of healing.

If your child has ADHD, consider that ADHD treatment may decrease their risk for other challenges. Hinshaw says that treating ADHD can decrease rates of suicidality in teens. “Treatment is a huge antidote to internalization, self-stigma, and the belief that there’s something wrong with you,” he explains. In addition, multiple research studies have indicated that children and adults with ADHD who are taking stimulant medication are less likely to engage in substance use than are their untreated peers.

Get Help

Suicide &Crisis Lifeline: Call or Text 988
988lifeline.org

National Sexual Assault Helpline: 1-800-656-HOPE

National Substance Abuse Helpline: 1-800-662-HELP

Stop Bullying

Mental Health in Teens: Next Steps

• Read: Special 2022 Mental Health Report from ADDitude
• Read: Compare & Despair: Social Media & Mental Health Concerns in Teens with ADHD
• Self-Test: Signs of Depression in Teens
• Learn: Nearly One in Four Women with ADHD Has Attempted Suicide

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Source

¹Centers for Disease Control and Prevention (2023). U.S. Teen Girls Experiencing Increased Sadness and Violence. Youth Risk Behavior Survey cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

ADHD is a stronger predictor of depression and anxiety in adults than is autism spectrum disorder, according to a new study that suggests patients with attention deficit hyperactive disorder are more likely that autistic patients to experience “internalizing problems” like mood disorder. The study, led by researchers at the University of Bath and published in Scientific Reports, underscores the importance of screening for comorbid conditions in adults with ADHD. ¹

As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder.² According to a recent ADDitude survey of 1,500 readers, anxiety and depression are the two most common comorbid conditions diagnosed alongside ADHD in adults, with co-diagnosis rates of 72% and 70%, respectively.

Despite this high rate of comorbidity, researchers said, “ASD has often been prioritized over ADHD in both research on internalizing problems and clinical practice, particularly for anxiety.”³

Notably, approximately 28% of autistic individuals have ADHD, making it difficult to determine which disorder — ASD or ADHD — more significantly impacts mental health outcomes.² (The ADDitude reader survey found that 9% of adults with ADHD have ASD.)

Researchers aimed to clarify the associations between self-reported ASD traits and ADHD traits with mental health conditions like anxiety and depression using a general population sample, which included 504 adults from the U.K. (49% male, 51% female) aged 18–79 years.

While the results linked both ASD and ADHD with anxiety and depression, ADHD was a stronger statistical predictor of both mental-health conditions than was ASD. Further analysis confirmed that ADHD traits were associated with more severe anxiety and depression symptoms in adults than were ASD traits.

Researchers “speculate that response inhibition difficulties, which appear to be a cognitive feature of ADHD, may also potentially underpin the stronger association between ADHD traits and internalizing problems.”

To the researchers’ knowledge, this is the first study showing ADHD more strongly predicts mental health outcomes in adults than do other neurodevelopmental conditions, like ASD.

“Our finding that ADHD traits dominated ASD traits in predicting internalizing disorder symptoms could inform strategies to identify individuals who are at an increased risk of internalizing problems,” researchers said. “This might allow preventative measures and interventions to be implemented at an earlier age, which, for example, could focus on managing ADHD symptoms for a greater impact on ameliorating internalizing problems and improving mental wellbeing in adults.”

Recognizing complex ADHD (attention deficit plus one or more co-occurring conditions) is of “high clinical importance,” said Theresa Cerulli, M.D., of Beth Israel Deaconess Medical Center and the Neuroscience Education Institute, in the ADDitude webinar titled, “Complex ADHD: The New Approach to Understanding, Diagnosing, and Treating Comorbidities in Concert.”

“The presence of co-occurring conditions almost always muddles the diagnosis, treatment, and prognosis of ADHD,” she said. “ADHD and comorbidities may also influence the presentation and severity of one another, which can complicate the detection and treatment of symptoms, and impair overall quality of life.”

Researchers hope the study’s findings will encourage more research probing whether genetics help explain why ADHD traits are more strongly associated with internalizing problems than are autistic traits.

Sources

¹Hargitai, L.D., Livingston, L.A., Waldren, L.H. et al. (2023). Attention-Deficit Hyperactivity Disorder Traits Are a More Important Predictor of Internalising Problems Than Autistic Traits. Sci Rep. 13, 31. https://doi.org/10.1038/s41598-022-26350-4

²Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC psychiatry. 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

³Bishop, D. V. M. (2010). Which Neurodevelopmental Disorders Get Researched and Why? PLoS ONE 5, e15112/

⁴Young, S. et al. (2021). Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement. Front. Psychiatry 12, 324.

Intravenous ketamine infusions could effectively reduce symptoms in patients with treatment-resistant depression (TRD), suicidal ideation (SI), and anxiety, according to a new study published in the Journal of Clinical Psychiatry. The study analyzed data from 424 TRD patients who received ketamine injections from November 2017 to May 2021. ¹

Patients received six ketamine infusions at a starting dose of 0.5 mg/kg, each one lasting around 40 minutes. Half of the patients responded to treatment within six weeks, and 20% reported remission of their depression symptoms. (After 10 infusions, response and remission rates for depression were 72% and 38%, respectively.) During the same period, 50% of patients with self-harm/suicidal ideation reported entering remission or had fewer symptoms. One-third of patients reported decreased anxiety symptoms.

“The high rates of response and remission were similar to those for interventional treatments in community samples of TRD,” researchers wrote. However, they acknowledged several limitations of the study, which included no control group and used self-reported patient data. “Comparative efficacy trials with other interventions and randomized controlled trials of racemic ketamine infusion as the primary treatment for SI are needed,” researchers said.

Roberto Olivardia, Ph.D., clinical psychologist and clinical instructor of psychology at Harvard Medical School, discussed ketamine treatment for depression in the 2019 ADDitude webinar titled “The ADHD-Depression Connection in Adults: Understanding the Link, Distinct Symptoms, and First-Line Treatments.”

“Ketamine is a hallucinogenic drug with properties that can be very useful in treating depression,” Olivardia said. “The drug affects glutamate and GABA — excitatory and inhibitory neurotransmitters of the brain. Ketamine promotes synaptic connections within the brain for learning and memory, but it can also block other receptors, leading to rapid antidepressant action. Studies have shown that the drug reduces or eliminates very acute or distressing symptoms of depression, including suicidal thoughts. Other studies show that 60% or more of patients find relief from depressive symptoms with these infusions.

“The drug, still considered experimental, is used for severe cases of treatment-resistant depression,” he continued. “When other antidepressant medications have failed, or if there’s acute suicidality, ketamine infusions may be appropriate.”

The U.S. Food and Drug Administration has not approved ketamine to treat psychiatric disorders. However, the “S” form of ketamine, which is derived from ketamine and known as Spravato (esketamine), is a Schedule III controlled substance that was approved by FDA in 2019 as a nasal spray for treatment-resistant depression in adults and depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior, in conjunction with an oral antidepressant.²

Sources

¹ Oliver, P. A., Snyder, A. D., Feinn, R., Malov, S., McDiarmid, G., & Arias, A. J. (2022). Clinical Effectiveness of Intravenous Racemic Ketamine Infusions in a Large Community Sample of Patients with Treatment-Resistant Depression, Suicidal Ideation, and Generalized Anxiety Symptoms: A Retrospective Chart Review. The Journal of Clinical Psychiatry. 83(6), 21m14336. https://doi.org/10.4088/JCP.21m14336

²U.S. Food and Drug Administration. (February 2022). FDA Alerts Health Care Professionals of Potential Risks Associated with Compounded Ketamine Nasal Spray. https://www.fda.gov/drugs/human-drug-compounding/fda-alerts-health-care-professionals-potential-risks-associated-compounded-ketamine-nasal-spray

Social distancing and remote learning have largely vanished. The same cannot be said of the pandemic’s mental health challenges. In a recent ADDitude survey, 72 percent of caregivers said their child has experienced anxiety, depression, and other mental health effects in the last two to three years. Many attributed this to the pandemic and cited new or aggravated challenges like mood changes, sleep issues, and anger.

Several parents reported an improvement in their child’s symptoms, which seemed to subside with a return to school and social activities. Others said they have learned how to cope with long-term social, emotional, and behavioral challenges. Still, many are at a loss with how to help their child acclimate to an almost-post-pandemic world.

Below, ADDitude readers describe the lingering impact of the pandemic on their child’s everyday life. What are some challenges your child has faced over the past few years, and have you found effective interventions? Let us know in the comments section.

“My son’s anxiety has increased exponentially. He always struggled in school, but distance learning for third and fourth grade — two very critical learning years — caused him to fall even further behind, both socially and academically. He’s come so far, but there’s so much ground to make up. He knows he isn’t like other kids and it has made him anxious and depressed.” — An ADDitude reader

“My child avoids all relationships even though he states how alone he feels.” — An ADDitude reader

“My son’s behavior has been difficult, but it worsened during COVID. He became visibly depressed, stopped making an effort in school (even when he knew answers), did not want to maintain any friendships, and became frightened of things that were previously common to him (like his bedroom at night). A decrease in his medications helped, but getting a neuropsychological exam that highlighted his anxiety and resulted in new medication changed the picture entirely.” — An ADDitude reader

[Download: Friendship Guide for Kids with ADHD]

“When COVID hit, we had to stay home for more than a year. Now, [our son] prefers to stay home most of the time.” — An ADDitude reader

“My son’s life changed drastically in 2020 after an already difficult fifth grade year. He has never recovered from loss of math skills, has lost many of his friends, uses food as comfort, and his picking disorder has increased tenfold. This past year was the worst we have ever had, and I hope that some changes made this summer make his eighth grade year better. I hope for happiness, if nothing else.” — An ADDitude reader

“We’ve noticed that over the last two years, our son started and continues to chew and bite on his nails and other non-food items to deal with anxiety. He has also developed a worry about going to the doctor. His concern seems to be around having to get tests, particularly nasal swabs, and shots.” — An ADDitude reader

“A lack of opportunity to socialize and isolation affected [my son’s] well-being during the pandemic. Since returning to class, he’s doing much better and is no longer having these concerns.” — An ADDitude reader

[Read: Safeguarding Youth Against Depression in the Pandemic]

“The pandemic and subsequent online learning has dug my child further into depression and anxiety. After two years of trying to succeed at school and failing enormously, she is finally taking a gap year to put her life back together through counseling. She is also being assessed for ADHD, which would explain so many of the symptoms that she has experienced since childhood.” — An ADDitude reader

“My daughter always had ADHD symptoms, but before the pandemic, she did well in school and functioned relatively normally in social settings. Once the pandemic hit, she was isolated and had to learn at home. She experienced severe depression, and her ADHD symptoms became more apparent without the structure of school.” — An ADDitude reader

“[My daughter] is combative and easily angered by family. She stopped taking her antidepressants and turned to smoking marijuana to cope with anxiety. Now that she’s 21, she’s buying alcohol.” — An ADDitude reader

“[My daughter] graduated from college in 2020 and moved to a large city with a new job and new responsibilities. The inevitable overwhelm swallowed her and magnified her symptoms to the point of taking action. She just recently got diagnosed with ADHD and has started taking stimulant medication. The good news is that, like so many of us twice exceptional women who have been diagnosed late in life, stimulant medication has made a big difference for her. The challenges remain, but now she has discovered and embraced the tools that help her meet and manage them. I’m grateful she is finally on ‘the journey’ now.” — An ADDitude reader

“My child has unofficially dropped out of school due to his inability to leave his bed on most days. He doesn’t eat, doesn’t practice self-care or personal hygiene, and has trouble maintaining and keeping track of material items. As he becomes more antisocial, his OCD, autism, and ADHD symptoms become more detrimental and debilitating.” — An ADDitude reader

“[My son] had sleep issues at the beginning of the pandemic and struggled to adjust to virtual school work and online classes. He did adjust after a few months and is now much better. He still worries and has started biting his nails, but overall, he is exhibiting much more ‘normal’ behavior than he did three years ago.” — An ADDitude reader

“My son has been homeschooled for five years and had a good social network in that community. COVID broke up our groups, some people left, and playmates went online. Friendships faded with struggles to solve online gaming disputes remotely, disagreements over wearing masks, and becoming a teen with big changes during isolation. Now I’m trying to return to work with the higher cost of living and get our son into an Early Intensive Developmental and Behavioral Intervention (EIDBI) program. Due to the shortage of qualified supervising professionals (QSP), he is still isolated and lonely.” — An ADDitude reader

Steps to Support Your Child’s Mental Health

Health experts have sounded the alarm on concerning youth mental health trends of recent years – undoubtedly worsened by the pandemic – and the need for all of society to step up for children and teens. Below are parent-focused strategies to support youth mental health.

1. Be on the lookout for signs of distress in your child.

Contact your child’s pediatrician if the following behaviors persist for more than a week, as they could indicate that your child or teen is struggling and needs help, according to Sharon Saline, Psy.D.

• Excessive worry, sadness, crying, irritation or withdrawal
• Inability to enjoy activities they previously liked
• Poor eating or sleeping habits
• Avoiding responsibilities they were previously able to meet
• Greater trouble with focus and concentration than you would expect
• Unexplained headaches or other physiological complaints
• Evidence of drug, alcohol or tobacco use
• Giving away belongings

2. Take care of your own mental health.

Put on your own oxygen mask first. Practicing self-care will help you regulate your own emotions and be present for your child. By prioritizing your mental health – through maintaining routines, taking breaks, getting enough sleep, eating nutritious meals, etc. –  you are also modeling healthy habits for your child.

3. Validate and acknowledge your child’s feelings.

According to Caroline Buzanko, Ph.D.: “Anxious children need to learn that overcoming anxiety is about doing what we’re afraid of in spite of – not without – fear. That means that even well-meaning reassurances like, ‘It’s not so bad’ and ‘It’s OK, nothing bad is going to happen’ minimize your child’s feelings.” Practice active listening as you validate.

4. Teach your child to externalize anxiety.

Externalizing anxiety will help your child separate themselves from their worries. Anxious teens especially tend to believe that anxiety is an ingrained, unchangeable personality trait. Encourage your child to think of anxiety as an outside force trying to infiltrate their brain.

5. Remain calm to de-escalate anger and meltdowns.

Shouts and arguing will only fuel your child’s anger. Temporarily walk away if you sense your child has lost control. As you walk away, be sure to communicate to your child that you need space to calm down, and that you are giving them a chance to do the same. Clearly indicate that you’ll be back after a certain number of minutes.

Learn more about de-escalating explosive reactions here.

6. Think of meaningful ways your child can connect with peers.

• Does your child have a hobby? Could they join an online group for teens interested in that activity?
• What steps, if any, is your child’s school taking to connect students with one another? Ask about extracurriculars and after school programs your child might be able to attend.
• If your child struggles with social anxiety or making friends, try setting up a couple of “have-tos” during the week (like calling grandma every Friday).

7. Foster resilience

The above strategies all serve to strengthen your child’s resiliency – the ability the cope and bounce back from difficult experiences – as do the following:

• Give your child responsibilities. Entrusting your child with important tasks (chores count) conveys trust, builds their self-esteem, and boosts their sense of purpose.
• Help your child focus on what they can control. According to Robert Brooks, Ph.D., resilient people focus their time and energy on what they can impact and influence, while those are not resilient often lead with defeatist attitudes.
• Teach your child that change and discomfort are part of life, and that it’s vital, nonetheless, to maintain a hopeful outlook despite setbacks. (More resiliency strategies here.)

ADHD and Youth Mental Health: Next Steps

• Download: Emotional Control Strategies for Kids with ADHD
• Read: Youth Mental Health Care Is Vital. And Hard to Access.
• Read: A COVID Timeline of ADHD Brains in Distress

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

All adults under age 65, including pregnant and postpartum people, should be routinely screened for anxiety and depression, according to new and groundbreaking draft recommendations from the U.S. Preventive Services Task Force (USPSTF). ¹

The task force, which comprises independent medical experts, has never before called for routine mental health screenings for adults ages 19 to 64. The group’s draft recommendations intend to help clinicians identify and treat symptoms of anxiety and depression, in particular, before they intensify and possibly interfere with a patient’s everyday life.

“We know that anxiety is such a common disorder,” said John Piacentini, Ph.D., a professor of psychiatry and biobehavioral sciences at UCLA. “If left untreated, it can increase the risk for depression, substance abuse, self-harm, and other negative health outcomes. This recommendation is a really important step toward helping people get treatment.”

Elizabeth Hovis, M.D., an assistant professor at the Medical College of Wisconsin, called the USPSTF draft recommendations for routine anxiety and depression screenings for pregnant and postpartum women—a demographic at higher risk for these disorders—long overdue.

“Depression and anxiety are leading and preventable causes of maternal morbidity and mortality, with one in five pregnant or postpartum women experiencing a mental health condition,” she said. “Unfortunately, 75% of these go untreated. Because of this, universal screening for depression and anxiety in the perinatal period is critical.”

Earlier this year, the task force recommended routine mental health screenings for children ages 8 to 18 as well.

According to the draft recommendation, U.S. data collected from 2001 to 2002 found that the lifetime prevalence of anxiety disorders in adults was 26.4% for men and 40.4% for women. Generalized anxiety disorder has an estimated prevalence of 8.5% to 10.5% during pregnancy and 4.4% to 10.8% postpartum. ², ³

The public may comment on the draft recommendation through Oct 17, 2022.

Sources

¹ U.S. Preventive Services Task Force. (2022) Screening for Anxiety in Adults. www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/anxiety-adults-screening

² Kessler, R.C., Petukhova, M., Sampson, N.A., et al. (2012) Twelve-Month and Lifetime Prevalence and Lifetime Morbid Risk of Anxiety and Mood Disorders in the United States. Int J Methods Psychiatr Res. 21(3):169-184. https://doi.org/10.1002/mpr.1359

³ Misri, S., Abizadeh, J., Sanders, S., et al. (2015) Perinatal Generalized Anxiety Disorder: Assessment and Treatment. Journal of Women’s Health. 24(9):762-70. https://doi.org/10.1089/jwh.2014.5150

Mood swings. Sleep disturbances. Deteriorating relationships. Worsening grades. Total lack of interest in recreational activities. These are among the troubling behaviors observed by more than half of caregivers since the start of the pandemic, according to a new ADDitude survey on the mental health of youth with ADHD.

Our 1,187 survey responses mirror reports by the U.S. Surgeon General with one important caveat: The mental health crisis plaguing today’s youth appears even more severe for adolescents with ADHD.

The mother of a 14-year-old in Michigan put it this way: “My daughter has developed social anxiety and sometimes has difficulty going to school or to stores where other teens might be present. She is overly obsessed with her looks, so much so that she covers our mirrors. She went from an honor roll student to Ds and Es.”

[ADDitude Special Project: Mental Health Out Loud]

Many high school students, as we now know, weren’t doing well before the pandemic: One in three reported a persistent feeling of sadness or hopelessness between 2009 and 2019, according to U.S. Surgeon General Vivek Murthy. And one in five children aged 3 to 17 reportedly had a mental, emotional, developmental, or behavior disorder during that time period.

But in the last two to three years, mental health challenges grew even more troublesome for high school students with ADHD, according to the caregivers who responded to the ADDitude survey: An astounding 67% of teens have now been diagnosed with anxiety and 46% with depression. Among children ages 3 to 17 with ADHD, the survey also revealed above-average levels of oppositional defiant disorder (11%), sleep disorders (6.75%), and eating disorders (5.32%), not to mention the learning differences that impact more than one in five students with ADHD.

The Social Media Effect

Less than 6% of parents surveyed said their adolescents with ADHD have “very good” mental health today. On a 4-point scale, this group’s average mental health rating was 2.27.

The most alarming signs of a mental health crisis revealed by the survey data involved adolescent girls with ADHD who use social media. The rate of anxiety among this group is a startling 75%, and the rate of depression is 54%, according to the survey. More than 14% have a sleep disorder, and nearly 12% report an eating disorder—more than three times the national average for neurotypical women. Though the survey cannot demonstrate causality with social media use, it does reveal that this demographic has the most severe mental health challenges.

The most “pervasive and troubling” emotions impacting all adolescents with ADHD today include anxiousness (66%), irritability (60%), apathy (59%), withdrawal (47%), and anger or aggression (45%).

[Free Resource: Too Much Screen Time? How to Regulate Your Teen’s Devices]

Among adolescent girls with ADHD, the most common sources of anxiety were school (76%); COVID-19 (54%); finances (31%); gun violence in schools and social media use (28% each). Among teens with ADHD who are not cisgender, 38% report feeling anxiety over political violence.

“Sometimes my son goes through acute depression,” said a caregiver of a transgender adolescent with ADHD, anxiety, and depression. “When this happens, the entire world goes dark for him, and we just do what we can to get him through.”

If your child is experiencing troubling symptoms of anxiety, depression, or self-harm, call or text 9-8-8 to access mental health services in the United States.

How to Protect Your Teen’s Mental Health

Talk to your child’s pediatrician if you are concerned about your child’s mental health. Learn about the signs of anxiety and depression (and other signs of distress) and ask your child’s doctor if screenings for these conditions are warranted. If your child has been diagnosed with anxiety, depression, and/or other conditions, ensure that they are adhering to treatment plans.

1. Model emotional regulation at home.

Practice self-care and prioritize your well being. Even if it doesn’t seem like it, your behaviors serve as a guide for your teen.  Keeping calm will help your teen do the same – or at least prevent emotions from escalating. Make sure you aren’t enabling your child’s anxiety.

2. Try to minimize exposure to negative news.

Avoiding discussing potentially stressful subjects – finances, marital problems, etc. – around your child, as these topics could undermine your child’s sense of safety and stability. Limit your family’s exposure to distressing news events. Learn more about navigating conversations around gun violence and school shootings here.

3. Encourage healthy social media use.

Have ongoing conversations about online experiences, and watch for warning signs of problematic Internet use. Listen to our conversation with Linda Charmaraman, Ph.D., on social media and youth mental health for more strategies. If unhealthy social comparison over social media is a problem for your teen, read this article.

4. Encourage healthy habits.

Consistency and routine ground us, as do sufficient sleep, nutritious meals, and physical activity. Social connection is also vital for teens. Take steps to ensure that your child’s life has all these elements.

5. Prioritize a good relationship with your child above all else.

A stable, supportive environment does wonders for fostering resiliency and confidence. Bond with your child over things they enjoy (don’t come in with an agenda), and really listen to your child’s concerns without judgment. (Check your immediate reactions and unsolicited advice at the door.)

ADHD & the Mental Health Crisis: Next Steps

• Join Us! Mental Health Out Loud Event on Eating Disorders in Teens
• Read: Special 2022 Mental Health Report from ADDitude
• Read: Compare & Despair: Social Media & Mental Health Concerns in Teens with ADHD
• Listen: “Mental Health Out Loud – The Mental Health Fall Out from Social Media Use”
• Free Resource: Social Anxiety Facts & Falsehoods
• Read: A Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth  

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

The mental health of adults with attention deficit hyperactivity disorder (ADHD) garners a passing grade — but barely.

In an exclusive ADDitude survey, 1,542 adults assigned their mental health status a rating of 2.27 out of 4 — a C-minus average. One contributing factor: Nearly three-quarters of respondents with ADHD also reported diagnoses of anxiety, depression, or both. This sky-high level of comorbidity is four to eight times greater than the national average.

This self-rating reflects the fact that, over the last 2 and a half years, ADDitude survey respondents said they have…

• …felt depressed (68%)
• …suffered with sleep problems (67%)
• …felt unmotivated (62%)
• …experienced mood changes (61%)
• …worried excessively (55%)
• …lost friendships or other relationships (54%) over the last three years.

More than half blamed the pandemic, and the issues it raised, for these and other mental health struggles.

“I worked face-to-face with customers who refused to wear masks,” said a mother of two in North Carolina. “This led to thoughts and feelings of anger, depression, and worthlessness because I didn’t understand why someone would think that my health wasn’t worth protecting by simply wearing a mask.”

In the survey, only about 7% called their mental health “very good” and fewer than 4% said they had no mood changes in the last three years.

[Get This Free Download: 9 Conditions Often Linked to ADHD]

The Burden of Anxiety

More than three-quarters of people reported feeling debilitating anxiety that impaired their daily living. The top reasons they cited were as follows:

• finances and money (61%)
• access to health care (38%)
• the pandemic (37%)
• political violence (33%)

Social isolation, once a pandemic requirement and now a complicated choice for many, has led to feelings of apathy, irritability, withdrawal, and sadness for more than half of respondents with ADHD. A whopping 86% said they used social media, though 60% of those individuals said it harms their mental health and even contributes to addiction issues, headaches, and eating issues for up to 24%.

The Scars of Trauma

An astounding 82% of ADDitude survey respondents said they have experienced trauma, a rate that is significantly higher than the national average compiled by the U.S. Department of Veteran Affairs: 50% for women and 60% for men. Sexual assault, the death of a loved one, car accidents, and bullying were among the traumatic incidents cited by ADDitude readers.

[Read: Does Trauma Cause ADHD? And Vice Versa?]

“I endured childhood emotional neglect and traumatic events (car accident, parents separating, violence, and bullying),” said a women diagnosed with ADHD and autism. “As an adult, I experienced sudden bereavements (my best friend and mother), and trauma based on supporting my bereaved father.”

The ADDitude survey captured many stories like these, suggesting that trauma is the rule rather than the exception for people with ADHD. The primary treatment for trauma is psychotherapy, namely, cognitive behavioral therapy (CBT), and other approaches. Yet only 25% of survey respondents said they were receiving CBT for trauma and only 57% reported receiving therapy of any kind. Almost 82% said they were taking medication, which most deemed “helpful” or “very helpful.”

“Finding a therapist who fit my schedule, was in my insurance network, and was seeing new patients was nearly impossible,” said a woman in Washington with ADHD, anxiety, and an eating disorder. “My health insurance does not cover my therapy, so I pay out of pocket. It’s been a nightmare.”

Strategies for Adults Living with Anxiety, Depression, or Trauma

A combination of ADHD medication and therapy has been found to be the most beneficial for adults with ADHD and anxiety, according to J. Russell Ramsay, Ph.D. He also offers the following daily coping mechanisms for ADHD and anxiety:

• Develop strict routines with space blocked out for downtime
• Exercise daily for at least 30 minutes, ideally outdoors
• Sleep at least 7 hours each night
• Fill your calendar with task- or time-based items that are clearly defined
• Maintain consistent treatment for ADHD
• Accept negative thoughts for what they are: just thoughts

“Sometimes we’re so caught up in our daily routines that we fail to step back and analyze sources of stress,” adds Kathleen Nadeau, Ph.D. “Whenever it starts to affect your moods, get out paper and pen and list the biggest stresses in your day. Then look for ways to reduce or eliminate them.”

She also recommends combatting anxiety and depression by cutting down on carbohydrates, which offer a quick energy hit but also a long crash and, often, weight gain. She urges adults with ADHD to create a chart where they can track progress against sleep, exercise, nutrition, green time, and stress reduction every day.

Edward Hallowell, M.D. recommends reaching out to friends, family, or a support group to avoid worrying alone.

For patients who have experienced trauma, Kerry J. Heckman, LICSW, uses somatic therapy, which “increases awareness of the sensations in the body to give the patient a roadmap to understand what they mean,” she says. “Focusing on the body’s response to the trauma — instead of the trauma itself — reduces the possibility of re-traumatizing the individual and starts the healing process. Through the body, we have more access to the traumatic residue, which may not be available in memories.”

Somatic therapy is a long-term treatment (lasting a year or more) that requires a licensed mental health practitioner trained in somatic therapy who also has experience treating people with ADHD. Since somatic therapy is a modality used by licensed therapists, most insurance policies that cover traditional talk therapy will cover somatic therapy as well.

5 Ways to Practice Somatic Therapy at Home

Though working with a trained therapist is the best treatment, Heckman says patients with trauma and ADHD can follow these simple rules to increase awareness of the nervous system.

#1. Note body sensations throughout the day. Noting and amplifying good experiences can be especially helpful when treating both ADHD and trauma, both of which carry a history of negative experiences.

#2. Find safety in structure. Structure — knowing consistently what to expect — can foster a sense of safety and decrease chronic stress-related activation or vigilance.

#3. Build a strong foundation. Diet, exercise, and sleep are the foundations of a healthy nervous system function.

#4. Notice agency. Paying attention to the areas of life where there are choices brings awareness to what can be controlled, rather than what feels uncertain.

#5. Communicate with the nervous system to calm it down. One way to quiet activation in the body is the gentle reminder that this is not a survival situation. To do this, slow down your movement and speech; check for muscle tension; and check in periodically with your body to see what movement it craves.

Learn more about somatic therapy here.

Trauma, Mental Health, & Adult ADHD: Next Steps

• Get 5 Daily Rituals to Reduce Stress
• Free Download: Make Mindfulness Work for You
• Read: The Relationship Between PTSD and ADHD
• Read: Treating Traumatic Stress Alongside ADHD

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Anxiety is good at making us believe that we can’t handle what comes our way. The best way to convince your child that she can do hard things is not by telling her, but by showing her.

1. What Can You Handle?

What “showing” means will depend on the situation, but it will almost always mean breaking the seemingly insuperable situation or task into smaller parts. Let’s assume your child is filled with anxiety over an essay that is due. She might be telling herself that she’ll never be able to finish the assignment. But essays are made up of paragraphs, which are made up of sentences. And those sentences are made up of words and letters. We want to shift your child’s focus from the top of the hill to all the small but important steps needed to get there.

[Take This Self-Test: Could Your Child Have Anxiety?]

We also want to emphasize that not all the steps have to be perfect. Can she type/write her name at the top of the page? Can she create something of an outline? Can she write the first sloppy sentence? The essay will soon come together before her eyes.

2.What Have You Accomplished?

It’s also a good idea to remind your child of the things they successfully do now that they had to learn from scratch. (Anxiety has a way of making us forget our successes but remember every failure.) A Venn diagram works well for this visual.

List successes – like learning to read, to ride a two-wheeled bike, to play a video game, etc. – in the right circle. Use a pen for these skills to emphasize permanence. In the circle all the way to the left, use sticky notes (they emphasize impermanence) to write hard things. Then, move those sticky notes to the middle – the “learning” section. Once your child feels successful, she can move that skill to the success section.

3. There Goes Anxiety Again!

Externalizing anxiety and its “henchmen” can also help your child detach from anxious thoughts and recognize its many forms. In her case, “Permanent Paula,” one of anxiety’s henchmen, is pulling her into the thinking trap of “I’ll never be able to do this.

[Read: Shake Loose of Your Limiting Beliefs – a Guide for Teens with ADHD]

4. Carry a Tone of Confidence

Be sure to validate your child’s feelings and the real effect anxious thoughts are having over her. At the same time, convey your confidence in her ability to handle her fears and exist with discomfort. If she’s nervous about going to school because x, y, or z might happen, you can say, “Yeah, that sounds so difficult. And anxiety isn’t making it easier, I know. But you let me know how your school day goes when you get home, OK?”

Anxious Child Doing Hard Things: Next Steps

• Free Download: Easy Mindfulness Exercises for Kids with ADHD
• Read: What If You Are Enabling Your Child’s Anxiety?
• Read: 5 Ways to Reframe Anxiety for Your Worried Teen

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Anxiety in Children: Overlooked Signs and Effective Supports” [Video Replay & Podcast #401],” with Caroline Buzanko, Ph.D., which was broadcast on May 19, 2022.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Thankfully, the inverse is also true: Parents can prevent anxiety from developing and/or worsening in their children by modeling and encouraging behaviors that promote resilience instead.²

7 Parenting Behaviors That Worsen Anxiety in Children

Catastrophic Language

Too often, parents make the mistake of using catastrophic language to scare their children into obeying them. A child old enough to stay at home alone only needs a directive like, “Lock the door and don’t answer it for anyone.” With catastrophic language, it becomes, “Lock the door and don’t open it or else a stranger will come in, kidnap you, and steal our stuff.”

Emphasizing safety is important. But catastrophic language and worst-case dramatics only teach children to scan for dangers at every moment, which fires up and over-activates the amygdala.

Too Much Corrective Feedback

Excessive corrective feedback happens when parents over-monitor children. Corrective feedback may look like incessant, repetitive prompts that rob children of the opportunity to think and problem-solve for themselves:

[Take This Self-Test: Does My Child Have Anxiety?]

• “Move your cup from the edge of the table so it doesn’t spill.”
• “Make sure to get your homework out.”
• “Put away your shoes before you trip on them.”

Corrective feedback is a form of perfectionism, which is anxiety provoking. Children learn to assume that there is something wrong with their every action, and they will try their best to avoid negative feedback by refusing to engage.

Corrective feedback is especially problematic for anxious children with attention deficit hyperactivity disorder (ADHD), who are more likely than their neurotypical peers to receive corrective or negative messaging at school and at home.

Overprotectiveness

Are you bubble wrapping your child against disappointment and failure? Are you too quick to jump in and “save” them from bad feelings? What accommodations have you established that wouldn’t be there in the absence of anxiety?

[Read: Which Came First – the Anxiety or the ADHD?]

Children need exposure to normal, manageable threats and stressors. It’s how they develop appropriate coping skills that increase confidence and resilience. Interrupting this process through overprotectiveness conveys a message that anxious children are already telling themselves: “I can’t handle it.”

Too Much Reassurance

Anxiety wants certainty and predictability. It wants a guarantee that “everything will be OK” and that “nothing will go wrong” – which no one can promise with unwavering certainty. That’s why too much reassurance can reinforce anxiety, especially when the unpredictable inevitably occurs. Constant reassurance robs children of opportunities to learn how to roll with the punches.

Watch out for dependency traps, too. Small things – like letting your child sleep in your bed, speaking for them at restaurants, and sticking to rigid routines – can turn into problematic habits if done often enough.

Unchecked Digital Media Time

Too many children and teens have unchecked access to a crisis-saturated world on their devices. Doomscroll upon doomscroll, anxious, developing brains can’t process that a disaster or a tragedy happening thousands of miles away isn’t a danger to them. And for anxious children with ADHD, poor self-regulation may make it that much harder to look away. All parents should make it a priority to limit their child’s screen time and digital media use.

How to Help Anxious Children

Anxiety in children is a family problem, and it requires a family solution. Step one is examining and regulating your own anxious behaviors. Then comes changing how you and the rest of the family respond to your child’s anxiety.

1. Act as an emotional coach. Coaches can’t play the game, but they can offer their support and guidance. This mentality will help you resist interfering with experiences that will help your child grow.

2. Validate and acknowledge your child’s feelings. Don’t fall into the trap of dismissing your child’s genuine fears and concerns in an attempt to eradicate anxiety. Validating your child’s fears, even if those fears seem disproportionate to the situation, is not the same as coddling them. Anxious children need to learn that overcoming anxiety is about doing what we’re afraid of in spite of – not without – fear. That means that even well-meaning reassurances like, “It’s not so bad” and “It’s OK, nothing bad is going to happen” minimize your child’s feelings.

If your child is afraid that there are monsters under their bed, validate that feeling: “That does sound scary. I’d be afraid if I thought there were monsters under my bed, too.” At the same time, show confidence in your child’s ability to handle the situation with a supportive response: “What are you going to do to get to sleep tonight?”

3. Teach your child to externalize and expose anxiety. Help them think of anxiety as a sneaky trickster trying to get the best of them. I personally like to refer to anxiety as a tricky gremlin, but other names work. (Loki, the god of mischief, is another good one, but naming anxiety “Bob” or another average name also works.)

Encourage your child to think of what the gremlin/their preferred name for anxiety is up to when anxious feelings come up. They can say things to themselves like

• “The gremlin sure is trying hard to make me think the worst today!”
• “Loki really knows how to stress me out.”
• “Bob is trying to insert this scary story into my head.”

Externalizing anxiety in the form of a character is a kid-friendly version of the “name it to tame it” principle. Externalizing anxiety also helps children separate themselves from their worries, which is crucial. Anxious teens especially tend to believe that anxiety is an ingrained, unchangeable personality trait. Doing away with this mentality is often the biggest hurdle that I help patients navigate in my practice.

4. Acceptance over elimination. Children – and adults – often make the mistake of trying to stamp out anxious thoughts and feelings as soon as they arise. Sure, some strategies, like breathing, can help calm the body and mind in the moment. But trying to completely eliminate anxiety is a recipe for hopelessness that only perpetuates the anxiety cycle.

Rather than eliminate anxiety, teach your child to acknowledge and accept its presence. Just as they learn to acknowledge when Loki, Bob, or the gremlin show up, teach them to accept that anxiety will tag along with them sometimes – an annoyance that shouldn’t stop them.

5. Build their worry tolerance. Your child’s ability to manage anxiety directly relates to their willingness to feel anxiety. Acceptance is one avenue toward building worry tolerance. Other methods:

• Avoid swooping in, whether it’s through reassurance, ritual, or other behaviors that enable anxiety. Encourage your child to face their fears without safety behaviors.
• Provide your child with ample opportunities to experience and learn. Anxiety wants us to avoid life, and anxiety becomes a disorder when we let it do what it wants. So say “yes” more often. (Saying “no” often invites opposition and stress.) Children need exposure to difficult, hard things to learn coping skills.
• Admit to uncertainty. Anxious children will demand answers to unknowns. It’s OK to say, “I don’t know” to your child. It’s even better to say, “I don’t know, but let me know what you figure out.”
• Instill responsibility. Resilience begins with responsibility. Let your child independently take on chores and other activities at home to increase their confidence. (If they know how to work a tablet or smartphone, they can work a washing machine.)

Children’s Anxiety and Anxious Parenting: Next Steps

• Read: When Should We Worry About Childhood Anxiety Disorders?
• Read: Understanding the Role of Anxiety in Children with ADHD
• Read: Is Your Child Worrying Too Much?

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Anxiety in Children: Overlooked Signs and Effective Supports” [Video Replay & Podcast #401],” with Caroline Buzanko, Ph.D., which was broadcast on May 19, 2022.

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Sources

¹ Fisak, B., Jr, & Grills-Taquechel, A. E. (2007). Parental modeling, reinforcement, and information transfer: Risk factors in the development of child anxiety? Clinical Child and Family Psychology Review, 10(3), 213–231. https://doi.org/10.1007/s10567-007-0020-x

² Ginsburg, G. S., Drake, K. L., Tein, J. Y., Teetsel, R., & Riddle, M. A. (2015). Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. The American Journal of Psychiatry, 172(12), 1207–1214. https://doi.org/10.1176/appi.ajp.2015.14091178

Childhood Anxiety Disorders in a Young Child

The developmental trajectory for childhood anxiety disorders in toddlers or preschoolers typically involves a specific phobia, selective mutism, or separation anxiety. Recognizing anxious behaviors in preschoolers or young children is crucial. Without early treatment, they risk developing a social anxiety disorder, a general anxiety disorder, or a panic disorder as they age.

I recommend asking the parent to complete the Spence Preschool Anxiety Scale for a quick, reliable measure of anxiety in young children who can’t necessarily express their feelings. A more comprehensive assessment is the Anxiety Disorders Interview Schedule for Children, which I developed with my colleague, Anne Marie Albano, Ph.D., For young children, the interviews are conducted alone with parents. For older children, the interviews are conducted with the child and parents.

To help determine whether anxiety is impairing or interfering in children’s lives, I ask the following questions using the acronym FISH. (This can be applied to children of all ages.)

• Frequency — What is the frequency of the child’s anxious behaviors? Is it every day? Once a week? Once a month?
• Intensity — How intense is the child’s anxiety on a scale of 1 to 10?
• Severity — How severe is the child’s anxiety on a scale of 1 to 10?
• How long — How long have anxious behaviors occurred?

[Self-Test: Does My Child Have Generalized Anxiety Disorder?]

Childhood Anxiety: How to Help an Anxious Child

We want to be sure children and adolescents can distinguish between what they can control (their attitude) and can’t control (the pandemic).

I like to think about the “As of anxiety,” including arousal, attitudes, and avoidance. How does a child with anxiety disorders think about things? We all worry; an anxiety problem means you think about something more frequently, more intensely, and for much longer. The following tendencies among children should send up red flags:

• Overestimating a threat: “I’m going to get COVID. I’m going to die.”
• Difficulty tolerating uncertainty: “I don’t know what’s going to happen if I go to school. What’s going to be there? I don’t know that I can handle it.”
• Underestimating the ability to control a situation: “I never will be able to handle all this uncertainly. It is going make me really sick to my stomach or feel like I’m going to die.”
• Feeling increased responsibility: “If I get sick and I get my parents sick, it’s my fault. They will never forgive me.”

Avoidance is a common behavior in children with anxiety disorders. For example, they may not go to school, they stay away from social interactions, they won’t be alone, or they may stay away from places with germs and contaminations. Avoidance is at the core of anxiety.

There are several ways to do this. We can work directly with the child. We can work with the child and parents together. Or we can work with parents alone. All these instances emphasize teaching the child non-avoidance behaviors. This also can include providing parents with strategies to help their child to face their fears. This is our approach at the Yale Child Study Center’s Anxiety and Mood Disorders Program.

[Watch: Managing Anxiety in Children and Adolescents with ADHD and Learning Differences]

Most importantly, pay attention to any signs of anxiety. Severe anxiety can affect a child’s interactions with friends, family, and school life and become a clinically significant problem if it’s not recognized.

Childhood Anxiety Disorders: Next Steps

• Read: The Heartbreak of Childhood Anxiety
• Learn: Understanding the Role of Anxiety in Children with ADHD
• Download: Free Guide: Social Anxiety Facts & Falsehoods

Wendy Silverman, Ph.D., is the Alfred A. Messer Professor of Child Psychiatry and director of the Yale Child Study Center’s Anxiety and Mood Disorders Program at the Yale University School of Medicine in New Haven, Connecticut. She is also a trainer at The REACH Institute, a New York-based non-profit that promotes evidence-based mental health care for children. The content for this article was derived, in part, from The REACH Institute’s “Back-to-School: Transitions” webinar, in which Dr. Silverman was a panelist.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Nervousness, worry, and anxiety are closely related concepts. Though the terms are often used interchangeably, they each have different meanings and manifestations.

• Nervousness typically occurs when there is uncertainty around an unfamiliar situation. It diminishes once a new skill is learned.
• Worry refers to the expectation of a negative outcome.
• Anxiety is a condition of over-responding to a fear or worry.

[Get This Free Download: Understanding Social Anxiety Disorder]

Worry Vs. Anxiety

Worry is related to how we think about something and, despite what you may believe, there are some good things about being a worrier. Worriers (I’m one of them) have great imaginations. We have terrific future-focused thinking and creative ways of seeing things, all of which makes us good planners.

There are two types of worry: productive and poisonous. Productive worry focuses on things within our control – like homework, getting to work on time, remembering to charge your phone, etc. – and it  is often helpful. On the flip side, poisonous worry centers around things outside of our control – like thunderstorms, plane crashes, or whether people will like us – and it’s typically unhelpful.

There are several diagnoses under the wide umbrella of anxiety – from separation to general to social anxiety, various phobias, obsessive-compulsive disorder and post-traumatic stress disorder (PTSD). Here, we’re concentrating on general anxiety, although much of what we discuss is applicable to other conditions.

With most types of anxiety, there’s a tendency to interpret predictions as facts and exaggerate uncertainties. Fear or worry may abound in absence of a genuine threat. Or, when there is a real threat, there’s a disproportionate reaction to it. Anxiety, therefore, increases overwhelm and is associated with catastrophizing. Anxiety, comprised of worry and nervousness, affects memory, executive functioning skills and self-esteem.

[Read: My Paralyzing Anxiety Tells Me I’m Not Good Enough]

Anxiety and ADHD

Many people with ADHD suffer from anxiety. This is due, in part, to the ADHD brain’s difficulty with emotional regulation and with filtering internal and external stimuli (the triggers behind anxiety). This combination often leads to ‘flooding’ – intense emotional overwhelm that is difficult to manage and recover from. What’s more, executive functioning challenges inherent to ADHD may limit the acquisition and implementation of coping strategies, exacerbating stress and emotional dysregulation.

Anxiety vs. Nervous vs. Worry: Next Steps

• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: I Can’t Handle Rejection. Will I Ever Change?
• Read: Is ADHD or Anxiety to Blame for My Perfectionism?

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Start with ‘Hello’: How to Reduce Social Anxiety and Foster Connections” [Video Replay and Podcast #395] with Sharon Saline, Psy.D., which was broadcast on April 6, 2022.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.