Anxiety and ADHD are very different, but sometimes the symptoms can look similar. The correct diagnosis is critical to guide treatment and make sense of things when kids seem to be struggling or something doesn't feel right. The proper diagnosis can heal, but the wrong one can also harm. Understanding how anxiety might look like ADHD, and the telltale differences between the two, can make an essential difference in avoiding a misdiagnosis, and helping kids deal with the symptoms that might be getting in their way.

ADHD is one of the most diagnosed childhood conditions, which seems to be increasing. The Centre for Disease Control reports that 11% of children between 4-17 have been diagnosed with ADHD at some point. Reports suggest that about 8% have ADHD, and about 6% are taking medication. The prescription of medications for ADHD has increased by 800% in the last two decades.

ADHD has been the firestarter for plenty of hearty debate, with some questioning whether or not it exists. Let's start by putting that argument to bed or somewhere less cozy and far away so it won't find its way back. ADHD does exist, and there are pictures to prove it. Brain imaging shows definite differences between a brain with ADHD and a brain without. 

Researchers don't know exactly what causes ADHD, but they know it is a neurobiological condition. It has nothing to do with bad behavior, bad parenting, too much sugar, insufficient sleep, fairy dust, wearing too much yellow – or whatever other crazy theories are out there. Fortunately, these theories have been debunked, which means now researchers can get on with finding out what's going on, which they are. 

Perhaps something that has given buoyancy to the 'does it exist or doesn't it' debate is the overdiagnosis of ADHD or the misdiagnosis of symptoms that look like ADHD. A major problem facing doctors and clinicians is that there is currently no widely available objective physiological assessment for the presence of ADHD. Brain imaging can't be used for diagnosis, but researchers are developing a more accurate and objective diagnosis tool. 

In the meantime, diagnosis relies on reports of the child's behavior from two different environments, typically school (from teachers) and home (from parents). If your child seems to struggle at school but seems fine at home, it's not ADHD, and vice versa. Diagnosis of ADHD is based on a list of 18 possible symptoms, all of which exist on a spectrum and could apply to any child at some point. The 18 symptoms are divided into two clusters, with nine symptoms each ('inattentive' and 'hyperactivity/impulsivity' cluster). A formal diagnosis of ADHD comes down to a question of degree. To be diagnosed, a child has to have most of the symptoms from both clusters (combined inattentive and hyperactivity/impulsivity) or one of the clusters (predominantly inattentive or predominantly hyperactive) most of the time, and they have to intrude significantly into day-to-day life.

Studies that have looked at the way clinicians assess ADHD have found that a large majority of practicing clinicians did not regularly follow assessment procedures that are in line with best practice guidelines. One of these guidelines is to use multiple methods to diagnose, but only 15% of clinicians reported doing this. 

Research has also found that the youngest children at a year level are more likely to be diagnosed with ADHD and medicated than older children in the year level. Interestingly, this trend is only found with preschool and primary school (elementary) age children, not adolescents. Researchers suggest this may be because younger children, because of their age and stage of development, don't quite yet have the neurocognitive development of their older classmates and may wrongly be diagnosed with ADHD. 

Without a reliable, objective measure of ADHD, there will inevitably be times when a cluster of behaviors in a child is labeled as ADHD but isn't. The key symptoms of ADHD – inattention, distraction, fidgeting, problems at school, and problems focusing – don't automatically mean ADHD. They can indicate several other conditions, one of which is anxiety. 

THE PROBLEM WITH MISDIAGNOSIS

No parents want their child to be diagnosed with ADHD. Understandably, it can be a massive relief when there is finally an explanation for behaviors that don't seem to make sense or are causing problems at school, home, and friendships. 

Having a correct diagnosis is vital. It can bring clarity and guide the management of symptoms in ways that significantly improve essential parts of a child's life (relationships, academics, behavior, self-esteem). But as much as a diagnosis can heal, it can also harm. When a child is misdiagnosed, the fallout can be immense. The child might be exposed to unnecessary medication, but the wrong diagnosis can mean they aren't receiving the support or treatment to help their symptoms. 

Misdiagnosis can set a path for unhelpful or detrimental treatment and risks overlooking the actual cause of any child's difficulties. Labeling a child with the wrong diagnosis can also shrink the expectations of teachers or other adults regarding what that child is capable of. Children will live up to expectations or down to them. They'll look to the critical adults in their lives for clues about how hard they should try and whether the reach is in them.

BUT THEN THERE'S THE OVERLAP

The overlap between the symptoms of ADHD and other conditions can also add to the potential for misdiagnosis. As many as 75% of children with ADHD meet the criteria for another diagnosis. About a third of children who have ADHD will also have clinical levels of anxiety. The presence of anxiety seems to be related to more severe ADHD, so it's massively important that the diagnostic process is open to this. If stress is present, it must be given the attention it needs and not overlooked or treated as part of ADHD.

The Masquerade: When anxiety looks like ADHD.

Anxiety and ADHD are very different, but the symptoms sometimes look similar. This is because changes in the prefrontal cortex drive both symptoms, BUT the nature and processes behind those changes are different. With anxiety, the symptoms are brought about by the fight or flight response. This response can be enduring and intense, and it can happen even when there is no threat and no real need for fight or flight. With ADHD, the symptoms are brought about by structural, functional, and chemical changes in the brain. 

When there are changes in activity in the prefrontal cortex, as happens during anxiety and ADHD, symptoms can include inattention and distraction, impulsivity and hyperactivity, and difficulty controlling emotions, impulses, and habits.

But if the symptoms are the same, does it matter how it's treated?

Yes. Yes. Yes. It matters. The symptoms aren't the problem. The condition driving the symptoms is the problem. Understanding whether it's ADHD, anxiety, or both is the first and most crucial step in ensuring your little person gets what they needs to move forward. Although both anxiety and ADHD are manageable, they need different types of support to improve. 

ADHD is generally treated with medication that boosts the necessary neurochemicals and stimulates the parts of the brain that need to work a little more complicated. This may be effective for ADHD, but if the symptoms are being driven by anxiety, ADHD medication is massively heavy-handed and fails to give the child the skills or resources to manage the symptoms best. Even if anxiety and ADHD are happening together, treating the anxiety as a separate condition is essential. A growing body of highly regarded research shows that mindfulness and exercise are powerful ways to do this.

If the symptoms are from ADHD, what's driving them?

An ever-increasing body of research has found widespread structural, functional, electrical, and neurochemical differences in the brains of children with ADHD. Researchers aren't exactly sure what causes these changes, but a lot of research is happening in the area to get us closer to the answers.

The changes are mainly in executive functioning (planning, organizing, concentration, impulse control, focusing attention, remembering instructions, inhibition, and self-control) and sensorimotor processing (using the information we receive through our senses to produce an effective motor response). 

The frontal cortex and other brain parts are smaller in children with ADHD. Size makes no difference in intelligence, and many kids with ADHD will have above-average IQs. What it does affect is behavior. An ADHD brain is powerful, intelligent, and very capable, but it cannot filter the 'noise' from the relevant information coming in. A brain with ADHD is like a beautiful, high-powered, high-performing sports car without brakes. 

In any brain, the different parts interact to form various networks that control processes such as behavior, movement and attention. These networks are like a symphony – they increase or decrease activity depending on what we are doing. For a brain to do what it needs to do effectively, the networks need to work together and increase or decrease activity just enough to make things happen. When we are trying to learn something, for example, the networks that process information increase in activity, while at the same time, the networks involved in daydreaming decrease in activity. In a child with ADHD, some networks switch on too much, and some don't switch on enough. When this happens, they may struggle with tasks or behavior. 

Many people seem to grow out of ADHD, and there appears to be a good reason for this. Research suggests that with ADHD, the brain is delayed in some areas by about three years. It still develops in a typical pattern, but some areas will take longer. Eventually, the functioning in these areas catches up, which is when the symptoms of ADHD seem to lessen or disappear.

And if the symptoms are from anxiety?

Anxiety comes from a part of the brain called the amygdala. It's a tiny almond-shaped part at the back of the brain, and its job is to keep us safe by warning us when there might be danger. When the amygdala senses a threat, the brain immediately switches to auto-pilot and initiates the fight or flight response. It hands the bulk of the workload to the more primitive, automatic, impulsive lower brain (at the back of the brain). At the same time, it organizes for the prefrontal cortex to sit out for a while until the threat has passed. When this happens, behavior becomes less planned, more intuitive, and more impulsive. 

There's a good reason for sending the prefrontal cortex offline when there's an immediate threat. The amygdala doesn't want the prefrontal cortex to use valuable survival time thinking, planning, and deciding – it just wants to get you safe. If a wild animal runs at you, there's no time to think about whether it might be lost, angry, hungry, or misunderstood. Your brain wants you out of there – fast. 

It's important to remember that the fight or flight response doesn't only happen when there's a threat. For kids with anxiety, it can feel constant. Sometimes, the amygdala gets a little too overprotective and initiates the fight or flight response too many times, too unnecessarily – just in case. It's evidence of a robust and healthy brain switching into survival mode, but just a little more than it needs to. That's evolution for you. Sometimes, it gives us opposing thumbs, and sometimes it gives us anxiety. 

Anxiety, ADHD, and the look-alike symptoms. 

Even though the symptoms of ADHD and anxiety might look the same, they will be driven by different processes. It's also important to remember that not all ADHD seems the same, and not all anxiety appears the same, but there are versions of both that can look similar. Let's go through the symptoms:

Difficulty in class makes careless mistakes, distracted, inattentiveness, restless, difficulty focusing/ planning.

If it's caused by anxiety: 

When anxiety hits in class, it can shut down the prefrontal cortex, the part of the brain that is important for thinking, learning, and remembering. Anxiety protects you from threats, so the brain shuts down to detail. Instead, it becomes focused on staying safe. Anxiety can distract kids from worrying thoughts that they cannot apply themselves to whatever they are working on. This can make kids appear restless and distracted, making it difficult to focus, retain information, or pay attention. When kids are highly anxious, their thoughts are consumed with their worries. They might need help writing, sitting still, staying focused, or copying from the board. They might also be reluctant to ask questions or ask for guidance. 

If ADHD causes it: 

With ADHD, the symptoms are thought to be because, in the prefrontal cortex, the neurotransmitters norepinephrine and dopamine levels aren't quite what they need to be. Neurotransmitters are the chemicals in the brain that help brain cells communicate with each other. Everything we do depends on the levels of these neurotransmitters being at the proper levels. Even the most minor changes in norepinephrine and dopamine levels can significantly affect the prefrontal cortex's capacity to do its job effectively. Norepinephrine increases the signals for appropriate response. Dopamine decreases any irrelevant 'noise' that might get in the way. When the levels of these neurotransmitters are out, kids can have difficulty ignoring outside stimuli. It's not that they cannot pay attention; they are paying attention to different things or too many things simultaneously.

Hyperactivity, fidgeting, squirming, talking or moving too much, extra movement when doing simple tasks. 

If it's anxiety: 

When the brain feels there might be a threat, it surges the body with neurochemicals to prepare the body for fight or flight. The idea is to get the body faster, stronger, and more potent to fight or flee the danger. These neurochemicals build up if there is no need for fight or flight. The energy created has to go somewhere. Sometimes, this can look like 'too much movement,' such as fidgeting, tapping, wringing hands, or pacing.

If it's ADHD: 

The part of the brain that calms our behavior is a little slower to activate, meaning there need to be more messages instructing the body to stop or slow down. 

Impulsive behavior.

If it's anxiety: 

When the sensations of fear or anxiety are intense, the surging of fight or flight chemicals sends the prefrontal cortex (the seat of self-control) offline. The impulsive, instinctive amygdala takes charge. When this happens, the prefrontal cortex isn't available to help calm big feelings or plan a more considered, less impulsive response. When the anxiety passes, the prefrontal cortex will retake charge and guide healthier answers. Impulsive behavior can also resemble aggression, the 'fight' part of the fight or flight response. Anxiety and big emotions come from the same amount of the brain, so when pressure is on total volume, other emotions, such as anger, might also be switched up to high. Something else to be mindful of is that being silly, which can sometimes look like impulsive behavior, might be used as a mask by kids to cover up their anxiety or nervousness. 

If it's ADHD: 

Differences in the parts of the brain that manage self-control mean that behavior might be more impulsive. This isn't because of bad behavior but because of a brain not quite doing what it needs to. 

Need help to finish schoolwork, poor time management.

If it's anxiety: 

Kids with anxiety might have trouble completing their schoolwork. Anxiety can cause kids to worry about making mistakes. Because of this, they might do things over and over or take plenty of time to make sure their work is correct or as close to perfect as it can be. It's more about the need to produce perfect, mistake-free work than about ability, failure to focus, or failure to plan. 

If it's ADHD: 

Kids with ADHD cannot keep their attention on a task, most likely because of an inability to manage impulses or shut out irrelevant distractions. The work doesn't get completed because of the regular shifts in focus. 

Difficulty organizing tasks and activities and managing sequential tasks, disorganized work.

If it's anxiety:

The left brain loves logic and sequences, and it helps to give structure and order to our experiences ('this, then this, then this …'). The right brain is more concerned with emotion and 'what does this mean for me?'. It's heavily directed by bodily sensations and messages from the lower brain, the major player in anxiety. We need both sides of the brain to work well together, but sometimes, in all of us, one side will become dominant for a while. If a child feels anxious in class or about a specific task, the right' emotional' brain can take over and temporarily disconnect from the left side. While the anxiety is high, there will be more heightened emotion, a greater focus on 'what does this situation mean for me,' and less concern for order or logic. 

If it's ADHD:

Insufficient levels of neurochemicals make it difficult for the brain to screen out irrelevant stimuli. There needs to be more relevant information coming in and creating noise. This means that however hard kids with ADHD try to organize their work and do what's expected, their busy brains will make organization difficult. 

ANXIETY OR ADHD? HOW CAN I TELL THE DIFFERENCE? 

If you suspect ADHD, getting a proper assessment from someone qualified to diagnose is essential. Be mindful that many of our discussed symptoms might always point louder to ADHD than anxiety. In some instances, it may be that both anxiety and ADHD are driving behavior. Whatever's happening, getting to the bottom of it is the most crucial step in getting your child the support they need to push forward.

Because a diagnosis of ADHD depends on observation and interpretation of the behaviors, be open to the possibility that if you go to an 'ADHD specialist' or a doctor who specializes in ADHD, they may be more likely to read the symptoms as ADHD. Indeed, they can be an essential and excellent support for kids with ADHD, but always be ready to seek a second opinion if that's what you need for clarity. Ask as many questions as you need to, and remember, you are the expert on your child. If something feels wrong, keep chasing it down until things make sense.

Here are some clues that the symptoms might be more indicative of anxiety (or perhaps anxiety and ADHD) than ADHD.

• Kids with anxiety are generally more sensitive to social cues, what others think and feel, or what they need.
• Anxiety can create physical symptoms such as a racy heart, clamminess, tense muscles, tummy aches, headaches, nausea, or dizziness. This is the physiological basis of anxiety. When the neurochemicals that are there to ready you for fight or flight build up, they lead to physical symptoms. These symptoms feel awful, but if they are driven by anxiety, they are all completely safe.
• Children with anxiety don't tend to have as many problems with impulsivity. Their impulsive behavior generally happens in isolated bursts when they are anxious and is less likely to happen when they feel calm and safe.
• Children with anxiety will be unlikely to show problem behaviors when they are feeling calm, secure, and doing things they enjoy. Children with ADHD might struggle even when they are doing the things they want to be doing.
• Children with anxiety are more likely to talk about feeling worried, even if they can't articulate precisely what they are concerned about. This is because anxiety comes from a brain that thinks there might be a threat, not necessarily because there is one.

SUMMARY

The importance of a correct diagnosis is essential to ensure that kids with ADHD receive the best possible support to manage the symptoms and limit the intrusion into their day-to-day lives. You will always be the expert on your child, and you're their voice when something doesn't feel right. There will be times when you'll need other experts on your team, but the glue that will hold it all together will be you – your questions, your questioning, your answers, your second opinions – whatever it takes for things to make sense. 

All kids need a support crew made up of the adults around them who are ready to help lift them to full flight. The support crew will look different for every child but will likely involve family, teachers, coaches, and sometimes therapists, specialists, and doctors. ADHD can be tricky to diagnose, but there are many excellent clinicians out there who, with you by their side, can widen your child's opportunity to be the best they can be.