Evidence-Based Reviews

Double jeopardy: How to treat kids with comorbid anxiety and ADHD

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Medication and CBT usually are necessary for these highly impaired children.



Aaron, age 10, has been diagnosed with an anxiety disorder and attention-deficit/hyperactivity disorder (ADHD) but is not being treated with medication because his parents do not believe in psychopharmacology. They bring him to a specialized child anxiety clinic and ask for “urgent CBT” because his behavior at school is out of control.

Aaron rearranges the therapist’s office furniture during much of the assessment interview. He also acknowledges many anxiety symptoms. The therapist doubts that cognitive-behavioral therapy (CBT) would help without other interventions.

Children with anxiety disorders and ADHD—a common comorbid presentation—tend to be more impaired than those with either condition alone.1 Effective treatment usually requires 4 components (Table 1), including medication plus behavioral or cognitive-behavioral therapy. This article discusses clinical issues related to each component and describes how to successfully combine them into a treatment plan.

Table 1

Comorbid ADHD and anxiety: 4 treatment components

Successful treatment usually involves combining 4 components:
  • medication trial of a stimulant or atomoxetine
  • psychological intervention with behavioral or cognitive-behavioral therapy
  • family psychoeducation, with particular attention to possible anxious or inattentive traits in parents that may affect treatment
  • treating the whole child by collaborating with school personnel
Make individual adjustments as needed, depending on the child’s symptom profile, social context, and developmental level
ADHD: attention-deficit/hyperactivity disorder

Medication options

Stimulants, atomoxetine, and selective serotonin reuptake inhibitors (SSRIs) have been advocated for children with anxiety and ADHD. Given the high risk of behavioral disinhibition with SSRIs in children,2 stimulants or atomoxetine are suggested as first-line medications.3,4

Stimulants target ADHD symptoms primarily, but anxiety decreases in some children (24% in a recent trial) as ADHD symptoms are controlled.4 Because it is a selective norepinephrine reuptake inhibitor (SNRI), atomoxetine may target both ADHD and anxiety symptoms. When initiating these medications, “start low and go slow.” Recommended dosing is no different for children with ADHD and anxiety than for those with ADHD alone (Table 2).5

Stimulant response rates for children with ADHD and anxiety vary among studies. Some report lower response rates than for children with ADHD alone and possibly more treatment-emergent side effects.6 The National Institute of Mental Health’s Multimodal Treatment Study of Children with ADHD (MTA) found that comorbid anxiety did not adversely affect behavioral response to stimulants but did moderate outcomes (Box 1).7,8 Adding intensive psychosocial intervention to stimulant treatment appeared to yield greater improvements in anxious children with ADHD, compared with stimulants alone.8

Cognitive impairments related to inattention do not consistently improve with stimulant treatment.9 This is clinically important because children with ADHD and comorbid anxiety disorders can be very cognitively impaired.10

Add an SSRI? Monotherapy is simpler and usually more acceptable to families, but a placebo-controlled study examined adding an SSRI (fluvoxamine) to methylphenidate treatment.4 Children with anxiety and ADHD who received adjunctive fluvoxamine did no better than those who received methylphenidate plus placebo.

Atomoxetine. A large, randomized, controlled trial of atomoxetine in this population found good tolerability and statistically significant reductions in ADHD and anxiety symptoms compared with placebo. Effect size was greater for ADHD symptoms than for anxiety symptoms,11 however, which supports smaller trials that show more consistent evidence of atomoxetine reducing ADHD symptoms than anxiety symptoms.

Similar to antidepressants with the SNRI chemical structure, atomoxetine’s effectiveness for a given child takes several weeks to determine. This can be a problem in children who are highly distressed or impaired and require rapid symptomatic improvement.

Recommendation. Consider a stimulant or atomoxetine initially for children with anxiety disorders and ADHD, and seek concurrent behavioral or cognitive-behavioral therapy. Caution families that:

  • >1 medication trial might be needed, as response may not be as consistent as in children with ADHD alone
  • medication-related improvements in ADHD symptoms will not necessarily be associated with reduced anxiety symptoms or improved academic ability
  • improvements with atomoxetine might not be evident for several weeks.

Table 2

Medication dosing for children with ADHD*

MedicationRecommended starting dosageRecommended maximum dosage5 most common side effects in descending prevalence
Methylphenidate hydrochloride (Ritalin)5 mg tidTotal 60 mg/dInsomnia, nervousness, decreased appetite, dizziness, nausea
Methylphenidate hydrochloride (Concerta)18 mg every morning54 mg every morningHeadache, abdominal pain, decreased appetite, vomiting, insomnia
Dextroamphetamine sulfate (Dexedrine)5 mg every morningTotal 40 mg/dPalpitations, restlessness, dizziness, dry mouth, decreased appetite
Mixed amphetamine salts (Adderall)10 mg every morning30 mg every morningDecreased appetite, insomnia, abdominal pain, emotional lability, vomiting
Atomoxetine (Strattera)0.5 mg/kg/d1.2 mg/kg/dDecreased appetite, dizziness, stomach upset, fatigue, irritability
ADHD: attention-deficit/hyperactivity disorder
* Recommended dosing is no different for children with ADHD and anxiety than for children with only ADHD
Source: Reference 5


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