ADHD and Anxiety: The Complex Interplay of Sex, Age, and ADHD Subtypes

For children and adolescents with attention-deficit/hyperactivity disorder (ADHD), inattention and anxiety are reciprocally related among girls whereas anxiety predicted hyperactivity-impulsivity among boys. These study findings were published in The Journal of Child Psychology and Psychiatry.

Although previous research has demonstrated an association between ADHD and anxiety, it remains unclear as to how different subtypes of ADHD are associated with anxiety and whether this relationship significantly differs by sex and age.

To address this uncertainty, investigators from the Norwegian University of Science and Technology conducted a cohort study using data from 2 birth cohorts in Norway. When children were aged 4 and 6 years, parents completed the semi-structured Preschool Age Psychiatric Assessment (PAPA) to evaluate ADHD and anxiety. Once children reached 8 years of age, both parents and children underwent separate Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime version (K-SADS-PL) interviews every 2 years until the children reached 16 years of age. The study cohort included a total of 1077 children, 49% of whom were girls.

The investigators found that as the children aged, hyperactivity-impulsivity remained relatively stable whereas the prevalence of inattention and anxiety increased. At each time point, greater levels of inattention and hyperactivity-impulsivity were associated with higher levels of anxiety (P <.05).

Among all children, anxiety was significantly predicted by increased levels of inattention at 4 to 6 (b, 0.13; P =.046), 6 to 8 (b, 0.16; P =.016), 8 to 10 (b, 0.17; P =.002), and 10 to 12 years of age (b, 0.23; P =.001). When evaluating the reciprocal association, the investigators found that inattention was predicted by increased anxiety at 12 to 14 (b, 0.15; P =.009) and 14 to 16 years of age (b, 0.14; P =.011). Further, increased hyperactivity-impulsivity at 6 to 8 years of age (b, 0.16; P =.017) and 8 to 10 years of age (b, 0.13; P =.042) predicted increased anxiety 2 years later.

When stratified by sex, the investigators found that increased anxiety was significantly associated with increased attention among girls at 6 (b, 0.15; P <.001), 8 (b, 0.26; P <.001), 10 (b, 0.25; P <.001), 12 (b, 0.22; P <.001), 14 (b, 0.11; P =.040), and 16 years of age (b, 0.07; P =.041). For boys, increased inattention at only 10 to 12 years of age predicted anxiety 2 years later (b, 0.24; P =.015). In addition, increased anxiety at 6 and 8 years of age predicted increased hyperactivity-impulsivity at ages 8 (b, 0.29; P <.001) and 10 (b, 0.27; P <.001) years of age among boys.

The investigators concluded, “These findings suggest that efforts to minimize attention problems may mitigate the risk of anxiety in girls throughout childhood and adolescence, whereas targeting hyperactivity-impulsivity in boys during early school years may reduce their susceptibility to anxiety.”

The primary study limitation is the reliance on only parental reports of anxiety before children were 8 years of age.

This article originally appeared on Psychiatry Advisor