Modern-day management and diagnosis of ADHD all too often leave out one major factor: the increasing rates of anxiety in our culture. And we must ask if anxiety is making it more difficult to diagnose ADHD.

As a pediatrician with additional training in mental health, over four decades, I have witnessed vast changes in the diagnosis and treatment of what we now know as ADHD. Labels have changed from Minimal Brain Dysfunction to the current ADHD, medication choices are vastly improved, and comprehensive educational evaluations and innovative treatments such as neurofeedback, CBT, and coaching are now available.

A New Challenge to Diagnose ADHD

But there is a new challenge for physicians, educators, and psychologists as they diagnose ADHD because increasing levels of anxiety are added to the clinical picture.

Anxiety-related problems have increased significantly in society at large, as well as in the kids we are seeing with attention issues. I see this trend in my practice, and it is confirmed by numerous published reports. In the 1970s, it was rare to see a child/teen who had co-morbid anxiety with ADHD.

Today, at least one in three children/teens have either clinically significant anxiety as the cause of their executive dysfunction or ADHD and co-morbid anxiety. This significantly complicates diagnosis and treatment because stimulant medication has the potential to exacerbate anxiety, especially in higher doses.

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Why Is Anxiety Increased?

While society's increased anxiety is a complex issue, here are a few contributing factors:

• The world is perceived, rightly or not, as much more dangerous. From our neighborhoods where few kids go out to play without supervision to the fear of terrorism, we can easily see the seeds of doubt in the public's psyche.
• There is an educational arms race to get children into the “best school.” The age of “tiger moms and dads” has become a “normal” part of American culture. This increases pressure to take more AP courses and stay up until midnight doing homework.
• Kids with ADHD as a group face their own educational challenges, which leads to additional stress.
• While giving us a powerful communication tool, there remain questions about whether social media leaves us happier and better off for our online connectivity and dependence on immediate feedback from our “friends.” MIT's Sherry Turkel, in her recent best-seller, Alone Together, gives one pause when it comes to the issue of anxiety.
• Did you know that most teens' anxiety levels begin to increase if they have not received a return text within 10 seconds?! What happens to your anxiety level if someone responds negatively or, worse, not at all?
• This is particularly a problem for ADHD kids, many of whom have social difficulties and may retreat “into a world of social media for connecting with others.”

Addressing the Problem

Professionals need to acknowledge this real change in anxiety levels and begin to mitigate the problem by initiating a dialogue about stress related to unhealthy levels of academic demands and the impact of social media.

We need to create environments where it is safe for kids to try and fail. When a child is struggling in school, parents must play a balancing act between protecting (not enabling) and supporting. Allowing kids to be able to succeed while overcoming challenges is especially difficult. A parent's natural instinct may err on the side of over-protectiveness, inadvertently stunting the growth of a child's independence. My experience with helicopter parents is that many of their children suffer the most from anxiety. It is important for parents to find a healthy balance in the educational and emotional lives of their kids.

3 Needed Changes 

1. Parents must learn to support without enabling. Nothing builds self-esteem better than children or teens knowing that they have the freedom to learn from their failures in a loving, supportive environment and they have been successful in their accomplishments.
2. Pediatricians working with the ADHD population need to receive more training and continuing education in behavioral medicine.*
3. Professionals doing ADHD evaluations need to place a greater emphasis on emotional assessment, including indices for anxiety.

All of us who care for patients or children with ADHD need to be aware of the pervasive effect of anxiety in our families, our schools, our financial institutions, and our nation. Remember what Charles Darwin said: “It is not the strongest or the brightest who survive, but those who can adapt.” We can help our kids adapt most effectively if we work together and keep them at the center of our ATTENTION.