Updated November 2026 · By Joel Blackstock, LICSW-S

ADHD and anxiety disorders turn up together far more often than chance would predict. In the U.S. National Comorbidity Survey Replication, 47.1% of adults with ADHD also had an anxiety disorder, and reviews of childhood ADHD put the overlap at roughly one in four children, with some estimates reaching one in three. Each can change how the other looks and how it responds to treatment.^{1, 2, 3}

My argument in this article is that, for many people, the overlap is not two diagnoses sitting side by side. It works as a loop. ADHD produces a steady stream of real misses: the forgotten form, the late bill, the half-finished project, the teacher or boss who calls it laziness. A nervous system that keeps getting ambushed by failure learns to expect it. The threat arousal that follows then degrades attention, working memory and mental flexibility, the same functions ADHD already strains. So treatment has to work on both ends: bring arousal down far enough that skills can actually be used, and treat the ADHD so the failures that feed the anxiety come less often. Organizing strategies taught to someone who is in a state of alarm are hard to use. No trial has tested that order of treatment directly. It is clinical reasoning built on the research below.

How common is the overlap?

The best-known adult estimate comes from the National Comorbidity Survey Replication (NCS-R), a nationally representative U.S. household survey. Clinicians re-interviewed a subsample, and the researchers estimated that 4.4% of adults aged 18 to 44 had current ADHD. Those adults were "highly comorbid" with other disorders, and most were not being treated for ADHD, even though many had received treatment for a co-occurring mental health or substance problem.⁴ That pattern will be familiar to many adults diagnosed late: years of treatment for anxiety or depression while the attention problem underneath went unnamed.

A 2022 systematic review of 32 studies compared adults with and without ADHD. Anxiety disorders were among the most frequent co-occurring conditions, after substance use and mood disorders. In general-population samples, the share of adults with ADHD who had an anxiety disorder ranged from 4.3% to 47.1%, the top figure being the NCS-R, where the rate among adults without ADHD was 19.5%. In clinical samples it ranged from 3.9% to 84%. In about two of every three studies that compared groups, anxiety disorders were more common among people with ADHD, and the authors suggested that the many different ways studies diagnosed ADHD may explain some of the spread.¹ Any single percentage deserves caution. The direction does not.

In children, reviews converge on roughly a quarter of those with ADHD meeting criteria for an anxiety disorder, and one trial team cites a range of 25% to 35%.^{2, 3} In the Multimodal Treatment Study of Children with ADHD (MTA), 33% of participants met criteria for an anxiety disorder other than a simple phobia.⁵ In the 2022 National Survey of Children's Health, based on parent report, 77.9% of U.S. children with current ADHD had at least one co-occurring disorder of some kind.⁶

None of this is a new discovery. Biederman and colleagues reviewed the literature in 1991 and found "considerable comorbidity" between ADHD and anxiety disorders, as well as mood disorders, conduct problems and learning disabilities. They proposed that these subgroups might differ in risk factors, course and response to medication.⁷ Nor is the combination its own disorder. "Anxiety-ADHD" is not a diagnostic category in the DSM-5-TR. Clinicians diagnose each condition on its own criteria and record both when both are present.⁸

How each condition feeds the other

Researchers have not settled why the two travel together. A 2008 review by Jarrett and Ollendick sorted the explanations into two groups. Some are about method, such as overlapping definitions and who reports the symptoms. Others are substantive: shared genetics, temperament, brain function, family influences, and which condition appears first.² What follows is the part of the picture that matters most in a therapy room, the ways each condition makes the other worse.

From ADHD to anxiety

People with ADHD get criticized a great deal. In a 2022 qualitative study, 162 adults with ADHD or high ADHD traits wrote about the criticism they had received. Inattentive behavior drew the most of it, impulsive behavior drew it mainly in social settings, and participants described harm to their self-worth and wellbeing. Some coped by avoiding situations where criticism might come.⁹ That detail matters, because in the cognitive-behavioral model avoidance is one of the main things that keeps anxiety going. Someone who has been called careless for twenty years starts scanning every email, meeting and deadline for the next mistake.

ADHD also brings emotional reactivity, even though it is not among the diagnostic criteria. A 2014 review in the American Journal of Psychiatry concluded that emotion dysregulation is common in ADHD across the lifespan and a major contributor to impairment.¹⁰ A 2020 meta-analysis of 13 studies with 2,535 participants found that adults with ADHD scored far higher than controls on emotion dysregulation (Hedges' g = 1.17, a large effect), with emotional lability showing the biggest gap.¹¹ The 2022 adult review proposes two more possible routes: the social and relational difficulties ADHD creates, and a higher rate of accidents and traumatic events.¹ The trauma route is large enough that we cover it separately in how PTSD and ADHD overlap and get confused.

From anxiety to weaker executive function

The other half of the loop is better established in the laboratory. The attentional control theory of Eysenck and colleagues holds that anxiety weakens the goal-directed attention system and strengthens the stimulus-driven one, so threat cues grab attention more easily. The theory locates those effects in two executive functions, inhibition and shifting.¹² A 2016 meta-analysis of 177 samples and more than 22,000 people found that higher self-reported anxiety goes with poorer working memory capacity (g = −0.33), a finding that held across simple span, complex span and n-back tasks.¹³ In people who have ADHD, reviews report that co-occurring anxiety may make working memory problems worse.^{14, 15}

The neurobiology points the same way. Amy Arnsten at Yale has studied how stress acts on the prefrontal cortex, the region that supports planning, working memory and impulse control. Her 2009 review describes it as the brain region most sensitive to stress: even mild, uncontrollable stress can cause a rapid loss of prefrontal abilities, and prolonged stress changes the structure of prefrontal dendrites.¹⁶ In a review with Pliszka, she notes that the same region is underactive in many patients with ADHD and that relatively small changes in norepinephrine and dopamine produce significant changes in how well it works. ADHD medications appear to help in part by optimizing that signaling.¹⁷ Much of this work comes from animal studies, and it should not be stretched into a tidy brain diagram. The practical implication is still clear. A person with ADHD who is also chronically alarmed is running an already sensitive system under the conditions most likely to knock it offline.

When anxiety becomes the engine

Anxiety is not only a cost. Attentional control theory draws a distinction that matters a great deal here: anxiety damages efficiency more than it damages output. An anxious person can often still turn in good work by throwing extra effort at the task, at a hidden price in energy.¹² In ADHD that trade has a particular shape. Reviews report that co-occurring anxiety may partly dampen the impulsivity and weak response inhibition typical of ADHD, at least in childhood.^{14, 15} Fear of consequences works as a brake that the person's own executive system does not reliably supply.

Many adults with ADHD have built a working life on that brake. They wait until a deadline becomes an emergency, because the emergency is what finally switches on focus. They check the stove, the inbox and the calendar three times because they no longer trust their memory. They over-prepare for meetings, rehearse conversations in the car, and stay late to fix mistakes before anyone sees them. From the outside this can look like conscientiousness. From the inside it is exhausting, and it tends to give way when life gets fuller: a new baby, a promotion, the first semester away from home.

This kind of compensation is one reason ADHD gets missed, especially in girls and women. A review by Patricia Quinn and Manisha Madhoo found that girls' symptoms are more often inattentive than hyperactive and get judged "subthreshold," that females with ADHD may develop coping strategies that mask their symptoms, and that co-occurring anxiety and depression can lead to missed or wrong diagnoses. They warn that satisfactory grades should not rule ADHD out.¹⁸ Settings that prize achievement make the mask easier to wear. We have written about the achievement culture and anxiety built into Liberty Park, a master-planned community in Vestavia Hills. A child who meets that kind of standard through fear rather than steady attention can go unrecognized for decades.

There is a quieter psychological cost too. When anxiety has been the only thing that reliably gets work done, it starts to feel like part of the self. In depth-psychological terms, the vigilant, self-critical stance hardens into a persona the person cannot set down without fearing collapse. Many people in this position worry that if therapy makes them calmer, they will stop functioning. That fear deserves respect. It is a reasonable reading of the past. It is not necessarily a forecast, because the old bargain was struck without any treatment for the ADHD itself.

What the brain research does and does not show

The version of this topic that circulates online, including an earlier version of this page, splits the problem neatly. ADHD is a "prefrontal" disorder of dopamine depletion, anxiety "lives in" the amygdala, and the two fight like a gas pedal against a brake. The actual findings are messier and more useful.

Start with brain structure. The ENIGMA ADHD Working Group pooled MRI scans from 1,713 people with ADHD and 1,529 controls across 23 sites. People with ADHD had slightly smaller volumes in several subcortical regions, including the amygdala, nucleus accumbens, caudate, hippocampus and putamen. The effects were small (Cohen's d between −0.10 and −0.19), were largest in children, and were not statistically significant when adults were analyzed on their own. Medication use and co-occurring disorders did not explain them, and the authors read the pattern as delayed brain maturation.¹⁹ So the amygdala is part of the ADHD story as well, and group differences this small cannot diagnose an individual. These are differences in how a brain develops, not "neurological injuries."

Dopamine is part of the picture but is often overstated. Volkow's group at Brookhaven National Laboratory used PET imaging in 53 unmedicated adults with ADHD and 44 controls. They found lower dopamine transporter and D2/D3 receptor availability in the brain's reward pathway, and the lower levels tracked with inattention.²⁰ That is evidence of altered dopamine signaling in a reward circuit. It is not evidence that the brain "rapidly depletes" dopamine or is "starved" of neurotransmitters, and none of the studies reviewed for this article shows that.

Brain mapping has limits as well. For years an elevated EEG theta/beta ratio was promoted as a marker of ADHD. A 2013 meta-analysis of nine studies, covering 1,253 children and adolescents with ADHD and 517 without, concluded that the ratio "cannot be considered a reliable diagnostic measure of ADHD," though it may have prognostic value in a subgroup.²¹ Our practice offers qEEG brain mapping and neurofeedback. A map can describe a person's EEG pattern. It does not replace a clinical diagnosis, and no scan or EEG on its own can diagnose ADHD or an anxiety disorder.

Telling ADHD and anxiety apart, and seeing both

The overlap begins in the diagnostic criteria. Under the DSM-5-TR, generalized anxiety disorder in adults requires at least three of six associated symptoms, and two of the six are restlessness and difficulty concentrating, which also describe ADHD. ADHD has its own requirements: several symptoms present before age 12, symptoms in two or more settings, and a rule, criterion E, that the symptoms are not better explained by another mental disorder, anxiety disorders included.⁸

A careful evaluation asks questions that pull the two apart:

• When did it start? ADHD is developmental. Attention problems that began in childhood, before the worry did, point toward ADHD. Problems that arrived with a stressful period and lift when it lifts point toward anxiety.
• What kind of inattention is it? ADHD inattention is usually poor persistence: drifting off a task, losing the thread, leaving things unfinished, even when nothing is worrying the person. Anxious inattention is captured attention: the mind is busy with worry, or it goes blank under pressure.
• Does it show up in calm stretches? If focus problems persist when there is little to worry about, anxiety alone is a less likely explanation.
• What happens when one is treated? Sometimes the answer only appears over time, when anxiety treatment quiets the worry but the disorganization stays.

Questionnaires can start this conversation, not finish it. The six-question World Health Organization Adult ADHD Self-Report Scale screener was checked against blind clinical interviews of 154 NCS-R respondents. Its estimated overall accuracy was 97.9%, but its sensitivity was 68.7%, so it missed roughly three in ten people whom clinicians diagnosed.²² Our informal adult ADHD and AuDHD self-assessment is meant in the same spirit. A positive screen is a reason for a full evaluation, ideally one that also looks at anxiety, mood, trauma and sleep.

The DSM-5-TR lists a long set of conditions to distinguish from ADHD or to identify alongside it, among them anxiety, depressive and bipolar disorders, autism and PTSD.⁸ In mood disorders, ADHD-like symptoms tend to be confined to episodes of mania or depression, which is why bipolar disorder and ADHD need careful separation. Autism is on the list as well, and our guide to recognizing autism in adulthood covers what to look for.

What the treatment evidence says

The honest summary is that there are good treatments for each condition and fewer trials of the combination than anyone would like. Medication decisions belong with a prescriber who knows your full history. What follows describes research, not advice about any particular drug or dose.

Medication

The earlier version of this page had a section headed "The Pharmacological Trap" that broke off mid-sentence. The fear behind that kind of heading is usually that stimulants will make anxiety worse. The controlled evidence in children does not support that as a general rule. A 2015 meta-analysis of 23 double-blind, placebo-controlled trials with 2,959 children found that anxiety was reported less often on stimulants than on placebo (relative risk 0.86). The authors add that this does not rule out increased anxiety in some children.²³ In the MTA, anxiety did not weaken the response to medication.⁵ In a 12-week, industry-sponsored trial of 176 young people aged 8 to 17 with ADHD and an anxiety disorder, atomoxetine, a non-stimulant, reduced both ADHD and anxiety symptoms more than placebo.³ Studies of methylphenidate in people with both conditions have been conflicting, and some report a weaker response and more unpleasant arousal side effects, findings that reviewers say still need confirmation.¹⁵ Most of this evidence comes from children. If a medication seems to make anxiety worse, raise it with the prescriber rather than quietly stopping or concluding that treatment is impossible.

Psychotherapy

Cognitive behavioral therapy has a strong record for anxiety disorders. A 2018 meta-analysis of 41 placebo-controlled trials with 2,843 patients found a moderate effect on the target disorder (Hedges' g = 0.56), with large effects for generalized anxiety disorder, obsessive-compulsive disorder and acute stress disorder.²⁴ For adult ADHD, CBT adapted to the condition has support from a smaller body of trials. A 2020 systematic review found only nine randomized trials. In its pooled analyses, CBT outperformed waiting lists (four trials, 160 people) by a moderate-to-large margin and active control treatments (three trials, 191 people) by a small-to-moderate one.²⁵ In a JAMA trial, 86 adults already taking medication who still had symptoms received 12 sessions of either CBT or relaxation training with education. On the clinician global rating, 53% of the CBT group responded, against 23% of the comparison group, and responders kept their gains at 12 months.²⁶ Among children in the MTA, results on parent-reported outcomes favored including psychosocial treatment for those with anxiety.⁵

Exposure is a core part of CBT for anxiety, and it needs adapting for ADHD. Craske and colleagues' inhibitory learning approach treats exposure as new learning that has to compete with the old fear, rather than as simply waiting for fear to fade. Its strategies include deliberately violating expectations, removing safety signals, varying the practice and labeling feelings as they come up.²⁷ For someone with ADHD, the feared situation is often a task: the unopened email, the insurance form, the assignment avoided for weeks. Short, structured contact with that task, with a timer and without the usual rituals of checking and reassurance, is a way to work on both conditions at once. That is clinical reasoning drawn from the two literatures, not a separately tested protocol.

Body-based and lifestyle approaches

Lowering arousal is not only a matter of thinking differently. Exercise has some trial support for anxiety, though the evidence base is small: a 2017 meta-analysis of six randomized trials in 262 adults with anxiety or stress-related disorders found a moderate reduction in symptoms compared with control conditions.²⁸ Mindfulness-based therapies have been tested in ADHD, and a 2020 meta-analytic review of ten studies reported reductions in inattention and hyperactivity, which its authors framed as "possible benefits."²⁹

Some approaches we use have thinner evidence for this specific problem, and you should know that. Somatic Experiencing, which works with bodily sensation to resolve trauma responses, has preliminary evidence for PTSD symptoms from studies of mixed quality.³⁰ We are not aware of randomized trials of Somatic Experiencing or Brainspotting for ADHD with co-occurring anxiety. For neurofeedback in children and adolescents with ADHD, a 2016 meta-analysis of 13 trials found effects on ratings by the people closest to the treatment, but no significant effect on probably blinded ratings or against sham and active controls.³¹ We use body-based work because many anxious people cannot think their way out of a racing heart, and because calming the body can make the more structured work possible. We do not present it as a proven treatment for ADHD.

What this looks like in therapy

When someone arrives with both ADHD and anxiety, the first task is an accurate picture. That means a developmental history of attention, not just a current symptom count, plus a look at sleep, substance use, trauma, mood and medical contributors. It also means asking what the anxiety is about. Worry that clusters around forgetting, lateness and being found out is different from worry that would be there with perfect executive function, and the two call for different emphasis.

From there the work usually runs on several tracks at once.

Lowering the alarm. Early sessions often start with the body: noticing the shift into threat, slowing the breath, building in movement, protecting sleep. The aim is not relaxation for its own sake. It is bringing arousal into a range where planning and memory can work, so the next skill has somewhere to land.

Making ADHD less punishing. Alongside that, we build structure that does not run on fear: visible calendars, body doubling, tasks broken down to the first physical step, reminders that live outside the head, and graded contact with the tasks that have been avoided longest. If medication is part of the plan, we coordinate with the prescriber.

Working with the inner critic. Years of correction leave a harsh internal voice. Parts-based work treats that voice as a protector that learned to prevent humiliation by keeping the person on edge. It can be understood, thanked for its effort, and gradually relieved of a job that fear no longer has to do.

Throughout, the stance is neurodivergent-affirming. The goal is not to turn an ADHD brain into a neurotypical one, and it is not to remove all anxiety. It is to replace fear as the main organizing force in a person's life with structure, self-understanding and treatment that fits. We explain that stance in what neurodivergent-affirming therapy means and why it is not about fixing you.

If this loop sounds familiar, our page on therapy for ADHD and AuDHD describes how we approach attention differences at Taproot, and our page on anxiety and panic treatment covers the anxiety side. When you are ready to talk it through, you can contact us to set up a first conversation.

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