What questions should be asked in the medical history to differentiate ADHD from anxiety?

Differentiating ADHD from Anxiety Through History-Taking

Core Temporal and Developmental Questions

The most critical distinguishing feature is that ADHD symptoms must have onset before age 12 and persist continuously across multiple settings since childhood, while anxiety symptoms typically emerge later or in response to specific stressors. 1

Age of Onset and Chronicity

• Ask: "When did you first notice these symptoms?" ADHD requires symptom onset before age 12 years, documented through retrospective recall from parents or school records. 1
• Ask: "Have these difficulties been present continuously since childhood, or did they start more recently?" ADHD is a chronic, lifelong condition present since early development, whereas anxiety disorders can emerge at any age. 1, 2
• Ask: "Were there any specific events or stressors that triggered the onset of symptoms?" Anxiety often has identifiable precipitants or trauma exposure, while ADHD does not require a triggering event. 1, 3

Setting-Specific Manifestations

• Ask: "Do these problems occur at home, school/work, AND in social situations?" ADHD symptoms must be present across at least 2 settings with functional impairment documented in each. 1, 3
• Obtain collateral information from multiple sources: parents/guardians, teachers, school personnel, workplace supervisors, and partners to confirm cross-situational impairment. 1, 3
• Ask teachers/supervisors: "How does the child/adult function in structured versus unstructured activities?" ADHD symptoms persist regardless of structure, while anxiety may worsen in specific performance or social situations. 1

Symptom-Specific Differentiating Questions

Attention and Concentration Patterns

• Ask: "Is difficulty concentrating constant and present across all activities, or does it worsen in specific anxiety-provoking situations?" ADHD inattention is pervasive and chronic, while anxiety-related concentration difficulties are typically situation-specific and episodic. 1, 3, 4
• Ask: "Can you focus well on activities you enjoy or find interesting?" Individuals with ADHD often show preserved attention during highly stimulating or preferred activities, whereas anxiety impairs concentration even during enjoyable tasks when worry is present. 1, 4
• Ask: "Do you have trouble finishing tasks because your mind wanders to unrelated things, or because you're worrying about the task itself?" ADHD involves mind-wandering to irrelevant stimuli, while anxiety involves rumination about task performance or consequences. 1, 4

Hyperarousal versus Hyperactivity

• Ask: "Do you feel physically restless and driven to move, or do you feel tense and on-edge?" ADHD hyperactivity involves motor-driven restlessness present since childhood, while anxiety involves tension and hypervigilance that may fluctuate. 1, 4
• Critical caveat: Some hyperactivity symptoms (difficulty relaxing, feeling driven by a motor) overlap significantly between ADHD and anxiety and should NOT be used as primary differentiating features. 4
• Ask: "Does physical activity or movement help you feel better, or does it not change your internal sense of tension?" ADHD-related hyperactivity is often relieved by movement, while anxiety-related tension persists despite physical activity. 4

Impulsivity versus Anxiety-Driven Behaviors

• Ask: "Do you act without thinking in multiple situations (interrupting, blurting out answers, making quick decisions), or do you avoid situations because you're worried about what might happen?" ADHD involves pervasive impulsivity, while anxiety typically involves avoidance and over-planning. 1, 4
• Ask: "Do you have trouble waiting your turn or sitting still in situations where it's expected?" This is characteristic of ADHD hyperactivity-impulsivity present since childhood. 1

Trauma and Anxiety-Specific Screening

Trauma History and Reexperiencing

• Ask: "Have you experienced or witnessed any traumatic events?" Anxiety disorders, particularly PTSD, require trauma exposure and include reexperiencing symptoms (flashbacks, nightmares) that ADHD lacks. 1, 3
• Ask: "Do you have intrusive thoughts or memories about specific events, or is your mind just generally scattered?" Trauma-related intrusions are content-specific, while ADHD involves general distractibility. 1, 3
• Ask: "Do you avoid specific places, people, or situations because they remind you of something distressing?" Trauma-specific avoidance distinguishes anxiety/PTSD from ADHD. 1, 3

Worry Content and Patterns

• Ask: "What do you worry about most?" Anxiety involves specific worry content (performance, social evaluation, health, safety), while ADHD does not involve excessive worry as a core feature. 1, 2
• Ask: "Is it hard to control your worrying once it starts?" Uncontrollable worry is characteristic of generalized anxiety disorder, not ADHD. 1, 2

Functional Impairment Patterns

Academic and Occupational History

• Ask: "Have you always struggled with school/work performance, or did problems start at a specific point?" ADHD causes lifelong academic/occupational difficulties, while anxiety-related impairment may have later onset. 1, 3
• Ask: "What specific problems do you have at school/work: completing assignments, organizing materials, remembering instructions, or anxiety about performance?" ADHD involves executive dysfunction, while anxiety involves performance-related distress. 1, 3
• Review report cards and school records: Look for teacher comments about inattention, hyperactivity, or impulsivity dating back to elementary school for ADHD diagnosis. 1

Social Functioning

• Ask: "Do you have difficulty making or keeping friends because you interrupt, don't listen, or act impulsively, or because you feel anxious in social situations?" ADHD causes social problems due to impulsivity and inattention, while anxiety causes social withdrawal and avoidance. 1, 2

Mandatory Comorbidity Assessment

Critical: ADHD and anxiety disorders co-occur in approximately 14% of children with ADHD, and comorbidity significantly worsens functional outcomes. 3, 2

• Screen for depression: Approximately 9% of children with ADHD have comorbid depression, which requires separate assessment and may need to be treated first if severe. 3, 2
• Screen for oppositional defiant disorder, conduct disorder, substance use, learning disabilities, and sleep disorders: These commonly co-occur with both ADHD and anxiety. 1, 3
• Ask: "Do you use caffeine, alcohol, or other substances to manage your symptoms?" Substance use can mimic or exacerbate both ADHD and anxiety symptoms. 1

Common Diagnostic Pitfalls

• Do not rely solely on self-report in adolescents and adults: Individuals with ADHD often underestimate their symptom severity and impairment; collateral information from partners, parents, or supervisors is essential. 1, 5
• Do not diagnose ADHD based on current symptoms alone without confirming childhood onset: New-onset attention problems in adolescence or adulthood are more likely due to anxiety, depression, or other conditions. 1, 5
• Do not use hyperactivity symptoms alone to differentiate: Symptoms like "difficulty relaxing" and "feeling driven by a motor" overlap significantly and may reflect anxiety rather than ADHD. 4
• Recognize that oppositional behavior in children may be anxiety-driven: Children may use oppositional behavior to manage anxiety in the face of overwhelming demands, which can be mistaken for ADHD-related impulsivity. 2

Structured Assessment Tools

• Use DSM-5-based ADHD rating scales from multiple informants: Parent and teacher rating scales substantially enhance diagnostic reliability over unstructured interviews. 1
• For adults, use the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A as an initial screener: A positive screen requires 4 or more items marked "often" or "very often" out of 6 questions, but recognize that this tool has limited specificity in the presence of anxiety. 5, 6
• Use anxiety-specific measures (PARS for children, STAI for adults) to quantify anxiety symptoms separately: This helps distinguish overlapping symptoms and track treatment response. 1, 7, 6
• Consider using only inattentive items from ADHD scales when anxiety is present: Research suggests that inattentive symptoms have better discriminant validity than hyperactive-impulsive symptoms in differentiating ADHD from anxiety. 6