What are the most appropriate questions to ask a young patient to determine whether attention‑deficit/hyperactivity disorder or anxiety is more impairing and which condition should be prioritized for treatment?

Structured Clinical Interview to Differentiate ADHD from Anxiety and Determine Treatment Priority

Begin by establishing symptom chronology and cross-setting impairment, then assess functional domains systematically—this approach determines which condition is primary and guides treatment sequencing.

Essential Chronological Questions

Symptom Onset and Developmental History

• "Before age 12, did teachers or other adults comment that [child's name] had trouble paying attention, staying seated, or waiting their turn?" This establishes whether ADHD criteria can be met, since symptoms must begin before age 12. 1, 2
• "When did you first notice the anxiety symptoms—was it before or after the attention/hyperactivity problems started?" Anxiety that develops after longstanding ADHD suggests secondary anxiety from repeated failure, whereas anxiety predating attention problems suggests a primary anxiety disorder. 1
• "Has there been any traumatic event, major loss, or significant stress that coincided with when these symptoms began or worsened?" This screens for trauma-related conditions (PTSD, complex PTSD) that mimic both ADHD and anxiety. 1, 3

Cross-Setting Impairment Assessment

Multiple Informant Verification

• "Do teachers report the same attention/hyperactivity problems you see at home, or are the problems mainly in one place?" ADHD requires impairment in two or more settings; single-setting problems suggest situational anxiety or environmental factors. 1, 2
• "Have you received feedback from at least two different teachers, coaches, or activity leaders about these behaviors?" Obtain structured reports from multiple school personnel to document cross-setting patterns. 1

Functional Impairment Domains

Academic Functioning

• "Is [child's name] failing to complete homework because they can't focus long enough, or because worry makes them avoid starting it?" Inattention-driven incompletion suggests ADHD; avoidance due to perfectionism or fear of failure suggests anxiety. 4, 5
• "Does [child's name] understand the material when they do focus, or do they struggle even when paying attention?" This differentiates primary attention deficits from anxiety-driven performance blocks. 6, 7

Social Functioning

• "Does [child's name] have trouble making or keeping friends because they interrupt, can't wait their turn, or act impulsively—or because they're too worried to join activities?" Impulsive social problems point to ADHD; social withdrawal from worry indicates anxiety. 5, 7
• "When [child's name] has peer conflicts, is it usually because they didn't notice social cues or acted without thinking, or because they were afraid of being judged?" This distinguishes ADHD-related social impairment from anxiety-driven avoidance. 6, 7

Daily Living and Self-Care

• "Does [child's name] forget daily routines (brushing teeth, packing backpack) because they're distracted, or because worry overwhelms them?" Forgetfulness from distractibility suggests ADHD; paralysis from worry suggests anxiety. 4, 5
• "How much time does [child's name] spend worrying each day, and does the worry stop them from doing things they need or want to do?" Quantify worry time and avoidance behaviors to gauge anxiety severity. 5, 7

Sleep Patterns

• "Does [child's name] have trouble falling asleep because their mind is racing with worries, or because they can't settle their body down?" Worry-driven insomnia suggests anxiety; motor restlessness at bedtime suggests ADHD. 1, 8
• "Does [child's name] snore, gasp, or stop breathing during sleep?" Screen for sleep apnea, which mimics both ADHD and anxiety. 1, 8

Severity and Quality-of-Life Impact

Comparative Impairment

• "If we could fix only one problem right now—the attention/hyperactivity issues or the anxiety—which would make the biggest difference in [child's name]'s daily life?" This parent-priority question reveals which condition is most functionally impairing. 4, 5
• "On a scale of 0 to 10, how much does the anxiety interfere with school, friendships, and home life? Now rate the attention/hyperactivity problems the same way." Quantify relative impairment to guide treatment sequencing. 4, 5

Comorbidity Burden

• "Have you noticed sadness, irritability, or loss of interest in activities [child's name] used to enjoy?" Screen for depression, which affects treatment sequencing—severe depression becomes the primary target. 1, 3
• "Does [child's name] have repetitive behaviors, rigid routines, or difficulty with social communication beyond just anxiety or inattention?" Rule out autism spectrum disorder, which alters the treatment approach. 1, 2

Substance Use Screening (Adolescents)

• "Has [child's name] used marijuana, alcohol, stimulants, or other substances? If yes, when did the attention or anxiety symptoms start relative to substance use?" Substance use can mimic both ADHD and anxiety and must be addressed first. 1, 3, 8
• "Have you noticed [child's name] asking for medication refills early or sharing/selling their medication?" Screen for stimulant diversion risk. 1, 3

Treatment Sequencing Algorithm

When ADHD is Primary (More Impairing)

Initiate FDA-approved stimulant medication combined with parent training in behavior management (PTBM) and behavioral classroom interventions; anxiety often improves secondarily as ADHD-related failures decrease. 1, 3

• Stimulants achieve approximately 70% response rates and frequently produce secondary reductions in anxiety symptoms. 3
• The combination of medication and behavioral therapy allows lower stimulant doses, reducing adverse-effect risk. 1
• If anxiety persists after ADHD symptoms improve, add cognitive-behavioral therapy (CBT) targeting anxiety. 3, 9

When Anxiety is Primary (More Impairing)

Begin with evidence-based CBT for anxiety; once anxiety symptoms show clear reduction, reassess whether residual attention problems represent true ADHD or were secondary to anxiety. 3, 9

• Children with anxiety demonstrate attentional bias toward threat rather than generalized sustained-attention deficits. 6
• CBT for anxiety remains effective even in children with comorbid ADHD; ADHD symptoms do not preclude benefit from anxiety-focused therapy. 9
• If significant ADHD symptoms persist after anxiety treatment, initiate stimulant medication. 3

When Both are Equally Severe

Initiate stimulant medication first because of rapid onset (days to weeks), allowing quick assessment of whether ADHD symptom reduction improves the anxiety picture; add CBT for anxiety within 4–6 weeks if anxiety remains severe. 3

• Combined treatment (medication + behavioral therapy) offers greater improvements in academic and conduct measures than medication alone, particularly when anxiety is comorbid. 1
• Two or more anxiety comorbidities predict significantly poorer quality of life and daily functioning, necessitating aggressive treatment of both conditions. 5

When Trauma or Depression is Present

Trauma-focused therapy or depression treatment becomes the primary target and must be addressed before or alongside ADHD treatment. 1, 3

• If major depression is severe, it becomes the primary treatment target. 3
• Trauma symptoms (reexperiencing, avoidance, emotion dysregulation) require trauma-focused interventions before expecting full ADHD symptom control. 3, 8

Critical Pitfalls to Avoid

• Do not diagnose ADHD based on single-setting reports; this pattern reflects situational problems, not ADHD. 1, 2
• Do not withhold stimulants due to anxiety concerns; evidence shows good tolerability and frequent anxiety improvement with ADHD treatment. 3, 9
• Do not treat ADHD in isolation when comorbidities exist; untreated anxiety or depression markedly worsens outcomes. 1, 3, 5, 7
• Do not delay treatment while pursuing diagnostic certainty; behavioral interventions (PTBM) benefit families even without a confirmed diagnosis. 1, 2, 8