Anxiety and irritability symptoms frequently co-occur in children with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aims to investigate whether irritability and anxiety are uniquely associated with performance on measures of cognitive functioning in children with ADHD and whether these associations hold when accounting for confounding variables. Baseline data was used from a randomised controlled trial of cognitive behavioural therapy for anxiety in children with ADHD (N = 219, 8–13 years). Anxiety was assessed using the child- and parent-reported Spence Children’s Anxiety Scale, while irritability was assessed using the parent-reported Affective Reactivity Index. Children completed the National Institutes of Health Toolbox - Cognition Battery. Higher symptoms of anxiety were uniquely associated with performance on the Dimensional Card Change Sort Test (β = −2.75, confidence interval (CI) [−4.97, −.52], p = .02) and the List Sort Working Memory Test (β = −2.57, CI [−4.43, −.70], p = .01), while higher symptoms of irritability were negatively associated with Picture Vocabulary Test (β = −2.00, CI [−3.83, −.16], p = .03). These associations did not survive correction for multiple comparisons. There was little evidence of an association between anxiety or irritability symptoms and cognitive functioning. Frequent co-occurrence of anxiety and irritability suggests clinicians working with children with ADHD should assess co-morbid symptom profiles to inform the provision of optimum care.
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Adleman, N. E., Fromm, S. J., Razdan, V., Kayser, R., Dickstein, D. P., Brotman, M. A., Pine, D. S., & Leibenluft, E. (2012). Cross-sectional and longitudinal abnormalities in brain structure in children with severe mood dysregulation or bipolar disorder. Journal of Child Psychology and Psychiatry, 53(11), 1149–1156.
Adleman, N. E., Kayser, R., Dickstein, D., Blair, R. J. R., Pine, D., & Leibenluft, E. (2011). Neural correlates of reversal learning in severe mood dysregulation and pediatric bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 50(11), 1173–1185 e1172.
Albano AM, Silverman WK. (In Press) The anxiety disorders interview schedule for dsm-5, child version. Parent Interview, 1.0.
Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985). The aberrant behavior checklist: A behavior rating scale for the assessment of treatment effects. American journal of mental deficiency.
American Psychiatric Association. (2000). Diagnostic criteria from dsM-iV-tr: American Psychiatric Pub.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub.
Arendt, K., Hougaard, E., & Thastum, M. (2014). Psychometric properties of the child and parent versions of Spence Children's anxiety scale in a Danish community and clinical sample. Journal of Anxiety Disorders, 28(8), 947–956.
Australian Bureau of Statistics. (2006). Census of population and housing: Socio-economic indexes for areas (SEIFA). Australia-Data only.
Barkley, R. A. (1997). ADHD and the nature of self-control: Guilford press.
Barkley, R. A. (1999). Response inhibition in attention-deficit hyperactivity disorder. Mental Retardation and Developmental Disabilities Research Reviews, 5(3), 177–184.
Bauer, P. J., & Zelazo, P. D. (2014). The National Institutes of Health toolbox for the assessment of neurological and behavioral function: A tool for developmental science. Child Development Perspectives, 8(3), 119–124.
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal statistical society: series B (Methodological), 57(1), 289–300.
Biederman, J., Faraone, S. V., & Chen, W. J. (1993). Social adjustment inventory for children and adolescents: Concurrent validity in ADHD children. Journal of the American Academy of Child & Adolescent Psychiatry, 32(5), 1059–1064.
Bishop, C., Mulraney, M., Rinehart, N., & Sciberras, E. (2019). An examination of the association between anxiety and social functioning in youth with ADHD: A systematic review. Psychiatry Research, 273, 402–421.
Bloemsma, J. M., Boer, F., Arnold, R., Banaschewski, T., Faraone, S. V., Buitelaar, J. K., Sergeant, J. A., Rommelse, N., & Oosterlaan, J. (2013). Comorbid anxiety and neurocognitive dysfunctions in children with ADHD. European Child & Adolescent Psychiatry, 22(4), 225–234. https://doi.org/10.1007/s00787-012-0339-9.
Brotman, M. A., Kircanski, K., Stringaris, A., Pine, D. S., & Leibenluft, E. (2017). Irritability in youths: A translational model. American Journal of Psychiatry, 174(6), 520–532.
Burke, J. D., Boylan, K., Rowe, R., Duku, E., Stepp, S. D., Hipwell, A. E., & Waldman, I. D. (2014). Identifying the irritability dimension of ODD: Application of a modified bifactor model across five large community samples of children. Journal of Abnormal Psychology, 123(4), 841–851.
Chhabildas, N., Pennington, B. F., & Willcutt, E. G. (2001). A comparison of the neuropsychological profiles of the DSM-IV subtypes of ADHD. Journal of Abnormal Child Psychology, 29(6), 529–540.
Cockcroft, K. (2011). Working memory functioning in children with attention-deficit/hyperactivity disorder (ADHD): A comparison between subtypes and normal controls. Journal of Child & Adolescent Mental Health, 23(2), 107–118.
Cohen, N. J., Menna, R., Vallance, D. D., Barwick, M. A., Im, N., & Horodezky, N. B. (1998). Language, social cognitive processing, and behavioral characteristics of psychiatrically disturbed children with previously identified and unsuspected language impairments. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 39(6), 853–864.
Conners, C. K. (1997). Conners' Teacher Rating Scale--Revised (L): Multi-health systems North Tonawanda, NY.
Dickstein, D. P., Nelson, E. E., McCLURE, E. B., Grimley, M. E., Knopf, L., Brotman, M. A., et al. (2007). Cognitive flexibility in phenotypes of pediatric bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(3), 341–355.
DiGiuseppe, R., & Tafrate, R. C. (2007). Understanding anger disorders: Oxford University press.
DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD Rating Scale—IV: Checklists, norms, and clinical interpretation: Guilford press.
Eriksen, B. A., & Eriksen, C. W. (1974). Effects of noise letters upon the identification of a target letter in a nonsearch task. Perception & Psychophysics, 16, 143–149.
Eysenck, M. W., & Calvo, M. G. (1992). Anxiety and performance: The processing efficiency theory. Cognition & Emotion, 6(6), 409–434.
Feldman, H. M., & Reiff, M. I. (2014). Clinical practice. Attention deficit-hyperactivity disorder in children and adolescents. The New England Journal of Medicine, 370(9), 838–846. https://doi.org/10.1056/NEJMcp1307215.
Fujiki, M., Brinton, B., & Clarke, D. (2002). Emotion regulation in children with specific language impairment. Language, Speech, and Hearing Services in Schools., 33, 102–111.
Gold, A. L., Brotman, M. A., Adleman, N. E., Lever, S. N., Steuber, E. R., Fromm, S. J., . . . Leibenluft, E. (2016). Comparing brain morphometry across multiple childhood psychiatric disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 55(12), 1027-1037. e1023.
Günther, T., Holtkamp, K., Jolles, J., Herpertz-Dahlmann, B., & Konrad, K. (2004). Verbal memory and aspects of attentional control in children and adolescents with anxiety disorders or depressive disorders. Journal of Affective Disorders, 82(2), 265–269.
Jarrett, M. A., Wolff, J. C., Davis III, T. E., Cowart, M. J., & Ollendick, T. H. (2016). Characteristics of children with ADHD and comorbid anxiety. Journal of Attention Disorders, 20(7), 636–644.
Jensen, P. S., Martin, D., & Cantwell, D. P. (1997). Comorbidity in ADHD: Implications for research, practice, and DSM-V. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1065–1079.
Kane, M. J., Brown, L. H., McVay, J. C., Silvia, P. J., Myin-Germeys, I., & Kwapil, T. R. (2007). For whom the mind wanders, and when: An experience-sampling study of working memory and executive control in daily life. Psychological Science, 18(7), 614–621.
Kircanski, K., White, L. K., Tseng, W. L., Wiggins, J. L., Frank, H. R., Sequeira, S., Zhang, S., Abend, R., Towbin, K. E., Stringaris, A., Pine, D. S., Leibenluft, E., & Brotman, M. A. (2018). A latent variable approach to differentiating neural mechanisms of irritability and anxiety in youth. JAMA Psychiatry, 75(6), 631–639. https://doi.org/10.1001/jamapsychiatry.2018.0468.
Korenblum, C. B., Chen, S. X., Manassis, K., & Schachar, R. J. (2007). Performance monitoring and response inhibition in anxiety disorders with and without comorbid ADHD. Depression and Anxiety, 24(4), 227–232.
Kovacs, M. (1985). The children's depression inventory (CDI). Psychopharmacology Bulletin, 21, 995–998.
Leibenluft, E. (2011). Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. The American Journal of Psychiatry, 168(2), 129–142. https://doi.org/10.1176/appi.ajp.2010.10050766.
Leibenluft, E. (2017). Pediatric irritability: A systems neuroscience approach. Trends in Cognitive Sciences, 21(4), 277–289.
Lyneham, H. J., Abbott, M. J., & Rapee, R. M. (2007). Interrater reliability of the anxiety disorders interview schedule for DSM-IV: Child and parent version. Journal of the American Academy of Child & Adolescent Psychiatry, 46(6), 731–736.
Manassis, K. (2007). When attention-deficit/hyperactivity disorder co-occurs with anxiety disorders: Effects on treatment. Expert Review of Neurotherapeutics, 7(8), 981–988.
Manassis, K., Tannock, R., & Barbosa, J. (2000). Dichotic listening and response inhibition in children with comorbid anxiety disorders and ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 39(9), 1152–1159.
Manassis, K., Tannock, R., Young, A., & Francis-John, S. (2007). Cognition in anxious children with attention deficit hyperactivity disorder: A comparison with clinical and normal children. Behavioral and Brain Functions, 3, 4. https://doi.org/10.1186/1744-9081-3-4.
Mulraney, M. (2014). Irritability: An investigation of prevalence and clinical correlates in adolescence and adulthood. Monash University,
Mulraney, M., Schilpzand, E. J., Hazell, P., Nicholson, J. M., Anderson, V., Efron, D., Silk, T. J., & Sciberras, E. (2016). Comorbidity and correlates of disruptive mood dysregulation disorder in 6-8-year-old children with ADHD. European Child & Adolescent Psychiatry, 25(3), 321–330. https://doi.org/10.1007/s00787-015-0738-9.
Oosterlaan, J., & Sergeant, J. A. (1998). Response inhibition and response re-engagement in attention-deficit/hyperactivity disorder, disruptive, anxious and normal children. Behavioural Brain Research, 94(1), 33–43.
Pagliaccio, D., Pine, D. S., Barch, D. M., Luby, J. L., & Leibenluft, E. (2018). Irritability trajectories, cortical thickness, and clinical outcomes in a sample enriched for preschool depression. Journal of the American Academy of Child & Adolescent Psychiatry, 57(5), 336-342. e336.
Pan, P.-Y., & Yeh, C.-B. (2019). Irritability and maladaptation among children: The utility of Chinese versions of the affective reactivity index and aberrant behavior checklist-irritability subscale. Journal of Child and Adolescent Psychopharmacology, 29(3), 213–219.
Pfiffner, L. J., & McBurnett, K. (2006). Family correlates of comorbid anxiety disorders in children with attention deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 34(5), 719–729.
Pliszka, S. R. (1989). Effect of anxiety on cognition, behavior, and stimulant response in ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 28(6), 882–887.
Pliszka, S. R. (1992). Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 31(2), 197–203.
Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A revised measure of children's manifest anxiety. Journal of Abnormal Child Psychology, 6(2), 271–280.
Rutter, M., Bailey, A., & Lord, C. (2003). SCQ. The Social Communication Questionnaire. Torrance, CA: Western Psychological Services.
Sciberras, L. K., Efron, D., Mensah, F., Gerner, B., & Hiscock, H. (2014). Anxiety in children with attention-deficit/hyperactivity disorder. Pediatrics, 133(5), 801–808. https://doi.org/10.1542/peds.2013-3686.
Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. The American Journal of Psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966.
Silverman, W. K., Saavedra, L. M., & Pina, A. A. (2001). Test-retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule for DSM-IV: Child and parent versions. Journal of the American Academy of Child & Adolescent Psychiatry, 40(8), 937–944.
Sørensen, L., Plessen, K. J., Nicholas, J., & Lundervold, A. J. (2011). Is behavioral regulation in children with ADHD aggravated by comorbid anxiety disorder? Journal of Attention Disorders, 15(1), 56–66.
Spence, S. H., Barrett, P. M., & Turner, C. M. (2003). Psychometric properties of the Spence Children’s Anxiety Scale with young adolescents. Journal of Anxiety Disorders, 17(6), 605–625.
StataCorp, L. (2009). Stata statistical software. College Station TX.
Stoddard, J., Stringaris, A., Brotman, M. A., Montville, D., Pine, D. S., & Leibenluft, E. (2014). Irritability in child and adolescent anxiety disorders. Depression and Anxiety, 31(7), 566–573.
Stringaris, A., Goodman, R., Ferdinando, S., Razdan, V., Muhrer, E., Leibenluft, E., & Brotman, M. A. (2012). The affective reactivity index: A concise irritability scale for clinical and research settings. Journal of Child Psychology and Psychiatry, 53(11), 1109–1117.
Stringaris, A., & Taylor, E. (2015). Disruptive mood: Irritability in children and adolescents: Oxford University press, USA.
Tannock, R., Ickowicz, A., & Schachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child & Adolescent Psychiatry, 34(7), 886–896.
Toohey, M. J., & DiGiuseppe, R. (2017). Defining and measuring irritability: Construct clarification and differentiation. Clinical Psychology Review, 53, 93–108. https://doi.org/10.1016/j.cpr.2017.01.009.
Uran, P., & Kılıç, B. G. (2015). Comparison of neuropsychological performances and behavioral patterns of children with attention deficit hyperactivity disorder and severe mood dysregulation. European Child & Adolescent Psychiatry, 24(1), 21–30.
Vance, A., Ferrin, M., Winther, J., & Gomez, R. (2013). Examination of spatial working memory performance in children and adolescents with attention deficit hyperactivity disorder, combined type (ADHD-CT) and anxiety. Journal of Abnormal Child Psychology, 41(6), 891–900.
Vidal-Ribas, P., Brotman, M. A., Valdivieso, I., Leibenluft, E., & Stringaris, A. (2016). The status of irritability in psychiatry: A conceptual and quantitative review. Journal of the American Academy of Child and Adolescent Psychiatry, 55(7), 556–570. https://doi.org/10.1016/j.jaac.2016.04.014.
Vloet, T. D., Konrad, K., Herpertz-Dahlmann, B., Polier, G. G., & Gunther, T. (2010). Impact of anxiety disorders on attentional functions in children with ADHD. Journal of Affective Disorders, 124(3), 283–290. https://doi.org/10.1016/j.jad.2009.11.017.
Weintraub, S., Bauer, P. J., Zelazo, P. D., Wallner-Allen, K., Dikmen, S. S., Heaton, R. K., et al. (2013). I. NIH toolbox cognition battery (CB): Introduction and pediatric data. Monographs of the Society for Research in Child Development, 78(4), 1–15.
Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., & Pennington, B. F. (2005). Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review. Biological Psychiatry, 57(11), 1336–1346.
Yew, S. G. K., & O’Kearney, R. (2013). Emotional and behavioural outcomes later in childhood and adolescence for children with specific language impairments: Meta-analyses of controlled prospective studies. Journal of Child Psychology and Psychiatry, 54(5), 516–524.
This project has been funded by the National Health and Medical Research Council (NHMRC) of Australia (1106427) and the Sidney Myer Fund and Myer Foundation. ES is funded by an NHMRC Career Development Fellowship (1110688: 2016–21) and a veski Inspiring Women’s Fellowship. The MCRI is supported by the Victorian Government’s Operational Infrastructure Support Program. We would like to thanks all parents and children for their participation in this study.
Conflict of Interest
Jane McGillivray currently recieves funding from the Moose Foundation, Victoria Department of Education and Training, the Wenig Family and Grace & Emilio Foundation, to conduct research in the field of neurodevelopmental disorders and inclusion, and from the Ferrero Group Australia as part of its Kinder + Sport pillar of Corporate Social Responsibility initiatives to promote active lifestyles among young people. All remaining authors have declared no conflict of interest.
This study has ethical approval from the Royal Children’s Hospital Melbourne Human Research Ethics Committee (35164) and Deakin University Human Research Ethics Committee (2016–387).
Informed consent was obtained from a parent or caregiver of each child.
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Read, N., Mulraney, M., McGillivray, J. et al. Comorbid anxiety and irritability symptoms and their association with cognitive functioning in children with ADHD. J Abnorm Child Psychol 48, 1035–1046 (2020). https://doi.org/10.1007/s10802-020-00658-z
- Attention-deficit/hyperactivity disorder
- Anxiety disorder
- Cognitive function