How “bad behavior” may signal anxiety in kids with ADHD

Many kids with ADHD also deal with anxiety. Together, this can end up looking like defiance, avoidance, or just acting out at school. 

In this episode, we’re breaking down what’s really going on behind these behaviors. And we share practical ways that parents can support their kids — at home and at school — through clear communication, behavior plans, and strategies that actually work.

Related resources

• Listen: How can you help an anxious child

• Read: 6 things I wish I’d known about my son’s anxiety

• Download: Anxiety tracker for kids

Timestamps:  

(05:40) Why teachers misinterpret ADHD behavior as defiance

(10:30) Behavior is communication: Decoding what kids are really saying

(16:00) How behavior intervention plans (BIPs) support kids with ADHD

(22:30) Motivating kids: Rewards, buy-in, and real-world success

Episode transcript

Julian Saavedra: Many kids with ADHD also struggle with anxiety. And when those two collide, the classroom can feel like a pressure cooker. The effort to stay focused, follow directions, and manage big emotions can build up fast. For some kids, that pressure spills out as frustration, avoidance, or acting out.

Dr. Kristin Carothers: And so in the classroom setting, that could look like some outright defiance or refusal to do some work. It could look like that kind of inattentive space-cadet-ish behavior where you've given the kid multiple prompts to engage, to start the work, and they just won't start.

Julian: That's Dr. Kristin Carothers, a clinical psychologist and Understood expert who helps kids and families navigate moments just like this. Welcome to "The Opportunity Gap," a show about how to navigate the education system. I'm your host, Julian Saavedra, an assistant principal with over 20 years of experience. On today's episode, we're unpacking the powerful trio: ADHD, anxiety, and behavior in the classroom.

Dr. Kristin: And I think it's really hard for teachers to tease apart, is this like an executive function ADHD issue? Is this an anxiety issue? Or is this defiance?

Julian: We'll talk about why ADHD and anxiety often go hand in hand, how they show up in school, and what parents can do to help, both at home and in partnership with teachers. Because when we understand what's driving a child's behavior, we can respond, not just react. Dr. Kristin Carothers, what's going on? How are you?

Dr. Kristin: Thank you for having me. I'm doing all right. How are you?

Julian: Oh, I'm fantastic, and happier that you're back on the show with us. All right, so first and foremost, Dr. Kristin, let's talk about ADHD and anxiety. Can you help us break down how ADHD and anxiety often occur together?

Dr. Kristin: ADHD and anxiety tend to co-occur, but the research is not super clear on what we call the comorbidity or the coexistence of the two. But anecdotally and in my work with children, adolescents, and adults, I've found that many people who struggle with ADHD also experience underlying symptoms of anxiety.

But it's hard for the people around them to be aware of the fact that they're experiencing anxiety because typically their ADHD symptoms are so loud. It's externalizing behaviors, disorganization, trouble with planning. But we can get into more about why they tend to co-occur or what I see in clinical practice and I think in life in general.

Julian: Got it. So, let's think about like a typical child that they might be experiencing both. Like they're experiencing ADHD, they're also experiencing anxiety. What might that look like in a classroom setting?

(05:40) Why teachers misinterpret ADHD behavior as defiance

Dr. Kristin: So, we know there's three presentations of ADHD. We got our inattentive presentation, hyperactive-impulsive presentation, combined presentation. And for a kid who struggles with either of those presentations and anxiety, what you might find is you may assume that they're avoiding doing work because they struggle with sustained attention or concentration or they lose focus easily.

But they might also avoid doing that work because they have thoughts about their ability to complete the work well or to complete the work quickly or what it means if the work isn't done right. And so in the classroom setting, that could look like some acting out behavior, some outright defiance or refusal to do some work. It could look like that kind of inattentive, space-cadet-ish behavior where you've given the kid multiple prompts to engage, to start the work, and they just won't start.

The other piece is kids may be coming to school with exposure to high levels of stress at home. And so not only do they present with ADHD, but they've got a family system that's chaotic or they're in the midst of a transition and they're worried about food, clothing, shelter, if their parents are going to get along, if somebody's going to come home that night. And those worries can get in the way of them being able to show up fully in the classroom. And then it's even more complicated when they have problems with planning, organization, and attention. Their attention resources are being used up by the stress that they're experiencing outside.

Julian: And I like that you identified how this shows up in real time. Like you just mentioned, planning, organization, attention. Those are all things that fall under executive functioning, which we know children with ADHD struggle with. Can you talk to us a little bit about how those challenges with executive functioning skills, how does that contribute to anxiety even more than what's already present?

Dr. Kristin: I think the concept that comes to mind most often when I think about this is the concept of anxious avoidance. So people who tend to experience high levels of worry tend to avoid things that they fear or that they don't think they're good at. And so the thought is, "I'll escape my discomfort or the anxiety that I feel by avoiding engaging in an activity."

What happens though when you have ADHD is you are already in a position where you often put things off until the last minute because of poor planning, poor time management skills. And so when you find that you're only kind of on target and planning the things that you enjoy or that you're hyperfocused about and everything else is kind of like, "Oh, go ahead and forget it. I can put it off until later."

What you find is this feedback loop where you're lacking the motivation to do something that you need to do, maybe because it's not in an area of interest, or you're not doing the thing you need to do because you have worried thoughts about what it means to get it done and whether or not you'll be able to get it done. Perfect storm, they come together. Next thing you know is the last minute and you're trying to get things done but you don't do them well because your attention resources are taxed or you're super anxious about it.

And I think it's really hard for teachers to tease apart, is this like an executive function in ADHD issue? Is this an anxiety issue? Like the kid is worried about things happening to them or around them or their abilities, like performance? Or is this defiance? And so this is where Julie and I would say we want to try to do a functional behavioral analysis to figure out what's driving these behaviors in the classroom.

Julian: And like you said, some of this is internal. And anxiety in many cases doesn't show up externally. You can't see how somebody's feeling. All these things could be happening inside the child's head and you have no idea. All you see is a child with their head down or a child that might be acting out or a child that just isn't doing the work. And so a lot of times, these struggles with ADHD and anxiety, for our listeners and parents especially, sometimes they show up as behavior problems. Right?

So let me ask you, Dr. Kristin, what kinds of behaviors might be misinterpreted in students with ADHD and anxiety? And I'm honing in on the word misinterpretation.

Dr. Kristin: I think acting out behaviors. So talking back. I also think that leaving the classroom because they've got to go to the bathroom or they say they've got to go to the bathroom, or refusal to work with other students because they may be embarrassed about their performance in comparison to others, or kind of getting involved in everybody else's business rather than focusing on getting a task accomplished or finished.

Julian: The head down is a big one. Putting a head down or being really honed in on a device if the child has a Chromebook or a phone or an Apple watch, if the teacher's reporting that the child is just looking at that, I've seen a lack of eye contact. Going back to that word of misinterpretation, a lot of times those things that we label as oppositional or defiant are triggered by anxiety. Talk to us a little bit about that. What are your thoughts?

(10:30) Behavior is communication: Decoding what kids are really saying

Dr. Kristin: Right. So if we look at what drives oppositional behavior, typically what drives oppositional behavior is a desire to have some need met and a belief that you need this need met by any means necessary and a little bit of difficulty with perspective taking. So your need is so important in that moment that you're unable to see how or why a person may not be able to meet your need because of other things that are going on in the context. So you're kind of blind.

Right? So if a kid comes in an oppositional stance, they're refusing to do work because they just don't want to do the work. They don't have the bandwidth for it. They're not taking in the perspective of, "Well, if I get the work done now, then I don't have to do it later, and then I might have more time for fun or it would make the teacher really happy, or it would free me up later to be able to do some other things." They're just thinking about how they feel in that moment and getting what they want in that moment.

So if we're trying to figure out how anxiety could drive that oppositionality, we're looking at, "Does the person have the resources? Does the person think they have the resources to be able to engage in a behavior in that moment and be successful?" So even if you believe they're the most brilliant person in the world, they've got so much potential, if they don't believe that they have the resources to be able to do it or perhaps they're so drained from other things biologically or socially that they're not able to approach, their oppositional stance is going to be even more firm.

Julian: There are a lot of internal thoughts that are happening and there's not a coping mechanism for the child to deal with that anxiety that's happening in the moment. And so they choose to act in a certain way to, like you said, get the need that they need met. For all of our listeners out there, behavior is communication. Yes. And when we think about the idea of oppositional or defiance or whatever you want to call it, whether it's cursing you out, whether it's putting your head down, whether it is sucking your teeth, whether it's rolling your eyes, whether it is not doing the work, whether it is going to hit somebody to get attention, all of that is communication.

The child is trying to tell us something. They're trying to tell us that they need something or that they want something, and they don't have the language or the skills or the capacity in that moment to tell us in a way that we think is appropriate. And so they're choosing to do it in a way that's going to get our attention. I'll do something so that I signal something's going on and I need help. And this is the way that I'm communicating it.

Dr. Kristin: And in that same frame, like if a kid is anxious and in their bodies, they're experiencing somatic symptoms, or stomach aches, headaches, dry mouth, they don't want to experience that. They're going to run to the bathroom, and they may legitimately be going to the bathroom because they've got to release because they've got a stomach ache because they're so worried. But it could be interpreted as they're just trying to avoid doing work, and they're so hyperactive and fidgety and restless that they're always leaving the classroom. But they might literally be experiencing some somatic symptoms related to anxiety, going to the bathroom because that's the way that they've learned to alleviate that anxiety.

Julian: For the parents listening right now, they've heard us talk about how these behaviors show up. They've heard us talk about anxiety and ADHD, how anxiety can be internal, ADHD symptoms can be external. And in some cases, all of it becomes visible, maybe defiance. What do I do? What are some strategies that as a parent, I can do at home to try to deescalate or respond when the child's anxiety is starting to drive some of this behavior that we're talking about? What are some specific strategies that a parent can do to start managing some of this anxiety and ADHD together when it's impacting behavior?

Dr. Kristin: I think first the parent has to have awareness that there is anxiety. Typically, as parents, we, parents and teachers, are better reporters of externalizing behaviors, children, adolescents, better reporters of internalizing experiences. And so parents and teachers may miss the anxiety because they're focused on the hyperactivity or the fidgetiness or the restlessness or the staring off into space. And so for parents, we've got to ask questions.

Julian: So, give me a couple questions that I can ask when I'm at home with my kid.

Dr. Kristin: Okay. So we start out benign. Tell me two things that went really well today. All right, now give me something that was disappointing for you today. And then how did you feel? Or coming right out and saying, "You know, I've been really stressed out at work this week because I have this deadline and it's made me worried that maybe I'm not going to meet the deadline. Have you had anything like that happened to you this week with school? Like have there been things you've been feeling pressured or worried about? What about with your friends? Like how is everybody doing? Have you been feeling okay about how you guys are getting along or anything that's been making you question yourself?" So you don't have to say anxiety.

Julian: Mm.

Dr. Kristin: Worry, question yourself, thinking about it, getting stuck in your head, making it difficult for you to sleep at night, is it waking you up in the middle of the night? When you think about it, it makes your stomach hurt. So naming those types of symptoms rather than saying anxiety or triggered.

Julian: So you're saying like don't necessarily use the word anxiety or trigger, but maybe replace it with "worry" or some of the physical symptoms that might be happening?

Dr. Kristin: I think you replace it with like a specific example of what it could show up as, because many times we're using these words and we don't know what they mean. So everybody's on TikTok diagnosing themselves, everybody's on Instagram, right? All these social media platforms, we're using these words. We've got gaslighting, we've got this, we've got that, but we don't really know what the words mean.

And so if we ask questions that are specific to kind of behaviors or specific to patterns of thought, then I think it can help elicit more of a response from the kid who may not know. They may not understand the term.

Julian: Got it. So you're asking a whole bunch of questions. Maybe the baby talks to you, maybe they don't. But maybe they start getting into the pattern of talking to you a little bit.

Dr. Kristin: It's going to take some time though. You can't just do this one time and then be like, "Well, I asked and they said nothing." It's got to be like, "Okay, it's we're on the way to school, or you just got home and we're going to keep at this thing."

Julian: Every day.

Dr. Kristin: Every day if you can. Five minutes of special time, five minutes of conversation.

Julian: And I love that you shared, like starting with a story about yourself. "Mom really struggled with something today at work and I felt this way." So sharing how you feel as the parent and how things make you feel might open your child up to sharing how they might be feeling.

(16:00) How behavior intervention plans (BIPs) support kids with ADHD

Julian: So, last thing I wanted to touch upon, and you mentioned it earlier, Dr. Kristin, about an FBA, or a functional behavioral analysis. In schools, there are sometimes processes, especially with children with IEPs and 504s. FBA can lead to something called a BIP, or a Behavior Intervention Plan. As we mentioned, behavior is communication. And the behavior might be communicating to us with that functional behavioral analysis that we need to put something in place. So, can you briefly tell us one, what is a Behavior Intervention Plan, or BIP? And secondly, how might that be tailored to kids who are experiencing ADHD and anxiety?

Dr. Kristin: So a Behavior Intervention Plan is an evidence-based tool that is used to develop a treatment plan for decreasing problematic behaviors, increasing optimal behaviors. So I would say it's like, okay, if we've got a cookbook and our cookbooks have recipes. A functional behavioral analysis is the tool we use to figure out what ingredients are we going to need to be able to create some dish. The behavioral intervention plan is our recipe.

What we do, we collect data looking at a specific behavior. So if a kid's, let's say it's a kid who's struggling with anxiety and ADHD, and we notice that they are doing a lot of classroom avoidance. So when they're in the classroom, they're not starting work right away or they're not finishing work, and then they're leaving the classroom often to go to the bathroom, staying in the bathroom for long periods of time. We know that this is happening during science class and during math class. It does not happen during reading. Okay.

We've collected our data over time and we've determined that the child really enjoys the reading class, really loves that teacher, loves the structure of the classroom. Science and math, the child has had an experience in the past where they haven't performed the way they thought they were going to perform, or they've gotten messages that they're not really good at it, they're not connecting with the teachers. So they're escaping or just before it's time to go to that class, they come up with an excuse to go someplace else and they're showing up late.

Behavioral intervention plan says, "Okay, here's what we know. We know that this kid is really reinforced by the reading class, really enjoys it. We're going to make sure that they have opportunities to help the teacher out in that class. We're going to keep things strong there. For science, what we're going to do is we're going to have that child transition to the science class with the aid of a friend that is also in the class that they can go and sit next to to get started. 

When they're there, our step one is to increase the amount of time that they're in the classroom. And so what we're going to say is, 'If you are in the classroom on time and you're there for the first 15 minutes, you can take a break after 15 minutes for a five-minute bathroom break and then you're going to come back. We're going to allow you to take a max of two breaks per class for three weeks. And we're going to see if you're able to complete your work and how often you show up on time.'

When we collect our data after three weeks and we know how many times you've been on time, how many times you've completed work on time, we can say, 'Okay, you've met that goal. So now we're going to decrease from having you leave the classroom twice in one period to once in the period because you've shown us that you are really getting this. You're doing a great job at staying focused in the classroom.'

You would also hopefully as part of a behavioral intervention plan, not just have things that are structures that are set up in the classroom, but also have some check-ins with a guidance counselor that are scheduled so that a kid doesn't have to act out to be able to go to a guidance counselor. You might even have an intervention where if there is some special activity that is happening around science, that child can earn the opportunity to participate in that activity by having attendance in the class for four out of five days. And so the behavioral intervention plan sets up a system, like a daily report card system where we're keeping track of the kid's on-task behaviors.

We've determined what the behaviors are based on what the deficits were from the functional behavioral analysis. We come up with some things in the environment to kind of reinforce them, right? And we also want to kind of validate that they're having a hard time and they can do more. So that behavioral intervention plan is just our treatment plan. Like when you go to the doctor, it's our recipe. If you're making a cake, it's the things that we need to do in specific increments to be able to get this kid's behavior to change to improve in some way.

For anxiety, ADHD, the classroom isn't going to be the only place we want to see some intervention. We're going to hope that a kid is able to access some individual therapy resources to also get some additional assistance. So that was a long way of answering.

(22:30) Motivating kids: Rewards, buy-in, and real-world success

Julian: I think you hit the nail right on the head in that it really clarifies how a behavior intervention plan can be spelled out. So let me tell you a story about my day today. As an administrator, I serve as LEA, or the local education advocate, at IEP meetings for 250 students. Like I have a really large case load that I work with in my school.

And today, I had six different IEP meetings. And at one of the IEP meetings I was present at, I had a ninth-grade boy and he has ADHD and he has a reading disability, but he also has emotional support services. His ninth-grade year has been really good. He started the year off great.

He talked about how in seventh and eighth grade, he didn't have a lot of teachers that supported him and that he would put his head down, he would act out, and he'd get in trouble. And he's being raised up by his auntie. And his aunt also said the same thing, that he really struggled in middle school. But he's doing really well in ninth grade.

And so I asked him, you know, "Tell me what's going on. Why are you doing so well here?" And he said, "Well, I have a behavior plan that's really helping me." And I was like, "Well, tell me more about that." He's like, "Well, my case manager, he and I work together and we have a plan in place where if I did what I needed to do, then I would get to earn something that I wanted."

"We set a plan in place where if I did all my work and I communicated when I needed a break and I checked that off for three weeks, that I would get to play one of your Nintendo Switches with one of my friends and I love 'Super Smash Brothers' and I'd play that during class."

This is a Switch that I have. I bought some Switches that we use in the classroom for incentives. And so he earned it and he and a bunch of his friends, they got some extra time to play "Smash Brothers" because he earned it based on his behavior plan. This boy is really motivated by video games and by food. And on Friday, he is going to get to eat a hot chicken sandwich. If you're not from Philly, Nanu's Hot Chicken in Philly, it's a thing. All the kids love it. And so he's getting a chicken sandwich and he's going to get to play his "Smash Brothers."

And it is written into his positive behavior support plan. We call it that, but it's a behavior intervention plan. It is written into the plan. It is in his IEP. We talked about it at the IEP meeting. And I can tell you that it is a motivating factor for him for somebody that is experiencing anxiety, for somebody that is experiencing ADHD and emotional support services.

And he was able to explain what the plan was. His auntie was able to explain what the plan was. His case manager explained the plan. And it's showing success. So when I say all that, this is real and it can show real results. The key to it working, everybody has to come together.

Dr. Kristin: And be on board.

Julian: And so parents, when you're out there trying to figure this out, my advice to you is to get together with the school, get together with your child and start to figure out, "How can we put a plan in place that is going to one, identify what the issues are, help our children get the language to communicate what they need, but then have a crystal clear plan? Who do I go to, what do I do when these feelings start coming up?" Because the goal is to increase communication. Yes. And then again, the IEP or the 504 plan, they are designed to be individualized. So if that means a hot chicken sandwich and a Nintendo Switch Super Smash Brothers tournament is going to be the thing, then make it happen. Right? Make it happen.

Dr. Kristin: That's a rewards menu.

Julian: But that's what you got to do.

Dr. Kristin: The rewards have to be really rewarding in order to change the behavior. So we don't come up with the things that we think are rewarding. We ask the kid, like, "What do you want to earn? What do you like? What are you looking forward to?" You get their buy-in. This is their plan. That is a kid who's empowered. Yep. He's like, "I worked with my case manager."

Julian: Oh, listen, he was hyped. And, you know, we ended the meeting. I explained that for our students that earn A's and B's, at the end of ninth grade, we take them to a really fancy Italian restaurant at the end of the year. And, you know, for a lot of my students, they don't get to go out to eat like that. Right. So we give them, you know, top shelf, three courses. You know, they get the cannolis, they get waiters and waitresses, the whole thing.

And when I told him that, you know, his face completely changed like, "I'm going to get those grades then. I'm going to be at that trip." But again, it's clarifying what is going to motivate our children and allowing them to be part of the process because we need to let them communicate. Yes.

Julian: Dr. Kristin, you know, you and I could do this all day long. We could chit chat all day long. But I always appreciate your expertise. I appreciate how you're able to break down really difficult concepts into bite-sized chunks for our listeners. And the feedback we get from the listeners is that it's needed and it helps them feel confident going into the meetings they have to go to to support their kids. So from my show to your expertise, I just really appreciate you coming on.

Dr. Kristin: Thank you. And I always appreciate you having me. For you as an educator with boots on the ground in your position as a Black male educator in a inner city setting, like you are doing so much to inspire so many people. So thank you for having me.

Julian: I appreciate that. And so our listeners and our viewers out there, please subscribe to "The Opportunity Gap" on YouTube. Please check us out on all of the different places you can find our podcast and everything that Understood.org does. Until next time, OG family, we appreciate y'all. Dr. Kristin, thank you so much.

Thank you.

Thanks so much for listening today. We love hearing from our listeners, so if you have any thoughts about today's episode, you can email us at opportunitygap@understood.org.

And be sure to check out the show notes for links and resources to anything we mentioned in the episode.

This show is brought to you by Understood.org. Understood.org is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at understood.org/give.

Credits

Julian: "The Opportunity Gap" is produced by Julie Subrin and Gretchen Vierstra. Video is produced by Calvin Knie and edited by Jessie DiMartino.

Briana Berry is our production director. Jordan Davidson is our editorial director.

From Understood.org, our executive directors are Laura Key and Scott Cocchiere. Thanks again for listening.