Is Clinical Anxiety a Risk or a Protective Factor for Executive Functioning in Youth with ADHD? A Meta-regression Analysis

Abstract

Comorbidity rates between ADHD and anxiety disorders (AD) are high, but little is known about the nature of this cooccurrence. A dominant idea is that AD may intensify some (i.e., attention and working memory) and attenuate other (i.e., inhibition) ADHD symptoms. Results are mixed, potentially because of between-study differences. To investigate this further we performed a meta-regression analysis on 11 studies (n 'ADHD-only' = 695; n 'ADHD + AD' = 608), containing 35 effect sizes on attention, inhibition and working memory. Main results were: (1) no evidence of a negative effect of AD on attention and working memory; (2) better response inhibition in children with ADHD with AD than those with only ADHD (medium ES g = − .40); (3) medication moderated this association: the effect seemed limited to studies that included medication-naïve participants; (4) the difference between the two groups increased with age for attention and with proportion of boys for working memory ability. There was no effect of comorbid disruptive behavior disorder. In conclusion, AD seems to be a protective factor for inhibition problems as assessed with laboratory tasks in ADHD, especially in children who are medication naïve. Further, AD may have a protective function for attention in older children, and for working memory in boys with ADHD. It is therefore important to screen for AD when diagnosing ADHD, and to educate those with comorbid AD about the possible positive function of feeling anxious. Potential negative effects of ADHD medication on inhibition in children with comorbid AD should be considered.

Does Co-Occurring Anxiety Modulate ADHD-Related Cognitive and Neurophysiological Impairments?

“…Unlike the meta-analysis by Maric and colleagues (Maric et al, 2018), we did not find that the presence of anxiety links with attenuated working memory deficits in male participants with ADHD. The lack of beneficial effects of anxiety traits on working memory impairments in our sample may results from the use of the digit span of the Wechsler scale, which yielded heterogeneous results in the previous studies summarised in the recent meta-analysis (Maric et al, 2018). Further studies, using more detailed measures of working memory, i.e., from computerised tasks such as the Cambridge Neuropsychological Test Automated Battery (CANTAB; Morris, Evendon, Sahakian, & Robbins, 1987), will need to clarify this issue further.…”

“…Additionally, we found no significant mitigation effects of anxiety on the remaining cognitive, electrophysiological and electrodermal activity measures, and the mitigation effects of anxiety on inhibition impairments were weaker when obsessive-compulsive traits were included in the anxiety scores. Our results are in line with a recent meta-analysis showing that, when pooling 11 studies which compared youth with ADHD and those with comorbid ADHD-anxiety, there were no differences in attention and working memory impairments in individuals with both ADHD and an anxiety disorder compared to those with ADHD only (Maric et al, 2018). However, our results did not align with previous evidence showing that high anxiety symptoms or anxiety disorders may ameliorate inhibition impairments in individuals with ADHD (Bloemsma et al, 2013;Maric et al, 2018;Ruf et al, 2017).…”

“…Our results are in line with a recent meta-analysis showing that, when pooling 11 studies which compared youth with ADHD and those with comorbid ADHD-anxiety, there were no differences in attention and working memory impairments in individuals with both ADHD and an anxiety disorder compared to those with ADHD only (Maric et al, 2018). However, our results did not align with previous evidence showing that high anxiety symptoms or anxiety disorders may ameliorate inhibition impairments in individuals with ADHD (Bloemsma et al, 2013;Maric et al, 2018;Ruf et al, 2017). It is worth noting that the association between anxiety disorders and reduced impairments in cognitive inhibition was limited to studies with medication-naive participants in the meta-analysis by Maric and colleagues (2018).…”

“…Moreover, the age range was wide in our sample. This prevented us from examining whether the impact of anxiety on cognitive-neurophysiological impairments in ADHD may vary with age, similar to a previous report (Maric et al, 2018), as stratifying the analyses by age would have resulted in small samples and low power to detect interaction effects. However, as we controlled for age in all analyses, it is unlikely that our results are confounded by age effects.…”

“…While supporting the potential attenuation effects of anxiety on inhibitory deficits in individuals with ADHD, this more recent evidence does not corroborate the negative interference of anxiety on attention and working memory functions in ADHD. Yet, it was noted that wide age ranges and predominantly male samples may limit the effects on attention and working memory, respectively (Maric et al, 2018).…”