A recent review of 41 research articles suggests that individuals with social anxiety disorder should be screened for attention-deficit/hyperactivity disorder (ADHD) and vice versa. The paper, published in the Journal of Attention Disorders, found that having both social anxiety disorder and ADHD is linked to more severe symptoms and higher levels of impairment compared to having just one of these conditions.
Social anxiety disorder is a mental health condition characterized by an intense fear of social situations due to the fear of being judged, embarrassed, or humiliated. Individuals with this disorder often experience significant anxiety and distress when interacting with others, which can lead to avoidance of social situations, difficulty forming relationships, and impairments in daily functioning.
ADHD, on the other hand, is a neurodevelopmental disorder characterized by persistent patterns of inattention, impulsivity, and hyperactivity. People with ADHD may struggle to focus on tasks, follow instructions, organize activities, and control impulses, often resulting in disruptive behaviors and difficulties in maintaining attention. The disorder is commonly diagnosed in childhood, but symptoms can persist into adulthood.
The review was motivated by the need to understand the overlap between these two common but seemingly different disorders. By systematically reviewing existing research, the study aimed to shed light on the prevalence, symptom severity, and potential subtypes of this comorbidity.
“As a clinical psychologist with a background in child and adolescent psychiatry, the intersection of ADHD with co-occurring anxiety represents a significant and underexplored area in clinical practice,” said study author Siri Jakobsson Støre, an assistant professor at Karlstad University and postdoctoral research associate at Örebro University.
“Through my training and clinical experience, I have observed the profound impact that these comorbid conditions can have on adolescents, affecting their academic performance, social interactions, and overall quality of life. This research provides an opportunity to contribute to a deeper understanding of comorbid ADHD and social anxiety disorder (SAD), which can ultimately inform future interventions – and provide more comprehensive and effective care for these individuals.”
The review followed the PRISMA guidelines for systematic reviews. The researchers searched databases like PsycInfo, PubMed, Scopus, and Web of Science for articles published from 2000 onwards that examined the relationship between ADHD and SAD. They included studies that used quantitative methods and met specific criteria, such as focusing on adolescents and adults and being peer-reviewed. The final sample comprised 41 studies conducted in various countries, primarily using cross-sectional designs.
Data extraction focused on the number of participants, age range, gender, diagnostic criteria used, and outcome measures related to ADHD and SAD. The quality of the studies was assessed using the Effective Public Health Practice Project Tool, which evaluates aspects like selection bias, study design, and data collection methods.
The prevalence of ADHD among individuals with social anxiety disorder varied widely across studies, ranging from 1.1% to 72.3%. Similarly, the prevalence of social anxiety disorder among individuals with ADHD ranged from 0.4% to 46.7%.
“This variation may be partly due to differences in how the studies defined and measured social anxiety and ADHD (clinical vs. subclinical conditions, diagnostic interview vs. symptom scale, clinical vs. general sample, etc.),” Støre explained.
The review also found that individuals with both social anxiety disorder and ADHD tend to experience more severe symptoms and greater impairments compared to those with only one of these disorders. This increased severity includes higher levels of social anxiety, more pronounced attention deficits, and greater difficulties in social functioning.
For example, individuals with both disorders were found to have more significant challenges in social interactions, such as generating fewer optimal solutions in social problem-solving tests and exhibiting lower levels of empathy. This suggests that the presence of both disorders compounds the difficulties associated with each condition, leading to a higher overall burden of symptoms.
“Having both social anxiety and ADHD was associated with more severe symptoms and higher levels of impairment compared to having only one of the diagnoses,” Støre told PsyPost. “Therefore, individuals with one diagnosis should be screened for the other to enable earlier detection of potential comorbidity. Clinicians should also note subclinical symptoms of both social anxiety disorder and ADHD since even subclinical symptoms can worsen the prognosis regarding treatment outcomes.
“More research is needed on subgroups of social anxiety in general, and specifically on the subgroup of social anxiety characterized by high impulsivity – particularly among adolescents and adults with comorbid ADHD.”
Another important finding was the identification of a specific subtype of social anxiety disorder characterized by high impulsivity. This subgroup, though less frequently studied, displayed higher levels of externalizing behaviors and ADHD symptoms. This impulsive subtype of social anxiety disorder includes individuals who, contrary to the typical presentation of social anxiety involving shyness and inhibition, exhibit impulsive actions that may appear as assertiveness, aggressiveness, or risk-taking behaviors.
The review also noted that the relationship between social anxiety disorder and ADHD is particularly relevant during adolescence, a critical period for the development of both disorders. Adolescence is a time when social relationships become increasingly significant, and the social challenges associated with both disorders can have profound impacts on an individual’s development. However, most of the reviewed studies focused on adults.
“Most of the included studies had been conducted with adult participants, which was surprising considering that adolescence is a critical stage of development, and a vulnerable period for both teenagers with social anxiety disorder and those with ADHD,” Støre said.
Finally, the review highlighted several limitations in the existing research.
“The qualitative ratings of the included studies were notably low, suggesting that our conclusions should be considered preliminary,” Støre noted. “However, the assessment tool used was not adapted for cross-sectional studies, which comprised the majority of the included studies. Excluding the ‘confounders’ aspect, along with the three initially excluded aspects (due to the non- interventional nature of the studies), improved the overall quality ratings from remarkably low to moderate, indicating more reliable conclusions than initially thought.”
“Another limitation was the inconsistent terminology, where different terms for subdiagnostic and diagnostic social anxiety disorder (such as ‘social phobia’) and ADHD were used in the included studies, which could affect the consistency of the findings.”
These shortcomings point to the need for more comprehensive and inclusive research to fully understand the complexities of social anxiety disorder and ADHD comorbidity.
“My long-term goal is to evaluate psychological interventions for adolescents and adults with neurodevelopmental disorders,” Støre explained. “While pharmacological treatments are commonly used to manage ADHD symptoms, they may not adequately address comorbid anxiety. Moreover, standard treatments for anxiety might not be fully effective for those with ADHD due to differences in cognitive functioning and behavior patterns.”
“Hence, there is a need for interventions specifically designed or adapted for this population. In the pipeline is a study on NeuroACT, a psychological intervention grounded in the principles of Acceptance and Commitment Therapy, which has previously been evaluated among adults with autism spectrum disorder by another research group. Our study will focus on adolescents diagnosed with ADHD and/or autism spectrum disorder, with psychological distress.”
“The intervention aims not only to reduce anxiety, depression, and stress, but also to enhance functional levels, psychological flexibility, mindfulness, and acceptance, moving beyond mere symptom reduction,” Støre said. “This aligns with my therapeutic philosophy of empowering patients to lead more fulfilling lives despite their challenges.”
The review, “The Relationship Between Social Anxiety Disorder and ADHD in Adolescents and Adults: A Systematic Review,” was authored by Siri Jakobsson Støre, Nejra Van Zalk, Wilma Granander Schwartz, Victoria Nilsson, and Maria Tillfors.