9 Jul 2021

Areces D et al. J Clin Med 2021; 10: 2534

Anxiety commonly co-occurs with ADHD, but little is known about how it affects attentional activities. This study aimed to investigate how anxiety levels may influence the performance of children and adolescents in a virtual-reality continuous performance test.

Children/adolescents aged 6–16 years entering the study had to meet Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5TM)-based criteria for ADHD,* and not be under medical treatment. Once informed consent was given, the patients were administered the State-Trait Anxiety Inventory for Children (STAI-C) scale and a virtual-reality continuous performance test (AULA Nesplora). The study included 68 boys and 35 girls (mean age [standard deviation] 12.24 [2.45] years), with a mean IQ of 106.36 (SD, 14.38) [measured using the Wechsler Intelligence Scale for Children [WISC] IV scale] who had been referred for clinical evaluation of ADHD symptoms.

Correlations between attention and anxiety in ADHD

There were significant correlations (Pearson bivariate) between state anxiety (STAI-C) and attentional scores of omissions (participant should respond but does not), commissions (participant responds without stimulus) and response time assessed via AURA Nesplora (p<0.01). Trait anxiety only showed bivariate correlation with commission errors (p<0.05). In addition, within each scoring system, trait and state anxiety were significantly correlated with each other, as were the attentional variables of omissions, commissions and response time (all p<0.01). Across all the attentional and anxiety variables examined, boys had higher scores than girls, indicating poorer performances.

General and anxiety variables predicting attentional performance in ADHD

Hierarchical regression models were performed to determine the predictive power of general variables (sex, age and IQ) and anxiety variables (trait vs state anxiety) over the attentional variables from the AURA Nesplora test that are related to ADHD symptomatology. Model 1 found that IQ had significant explanatory power for predicting omission errors (p<0.01), as did gender (p<0.05) and age (p<0.01) for commission errors. Model 2 found that state (but not trait) anxiety had significant explanatory power, predicting two of the four attentional variables – omission (p<0.01) and commission (p<0.001). Neither model identified significant predictors of response time or motor activity.

Limitations of the study included its small sample size. In addition, participants were not differentiated according to their ADHD presentation, and there were no control-group comparisons. The inclusion of only a small number of psycho-social variables – which can significantly affect ADHD symptoms – was also noted as a limitation.

The authors suggested that:

  • Attentional performance is affected by age and IQ
  • Girls (in general) have better results than boys in attentional variables
  • Anxiety levels should be considered during assessments for ADHD – to avoid biased data, it is important for children to be relaxed

Read more about the influence of anxiety on performance in children with ADHD here


*Subjects had to meet the following requirements based on DSM-5TM criteria: (1) there must be a persistent pattern of inattention and/or hyperactivity–impulsivity that has lasted at least 6 months; (2) the inattention and/or hyperactive–impulsive symptoms must interfere with functioning or developmental level; (3) these symptoms must have been presented before the subject was 12 years old; (4) several symptoms must be present in two or more settings (such as at home or school; with friends or relatives; in other activities); (5) there must be clear evidence that the symptoms interfere with, or reduce the quality of, social, school or work functioning; (6) the symptoms must not be better explained by another mental disorder.
The STAI-C consists of two 20-item scales: the state anxiety scale examines anxiety as a temporary reaction; the trait anxiety scale examines the stable tendency to deal with experience and report negative emotions (e.g. fears, worries), in individuals aged 8–14 years. Higher scores correspond to higher levels of anxiety.
AULA Nesplora is a virtual-reality-based continuous performance test that measures attention, impulsivity, processing speed and motor activity in individuals aged 6–16 years. Participants wear 3D glasses equipped with a mobile phone and headphones, and experience the perspective of sitting at a school desk with their responses assessed as they receive instructions from a virtual teacher.

Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.

Areces D, Rodríguez C, García T, et al. The influence of state and trait anxiety on the achievement of a virtual reality continuous performance test in children and adolescents with ADHD symptoms. J Clin Med 2021; 10: 2534.

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