ADHD and Depression
Several well conducted studies have shown that children with ADHD are more likely than others to become depressed at some time during their development. In fact, their risk for developing depression is as much as 3 times greater than for other children.
Symptoms of Depression
Lets begin by reviewing what mental health professionals mean when they talk about depression. The important point to emphasize is that the clinical diagnosis of depression requires the presence of a collection of different symptoms—just because one is feeling down or depressed does not necessarily mean that the diagnosis of major depression would be appropriate. According to DSM-IV, the publication of the American Psychiatric Association that lists the official diagnostic criteria for all psychiatric disorders, the symptoms of major depression are as follows:
- Depressed mood most of the day nearly every day. (In children and teens this can be irritable mood rather than depressed)
- Loss of interest or pleasure in all, or almost all, activities
- Significant weight loss when not dieting or weight gain, or a decrease or increase in appetite
- Insomnia or hypersomnia (i.e. sleeping too much) nearly every day
- Extreme restlessness or lethargy
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or inappropriate guilt
- Diminished ability to think or concentrate nearly every day
- Recurrent thoughts of death and/or suicidal thoughts
For the diagnosis of depression to apply, five or more of the symptoms listed above need to be present during the same two week period (i.e. the symptoms must have persisted for at least two weeks), and at least one of the symptoms must be either 1) depressed mood (irritable mood in children can qualify) or 2) loss of interest or pleasure. In addition, it must be determined that the symptoms cause clinically significant distress or impairment, are not due to the direct physiological effects of a medication or general medical condition, and are not better accounted for by bereavement (i.e. loss of a loved one.)
As you can see, the important point is that true clinical depression is indicated by a collection of symptoms that persist for a sustained time period, and is clearly more involved that feeling "sad" or "blue" by itself.
Let me also say a few words about depression in children. Research has shown that the core symptoms for depression in children and adolescents are the same as for adults. Certain symptoms appear to be more prominent at different ages, however. As already noted above, in children and teens the predominant mood may be extreme irritability rather than "depressed". In addition, somatic complaints and social withdrawal are especially common in children, and hypersomina (i.e sleeping too much) and psychomotor retardation (i.e. being extremely slow moving are less common).
What Does Depression Look Like in a Child?
What, then, would a ‚typical depressed child look like? Although there of course would be wide variations from child to child, such a child might seem to be extremely irritable and/or very sad, and this would represent a distinct change from their typical state. They might stop participating or getting excited about things they used to enjoy and display a distinct change in eating patterns. You would notice them as being less energetic, they might complain about being unable to sleep well, and they might start referring to themselves in critical and disparaging ways. It is also quite common for school grades to suffer as their concentration is impaired, as does their energy to devoted to any task.
As noted above, this pattern of behavior would persist for at least several weeks, and would appear as a real change in how the child typically is. (It is also important to note, however, that some children can experience a chronic, somewhat less intense type of mood disorder that is called dysthymic disorder. In this disorder, there is a pervasive and ongoing pattern of depressed mood rather than a more distinct change from the child's typical way of appearing).
Depression and Children with ADHD
As noted above, children with ADHD appear to be at increased risk for the development of depression. In addition, it is important to recognize that in some children, the symptoms of depression can be incorrectly diagnosed as reflecting ADHD. That is because diminished concentration, failing to complete tasks, and even agitated behavior that can resemble hyperactive symptoms can often be found in children who are depressed. It is thus quite important to be certain that depression has been ruled out as an explanation for the symptoms of ADHD a child may be displaying. Having said this, please remember that for many children, ADHD and depression can co-occur - i.e. be present at the same time. Thus, it is not always a matter of ruling out depression to diagnose ADHD, or ruling out ADHD and diagnosing depression. This is because in some situations both diagnoses would be appropriate and is one of the reasons why a careful evaluation by a trained child mental health professional can be so important to have done.
Recent research has suggested that in children with ADHD who are depressed, the depression is not simply the result of demoralization that can result from the day to day struggles that having ADHD can cause. Instead, although such struggles may be an important risk factor that makes the development of depression in children with ADHD more likely, depression in children with ADHD is often a distinct disorder and not merely "demoralization". The results of one recent study indicated that the strongest predictor of persistent major depression in children with ADHD was interpersonal difficulties (i.e. being unable to get along well with peers). In contrast, school difficulty and severity of ADHD symptoms were not associated with persistent major depression. In addition, the marked diminishment of ADHD symptoms did not necessarily predict a corresponding remission of depressive symptoms.
In other words, the course of ADHD symptoms and the course of depressive symptoms in this sample of children appeared to be relatively distinct. Implications Depression in children can be effectively treated with psychological intervention. In fact, the evidence to support the efficacy of psychological interventions for depression in children and adolescents is currently more compelling than the evidence supporting the use of medication. The important point that can be taken from this study, I think, is that parents need to be sensitive to recognizing the symptoms of depression in their child, and not to simply assume that it is just another facet of their child's ADHD.
In addition, if a child with ADHD does develop depression as well, treatments that target the depressive symptoms specifically need to be implemented. As this study shows, one should not assume that just addressing the difficulties caused by the ADHD symptoms will also alleviate a child's depression. If you have concerns about depression in your child, a thorough evaluation by an experienced child mental health professional is strongly recommended. This can be a difficult diagnosis to correctly make in children, and you really want to be dealing with someone who has extensive experience in this area.
Terms of Use: This educational material is made available courtesy of the author and Attention Deficit Disorder Resources. You may reprint this article for personal use only. Dr. David Rabiner is a child psychologist and Senior Research Scientist at Duke University and produces a monthly online newsletter, Attention Research Update , that helps parents, professionals, and educators keep informed about new research on ADHD. For more info go to www.helpforadhd.com
A FACT SHEET ON DEPRESSION IN CHILDREN AND ADOLESCENTS
Among both children and adolescents, depression leads to interpersonal and psychological difficulties that persist long after the depressive episode is resolved. In adolescents there is also an increased risk for substance abuse and suicidal behavior. Unfortunately, these disorders often go unrecognized. Signs of depressive disorders in young people often are viewed as “normal” mood swings typical of a particular developmental stage. In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.
Scope of the Problem
- Up to 2.5 percent of children and up to 8.3 percent of adolescents in the U.S. suffer from depression.
- Depression in young people often co-occurs with other mental disorders, most commonly anxiety, disruptive behavior, ADHD, or substance abuse disorders, and with physical illnesses, such as diabetes.
Suicide
Depression in children and adolescents is associated with an increased risk of suicidal behaviors. This risk may rise, particularly among adolescent boys, if the depression is accompanied by conduct disorder and alcohol or other substance abuse. In 1997, suicide was the third leading cause of death in 10- to 24-year-olds.
Clinical Characteristics
Children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are less likely to identify major depression in their adolescents than the adolescents themselves.
Symptoms of Major Depressive Disorder Common to Adults, Children, and Adolescents
Persistent sad or irritable mood
Loss of interest in activities once enjoyed
Significant change in appetite or body weight
Difficulty sleeping or oversleeping
Psychomotor agitation or retardation
Loss of energy
Feelings of worthlessness or inappropriate guilt
Difficulty concentrating
Recurrent thoughts of death or suicide
Signs That May Be Associated with Depression in Children and Adolescents
Frequent physical complaints such as headaches, muscle aches, stomachaches or tiredness
Frequent absences from school or poor performance in school
Talk of or efforts to run away from home
Outbursts of shouting, complaining, unexplained irritability, or crying
Being bored
Lack of interest in playing with friends
Alcohol or substance abuse
Social isolation, poor communication
Fear of death
Extreme sensitivity to rejection or failure
Increased irritability, anger, or hostility
Reckless behavior
Difficulty with relationships
Psychotherapy . Recent research shows that certain types of psychotherapy, particularly cognitive-behavioral therapy (CBT), can help relieve depression in children and adolescents. CBT is based on the premise that people with depression have distortions in their views of themselves, the world, and the future. Another specific psychotherapy, interpersonal therapy (IPT), addresses disturbed personal relationships that may contribute to depression. IPT has not been well investigated in youth with depression. However, one controlled study found that IPT led to greater improvement than clinical contact alone. Regardless of the form of counseling, children and adolescents may feel quite vulnerable and their trust first needs to be earned. At the same time, depending on the child or adolescent’s concerns, well timed integration of family counseling sessions can be of great value to reduce family/parenting issues that may be fueling the youth’s depression.
Medication. Research by the National Institute of Mental Health (NIMH) suggests that some of the newer antidepressant medications, specifically the selective serotonin reuptake inhibitors (SSRIs), have been shown to be safe and efficacious for the treatment of severe and persistent depression in young people, although large scale studies in clinical populations are still needed. The NIMH also emphasizes that medication as a first-line course of treatment should ONLY be considered for children and adolescents with severe symptoms that would prevent effective psychotherapy or those with psychosis, and those with chronic or recurrent episodes. Following remission of symptoms, continuation treatment with medication and/or psychotherapy for at least several months may be recommended, given the high risk of relapse and recurrence of depression.
It is very important for parents to understand their child's depression and treatment. Parents can be told that depression in youth is not uncommon, and be reassured that appropriate treatment with psychotherapy, medication, or the combination can mean improvements at school, with peers, and at home with family.
Sources for the above Fact Sheet: National Institute of Mental Health, American Psychological Association, American Psychiatric Association, and Psychologists’ Desk Reference
Websites for Further Information:
National Institute of Mental Health : www.nimh.nih.gov
American Academy of Child and Adolescent Psychiatry: www.aacap.org
American Psychiatric Association: www.psych.org
American Psychological Association: www.apa.org
Child & Adolescent Bipolar Foundation: www.bpkids.org