Everybody experiences feelings of depression or sadness on occasion. However, when these feelings are so overwhelming that the individual cannot function, they may be diagnosed with a depressive disorder. Depressive disorders are characterized by the presence of sad, empty or irritable mood that interferes with the individual’s ability to engage in everyday activities.
Over time, children with ADHD may become frustrated and demoralized because of their symptoms. They may develop feelings of a lack of control over what happens in their environment or become depressed as they experience repeated failures or negative interactions in school, at home, and in other settings. As these negative experiences accumulate, the child with ADHD may begin to feel discouraged. Typically, in these situations ADHD symptoms appear first and the depression comes later. These negative reactions are common in individuals with ADHD and some experts claim that up to 70 percent of those with ADHD will be treated for depression at some point in their lives.
In addition to being saddened or demoralized as a result of ADHD, children may also experience a true depressive illness. To date, studies indicate that between 10-30 percent of children with ADHD may have a separate serious mood disorder like major depression. However, overlap of symptoms often makes the mood disorder (major depression) more difficult to diagnose.
For instance, physical agitation (or hyperactivity) and poor concentration are symptoms of both ADHD and depression. If a child has these symptoms and appears to also be sad, hopeless, or suicidal, the clinician may consider a diagnosis of major depression. In such complex situations, it is important to see a psychologist or psychiatrist to diagnose and manage the conditions.
The incidence of depression in children with ADHD can also be affected by the presence of other coexisting conditions. In children with ADHD and oppositional defiant disorder or conduct disorder (ODD/CD) depression rates are substantially higher.
According to the Diagnostic and Statistical Manual, Fifth Edition, symptoms of major depression include the following, of which one of the first two must be present and at least a total of five during a two-week period:
- depressed mood for most of the day, nearly every day
- loss of interest or pleasure in all, or almost all, activities
- significant weight loss or weight gain
- insomnia or excessive daytime sleepiness
- series of unintentional or purposeless motions, such as pacing, wringing one’s hands or other similar actions
It should be noted, however, that these criteria for the diagnosis of depression are based on symptoms as seen in adults and that children may not exhibit depression in quite the same way. Clinicians more often observe irritability or hyperactivity as major symptoms in young children who are suffering from depression, so a careful evaluation should be conducted.
Treatment of children with ADHD and depression involves treating the symptoms of ADHD and minimizing environmental traumas that take a heavy toll on self-esteem. Individual psychotherapy for the individual with ADHD and depression helps him or her articulate and deal with his or her feelings and teaches appropriate coping skills. Cognitive therapy may also help reframe negative thoughts and result in a more positive outlook and reaction to situations. Additional family counseling sessions often result in everyone having a better understanding of the ADHD symptoms and resulting behaviors, as well as providing an opportunity to address parenting or marital concerns. Behavioral intervention programs with positive reinforcement of appropriate behaviors may also impact the individual’s feelings of self-worth.
Therapy involves talking to a psychiatrist, counselor or mental health professional about things that are occurring in a person’ life and family. The aim of therapy is to decrease suffering and to return a person to more normal functioning. Therapies used in cases of depression include: behavioral therapy, cognitive therapy, interpersonal or family therapy or school-based mental health interventions. Behavioral therapy focuses on current behaviors and ways to change them, cognitive therapy focuses on changing negative thoughts and thinking patterns and interpersonal (family) therapy focuses on current family issues and relationships.
It is extremely important to make sure to engage a therapist who is familiar with both ADHD and depression when seeking a course of treatment. In addition to these various therapies, the use of medication may be necessary to reduce symptoms of either ADHD or depression or, at times, to treat both disorders. When medications are used, however, they should always be part of a total treatment plan and in conjunction with therapy.
When initiating treatment, the clinician must first attempt to determine which symptoms are more prominent and are having the greatest impact before prescribing medication. If symptoms of ADHD are more impairing, treatment guidelines recommend that medication for this disorder be prescribed first. If symptoms of depression are of greater concern, these may need to be addressed as well. In some cases, antidepressants may be prescribed in addition to the medication used to treat ADHD. In these cases, antidepressants should be used with caution and strict follow-up during the first few months, especially in children and adolescents.
At present, there are over 20 antidepressants available to treat this condition. Some antidepressants are not recommended for children under 18 years of age. Others carry a black box warning because of increasing suicidal thinking that has been seen in some children. It is important that your child be followed closely as he or she begins taking any medication, and antidepressants are no exception. Any worsening of symptoms or emergence of new symptoms should be reported immediately to your prescribing physician.
Finally, ADHD medications and antidepressants may be prescribed together to treat both conditions under the close supervision of the physician or therapist. Usually, the clinician will start with one medication only to treat the most serious condition and, only after establishing efficacy, will proceed to treat the other condition with the appropriate medication, if necessary.
Identifying and treating coexisting depression and ADHD can be extremely complex and difficult; many factors need to be taken into consideration. Individuals who find themselves dealing with ADHD and depression may benefit from the following simple advice:
- Find a mental health professional, such as a psychologist or psychiatrist
- Be sure to seek out two opinions if you are unsure what path to take in choosing a treatment
- Engage a therapist who is familiar with diagnosing and treating both conditions
- Be aware that depression that includes suicidal thoughts or plans should be taken very seriously
- Read all you can about both disorders and their treatment.