ADHD/ADD and Depression

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David Rabiner, Ph.D.
Duke University

(Note: If you are looking for information on Attention Deficit  Disorder (ADD) please be aware that much of what is discussed below should also be relevant.  Technically, the term ADD is no longer used.  Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD.  These terms mean pretty much the same thing but the latter is no longer technically correct.)

                           ADHD/ADD and Depression

Several well conducted have shown that children with Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder 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.

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, 5 or more of the symptoms listed above need to be present during the same 2 week period (i.e. the symptoms must have persisted for at least 2 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 hypersomnia (i.e. sleeping too much) and psychomotor retardation (i.e. being extremely slow moving are less common).

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).

As noted above, children with ADHD/ADD 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/ADD.  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/ADD a child may be displaying. Having said this, please remember that for many children, Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder 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/ADD, or ruling out ADHD/ADD 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/ADD who are depressed, the depression is not simply the result of demoralization that can result from the day to day struggles that having ADHD/ADD can cause. Instead, although such struggles may be an important risk factor that makes the development of depression in children with  Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder  more likely, depression in children with ADHD/ADD 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/ADD was interpersonal difficulties (i.e. being unable to get along well with peers). In contrast, school difficulty and severity of Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder symptoms were not associated with persistent major depression. In addition, the marked diminishment of ADHD/ADD symptoms did not necessarily predict a corresponding remission of depressive symptoms. In other words, the course of ADHD/ADD 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/ADD.  In addition, if a child with ADHD/ADD 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 Attention Deficit Hyperactivity Disorder/Attention Deficit Disorder 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.

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