I have seen too many clients with ADHD whose psychiatric evaluation is summarized like this: "Age 10, diagnosis ADHD. Age 12, ADHD and depression. Age 14, ADHD, depression, and cannabis dependence." Giving a child or an adult a deficit-disorder label without underscoring their strengths impairs confidence and motivation. This may lead to clinical depression.
There are three other common patterns that I've noticed: ADHD and depression occur together (see "ADHD or Depression?"); depression is misdiagnosed as ADHD; ADHD is misdiagnosed as depression.
Determine the Diagnosis
Sorting out the diagnoses of ADHD and depression is like solving a Robert Ludlum mystery. Shayna, 14, came to me for an evaluation of ADHD. She had been treated for depression and no longer felt depressed, but she had challenges in school. She didn’t always follow through on assignments, and she had problems getting started on classwork. Her parents, along with her teachers, wanted to get to the root of the problem.
As I interviewed her, her family, teachers, and psychiatrist, I concluded that her depression was secondary to undiagnosed ADHD. The checklists, collateral information, and interview transcripts suggested this. Her teachers' comments prior to her depression read like a classic symptom checklist of ADHD. It was hard to believe that the ADHD symptoms and impairments had been missed.
One of the diagnostic requirements of ADHD and depression is that the symptoms cannot be "better accounted for by another mental disorder." The oversight of this rule by professionals has resulted in an elevated diagnosis rate of both ADHD and depression when only one diagnosis is correct. I asked a client why she did not finish her projects at school. She said, "I look at what I've done and I tell myself it stinks, so I just stop." This is not ADHD; it is low self-esteem.
The main requirement for diagnosing major depressive disorder is experiencing either a depressed mood most of the time for at least two weeks or a dramatic loss of interest in almost all activities. In addition to these symptoms, a person must report four of the following symptoms:
> Weight loss or weight gain
> Insomnia or hypersomnia
> Physically slowing down or physical agitation
> Fatigue and loss of energy every day
> Feelings of worthlessness and inappropriate guilt
> Difficulty concentrating
> Recurring thoughts of death or suicide
There is a high risk of misdiagnosing ADHD and depression because the symptoms of the two disorders overlap. The inability to concentrate often looks like the distractibility of ADHD. Physical agitation is almost impossible to distinguish from hyperactivity. Forgetfulness and low motivation are found with both ADHD and depression. Sleep problems and loss of appetite associated with depression are common side effects of ADHD medications. The result? ADHD and depression are frequently diagnosed together.
When Timothy came to me with both depression and ADHD, he was crippled by negative thoughts about himself. The first question I asked him was, "What does the diagnosis of ADHD mean to you?" His answers were a list of depressing conclusions:
> I am slow
> I am not on the same playing field as others
> I am not as smart as others
> I have a brain disorder
> I can’t control myself
> I stink at school
Research shows that if a person views himself negatively, he is at high risk for becoming depressed. Being diagnosed with ADHD often makes a child or adult feel like there is something intrinsically wrong with their brain (they're not just having a bad day), that it impacts all areas of their life (they stink at more than tennis), and that the disorder will not go away. In short, an ADHD diagnosis is a formula for developing depression.
For Jonathan, being diagnosed with ADHD became part of his identity. He saw himself as defective. Dwelling on what was wrong with him caused him to be depressed. When he sat down to do his homework, he told himself, "I can't do this; I have ADHD." Because behavior and emotions are shaped so powerfully by expectations, and because the label of ADHD sets up strong negative expectations, the label itself can create symptoms of depression.
A Five-Step Program
If your child has been diagnosed with both depression and ADHD, the following five-step plan could reverse the symptoms:
> Find and focus on a child's gifts. The five gifts I write about in The Gift of ADHD and The Gift of Adult ADD are creativity, emotional sensitivity, interpersonal intuition, exuberance, and feeling connected to nature. There are other possible gifts, including capacity to lead, being strong-willed, and being inner-directed. Help your child identify his gifts and ask him to focus on them to build motivation and confidence.
> Build emotional intelligence to serve as a corrective to impulsivity and, in some cases, hyperactivity. Accept your child's emotions, and teach him to recognize and label them. Being able to say, "I'm angry and I need support to calm down" may prevent aggressive behavior that leads to punishment, which worsens a child's opinion of himself.
> Use cognitive-behavioral therapy to reframe negative thoughts in a positive light. If your child says, "I'm not as good at school as other kids," ask him, "What if a classmate said those things to you? How would you feel?" Kids realize they would get mad. So you help them conclude, "It's not true, I can do well. I just need to try harder."
> Move it. Research shows that exercise increases focus and concentration, as well as improves depressive symptoms. Exercise boosts levels of the same neurotransmitters in the brain that ADHD medications do. Have your child do a half-hour or more of walking or jogging before school or before study time -- or as often as he can fit activity into his schedule.
> Ask your doctor about meds. Recent research suggests that psychotherapy and other treatments are as effective as antidepressant medications for mild or moderate depression. For severe depression, medication should be considered. Because research has found elevated rates of suicide attempts in children and teens treated with selective serotonin reuptake inhibitors (SSRIs), children should be closely monitored while taking these types of medication.
This article appears in the Fall issue of ADDitude.
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To discuss ADHD and depression with other parents, visit the Depression & ADHD support group on ADDConnect.