Is Your Child Depressed?
Depression isn’t unusual in children with ADHD—and it’s more serious than feeling a little “blue.” Here, doctor-recommended treatment options including therapy and medication.
Clinical depression is more than just the blues. It’s a serious illness, and it affects more young people than parents realize. Each year, four out of every 100 teens become severely depressed. By adulthood, one in five young people will have experienced depression.
In many cases, ADHD-related problems at school and with family and friends trigger depression by undermining a child’s self-esteem. This is called “secondary” depression, because it arises as the aftermath of another problem—including ADHD.
Depression can also be secondary to learning difficulties or substance abuse. Secondary depression is typically triggered at a specific point in time and can be directly linked to specific life experiences.
“Primary” depression arises independently of life experiences. It typically occurs in children who have a family history of depression, and it tends to recur. About half of all children who have ADHD have trouble regulating their emotions, and this problem can also lie at the root of primary depression.
The good news is that effective help is available. As a parent, you must be aware of your child’s feelings and behavior. If a teacher, friend, or anyone else suggests that your child is depressed, don’t take offense. Take action. Consult your family doctor. If he or she cannot recommend a psychiatrist, psychologist, or clinical social worker who is trained to work with children and adolescents, seek referrals from friends, a school counselor, or your health insurance directory.
Tailoring the treatment
The best remedy for depression depends upon the cause of the problem. Let me introduce you to three children I’ve treated for depression (names have been changed) and show you how treatment differed in each case.
Jimmy was always in trouble at school. His teacher constantly had to tell the fourth-grader to sit still, pay attention, and raise his hand before speaking. Home was no better. “I hate my life,” he told his mother. Once he said, “I’m so bad, maybe you should just send me away.”
At my first evaluation of Jimmy, it was clear that he was depressed. It was also clear that he had untreated ADHD. I sensed that his depression was secondary – resulting from years of experiencing negative reactions to his untreated hyperactivity, inattention, and impulsivity.
Once he began taking the stimulant I prescribed, Jimmy’s behavior improved. He was happier. He stopped his negative talk and started playing with friends again. Treatment for the ADHD was all he needed.
Another patient of mine, 13-year-old Louise, was already taking ADHD medication. With the help of her 504 Plan and a tutor, she was getting good grades. But she seemed unhappy. She had been ignoring her friends and had given up activities she once loved, her mom told me.
I could see that Louise was depressed. Her parents had separated recently, and I suspected that that might be the cause of her trouble. I prescribed an antidepressant and initiated therapy. In our sessions, she spoke of her sadness over the breakup of her family – and the fact that her father had moved in with the woman with whom he had been having an affair.
Over time, as we talked about her family, Louise’s depression lifted. She stopped therapy but stayed on the antidepressant for six months. When it was phased off, she showed no more signs of depression.
Finally, there was 16-year-old Gwen, who told me that she had not had friends since grade school. She seemed to get along well with her parents, though she preferred to spend time alone, listening to music. Her grades were mediocre, and she was worried about getting into college. She was having trouble falling asleep at night and had little energy.
I learned that Gwen had a history of inattentiveness and organizational problems, as well as a family history of depression. She told me she had been depressed, off and on, since second grade. Her depression did not appear to relate just to school; she was depressed everywhere.
I diagnosed Gwen as having ADHD, inattentive type. Her grades improved after she began taking stimulant medication, but she remained depressed. I worked with her to understand ADHD, and also put her on an antidepressant. Her mood brightened within a month, but she will probably remain on her antidepressant for another year.
What about antidepressants?
If depression appears to be secondary, the primary problem (ADHD, family discord, drug abuse, or some other trigger) must be addressed. Therapy is usually helpful. If depression continues to affect your child’s daily routine, even with this help, it’s probably best for your child to take an antidepressant.
Most cases of depression involve a deficiency of the neurotransmitter serotonin. For this reason, selective serotonin reuptake inhibitors (SSRIs), which raise serotonin levels, are typically the first approach. If an SSRI proves ineffective, a psychiatrist may prescribe a drug that boosts levels of the neurotransmitter norepinephrine. If the second medication doesn’t work either, the psychiatrist might try one that boosts both serotonin and norepinephrine. There’s no easy way to tell which neurotransmitter is low, so finding the right drug inevitably involves trial and error.
Once on an antidepressant, a youngster will probably have to take it for about six months. If the depression lifts, the medication will be phased out slowly. If the depression stays away, the medication will no longer be necessary. If the depression returns, medication will be tried for another six months.
Antidepressants can cause a range of side effects, including constipation, irritability, mild hand tremors, heart rhythm disturbances, and fatigue. If any of these prove troublesome, a psychiatrist may substitute another medication. Meds must be switched slowly, with one drug being phased out as another is being phased in. The psychiatrist should monitor the process very carefully.
You may have seen or heard reports in the media indicating that SSRIs increase suicidal thoughts. Are these reports true? Last year, an FDA advisory panel reviewed several studies and concluded that SSRIs can indeed raise the risk of suicidal ideation (thinking about suicide) in children and adolescents. But the panel noted that there was no evidence that these drugs increase the risk of children actually committing suicide.
In considering the panel’s findings, the FDA noted problems with the way data had been collected in some of the studies, and opted against banning SSRIs. Instead, the agency decided to alert physicians to the increased risk of suicidal ideation. My own feeling is that any risk associated with taking an SSRI is likely to be smaller than the risk of leaving depression untreated – since depression itself is known to increase the risk of suicidal ideation and suicide.
Most adolescents who are depressed do not attempt suicide—even if they talk about doing so. Nevertheless, suicidal thoughts, remarks, or attempts must always be taken seriously. Share your concerns with your child’s therapist or psychiatrist. If he or she does not take your concerns seriously, find another mental-health professional.
Perhaps you remember a parent or grandparent who suffered with depression for years. Don’t let your child struggle the same way. Treatments are available, and many of them are good.
Best Books on Childhood Depression
The Misunderstood Child: Understanding and Coping with Your Child’s Learning Disabilities
by Larry B. Silver, M.D. (Three Rivers Press)
Straight Talk about Psychiatric Medications for Kids
by Timothy E. Wilens, M.D. (The Guilford Press)
More Than Moody: Recognizing and Treating Adolescent Depression
by Harold S. Koplewicz, M.D. (Perigee Trade)
Do alternative remedies work for depression?
Bright-light therapy is effective against seasonal affective disorder, a form of depression associated with reduced exposure to daylight during winter months. Studies on omega fatty acids as a treatment for depression are inconclusive.
Symptoms of Depression
Sadness is only the most familiar symptom of depression. Other symptoms include irritability, anger, oppositional behavior, low self-esteem, fatigue, poor concentration, sleep disturbances, reduced appetite, and loss of interest in friends, sports, and other activities that once were enjoyable.