What is Depression?
Just because one is feeling down does not mean that the individual is suffering from major or clinical depression. Based on DSM-IV- TR, 2000, the manual used by mental health professionals to diagnose mental disorders, at least five or more of the following symptoms listed below must have persisted for at least two weeks:
• Depressed mood most of the day or 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 (e.g., very slow moving) ;
• 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;
It should also be determined if the symptoms cause clinically significant distress or impairment; are not side effects of a medication or general medical condition; and are not better accounted for by bereavement (i.e., loss of a loved one). The important point here is that true clinical depression is indicated by symptoms that are persistent for a sustained time period, and it is clearly more than feeling “sad” or “blue” by itself.
The Relationship Between ADHD and Depression
In my last column, I mentioned that children with ADHD are more likely to suffer from low self-esteem as a result of the child’s personal perception of being a failure at home and in school. They are more often at the receiving end of harsh criticisms and punishments for being extremely active, talkative and restless; or for their difficulty to pay attention, forgetting important things, and for interrupting others. They may also be labelled “not normal,” “weird,” or are “incapable of behaving” or worse, their peers avoid them altogether.
As all these build up over time, these children feel frustrated and demoralized. At times, they are overwhelmed with the things that happen around them and become discouraged as they face repeated failures in school, at home, and in other settings. When these negative experiences accumulate, the child with ADHD may begin to feel depressed.
In addition to being distressed or demoralized as a result of ADHD, children may also experience a true depressive illness. Unfortunately, symptoms of ADHD and depression may at times overlap thus making it more difficult for the doctor to diagnose a mood disorder like major depression.
A clear example: hyperactivity or physical agitation and poor concentration are symptoms of both ADHD and depression. If a child exhibits these symptoms and also appears to be sad, hopeless, or suicidal, the doctor may consider a diagnosis of major depression. In difficult situations such as this, it is important to see a psychologist or psychiatrist to diagnose and manage the conditions.
The prevalence of depression in children with ADHD can also be affected by the presence of other coexisting conditions. Research shows that rates of depression are substantially higher in children with ADHD and oppositional defiant disorder or conduct disorder (ODD/CD).
Significantly, nearly two thirds of children with ADHD may suffer from another condition such as depression or anxiety disorders in addition to their ADHD. Any co-morbidity can coexist with ADHD, but certain disorders like depression seem to occur more commonly.
Depression in Children
The core symptoms for depression in children and adolescents are the same as for adults. But some symptoms appear to be more prominent at different ages, such as extreme irritability, somatic complaints, social withdrawal, hypersomnia, psychomotor retardation (being extremely slow moving) are especially common in children.
So how does a “typical” depressed child look like?
Of course, symptoms would be variant from child to child, but a “depressed child” would seem to be extremely irritable, a notably distinct change from his usual or typical nature. The child may display a distinct change in their eating pattern and may stop participating or getting excited about things they used to enjoy. He may also become less energetic and may complain about being unable to sleep well. Alarmingly, the child may start referring to himself in critical and disparaging ways. As the child finds it more difficult to concentrate and there is less energy given to tasks, it becomes quite common for his school grades to suffer too. Again, it is important to note, that this pattern of behavior should persist for at least several weeks, and should appear as a real change in how the child typically is.
ADHD and Depression: Treatment
The treatment of children with ADHD and depression entails treating the symptoms of ADHD and minimizing environmental traumas that take a heavy toll on self-esteem. It usually includes:
• Individual psychotherapy — helps the child articulate and deal with his/her feelings and teaches him/her appropriate coping skills;
• Cognitive therapy assists the child in reframing negative thoughts which will hopefully result in a more positive outlook and reaction to situations;
• Family counseling sessions often results with the family members having a better understanding of the child’s ADHD symptoms and resulting behaviors. It also provides an opportunity to address parenting or marital concerns.
• Behavioral intervention programs works towards the positive reinforcement of appropriate behaviors which may also influence the child’s feelings of self-worth.
• Medication may be necessary to reduce symptoms of either ADHD or depression or, at times, to treat both disorders. However, it should always be part of a total treatment plan and in conjunction with therapy. The doctor must first determine which symptoms are more prominent (ADHD or depression) and have more impact before prescribing medication. Therefore, if symptoms of ADHD are more impairing, treatment guidelines recommend that medication for this disorder be prescribed first, and vice-versa. In some cases, antidepressants and ADHD medication may be prescribed simultaneously. The antidepressants should, however, be used with caution and strict monitoring and follow-up should be done during the first few months, especially in children and adolescents.
Early Intervention
Since symptoms of ADHD and depression may overlap at times, parents, teachers and other caregivers of a child with ADHD may all the more feel bothered and confused. Thus, it is important to keep open communication lines with the child and at the same time be more observant of the child’s behaviors so that depression can be identified early on.
The process of identification and treatment of children with coexisting depression and ADHD can be difficult and complicated. It is very important for parents, teachers and other caregivers to work together; educate themselves ADHD and depression; and be fully aware that depression includes suicidal thoughts or plans which should be taken very seriously. Better yet, they should involve medical experts and other knowledgeable professionals who can guide and assist them along the way.
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Children with ADHD needs special attention from their parents. They should support and help them utilize the talents they have. It's not a burden, it's a gift from God that parents should accept whole heartedly.
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