AD/HD and Childhood Depression

Depression may affect as many as 10% of all children before the age of 12, but is likely to affect an even higher percentage of children at greater risk, including those with anxiety, attention deficit or conduct disorder, learning difficulties, etc. If their parents are depressed or if they have parents with bi-polar disorder, the risk increases.

Depression is episodic, and ranges on a continuum from mild to severe. It is a syndrome -- a cluster of incapacitating symptoms and behaviors affecting the whole body. These symptoms affect both behavior and emotion.

There is a biological difference in each of us, and some of us are more resilient than others. It is estimated that approximately 20% of ADD people carry a trait or predisposition for depression. Thus when ADHD is diagnosed, it is important to consider the possibility of co-existing depression.

Causes are also suspected to include living with a depressed parent, a parent's lack of availability, and the modelling of depressed behaviors by depressed parents. Children also learn helplessness, leading them to view their lives as uncontrollable and beyond their capabilities.

Except in the case of substance abuse, depression is likely to occur after the onset of other disorders.

Comorbidity of depression with ADHD may be as high as 25% at any given time. Children with ADHD and a major depressive disorder are likely to have poorer outcomes over the long term. Depression and anxiety are found co-existing in from 17% to over 70% of cases.

Treatment and intervention should be systems oriented. Medication with antidepressants has proved to have a limited value, only appealing to help about half of the time (it is more effective in adults). Family therapy, cognitive behavioral therapy, social skills training, and general problem solving and skills building are some of the approaches which have been found to be effective. The context in which we put children makes a difference. Cognitive therapy techniques include the following:

• cognitive restructuring.
• attribution training.
• self-control training.
• building social skills.
• problem solving and conflict resolution.

This is how we go about one problem solving model:

1. We agree on the problem
2. Then make a list of solutions, *also using humor)
3. Then do some means, ends thinking
4. Do it! Let's see what happens!
5. Evaluate

(This doesn't solve every issue, but it very often helps. As a part of this we really need to talk to kids if we want to know how they feel.)

There are 10 core symptoms of depression in children under 11 years of age. These are:

1. The children are flat in affect and have a distinct look of unhappiness.
2. Nothing is pleasurable to them.
3. They underrate themselves and have low self-esteem.
4. They report feelings of guilt.
5. They experience social isolation.
6. Their schoolwork is impaired.
7. Chronic fatigue is typical.
8. They have low energy levels.
9. They have difficulties with sleep or appetite.
10. Suicidal thoughts are common.

The DSM IV criteria for major depression are as follows: (The person must have at least one of symptoms 1 & 2 below, and four of symptoms 3 to 9.)

1. Depressed mood.
2. Diminished interest or pleasure (kids will often say bored - look carefully.)
3. Weight gain or loss.
4. Insomnia or Hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy.
7. Feelings of worthlessness or guilt.
8. Diminished ability to concentrate or make decisions.
9. Recurrent thoughts of death or suicidal ideation.

These symptoms will last at least 2 weeks and reflect a difference from previous functioning. A collection of milder symptoms is called dysthymia.

Here there are symptoms of depression, but people are still able to have a good time and are not suicidal. Symptoms include low self-esteem or self-confidence, feelings of inadequacy, feelings of pessimism, despair or hopelessness, generalized loss of interest in pleasurable activities, social withdrawal, chronic fatigue, feelings of guilt or brooding, subjective feelings or irritability, and a decrease of activity or product. Lots of ADHD kids will talk about these kinds of feeling - and they need to be listened to carefully and taken seriously.

Ed Note: Dr. Goldstein is a psychologist working in the Neurology, Learning and Behavior Center in Salt Lake City, Utah. He holds a number of teachmg and clinical posts, as well as being Chairman of the Professional Advisory Board of CHADD. He is the author of several books and guides for parents and teachers on child development, attention problems and brain injury.