The mood disorders most likely to be experienced by children with ADHD include dysthymic disorder, major depressive disorder (MDD), and bipolar disorder. Dysthymic disorder can be characterized as a chronic low-grade depression, persistent irritability, and a state of demoralization, often with low self-esteem. Major depressive disorder is a more extreme form of depression that can occur in children with ADHD and even more frequently among adults with ADHD. Dysthymic disorder and MDD typically develop several years after a child is diagnosed with ADHD and, if left untreated, may worsen over time. Bipolar disorder is a severe mood disorder that has only recently been recognized as occurring in children. Unlike adults who experience distinct periods of elation and significant depression, children with bipolar disorder present a more complex disturbance of extreme emotional instability, behavioral difficulties, and social problems. There is significant overlap with symptoms of ADHD, and many children with bipolar disorder also qualify for a diagnosis of ADHD.
What to Look For
Every child feels discouraged or acts irritable once in a while. Children with ADHD, who so often must deal with extra challenges at school and with peers, may exhibit these behaviors more than most. If your child claims to be depressed, however, or seems irritable or sad a large portion of each day, more days than not, she may have a coexisting dysthymic disorder. To be diagnosed with dysthymic disorder, a child must also have at least 2 of the following symptoms:
- Poor appetite or overeating
- Insomnia or excessive sleeping
- Low energy or fatigue
- Low self-esteem
- Poor concentration or difficulty making decisions
- Feelings of hopelessness
Before dysthymic disorder can be diagnosed, children must have had these symptoms for a year or longer, although symptoms may have subsided for up to 2 months at a time within that year. The symptoms also must not be caused by another mood disorder, such as MDD or bipolar disorder, a medical condition, substance abuse, or just related to ADHD itself (low self-esteem stemming from poor functioning in school, for example). Finally, the symptoms must be shown to significantly impair your child’s social, academic, or other areas of functioning in daily life.
Major depressive disorder is marked by a nearly constant depressed or irritable mood or a marked loss of interest or pleasure in all or nearly all daily activities. In addition to the symptoms listed previously for dysthymic disorder, a child with MDD may cry daily; withdraw from others; become extremely self-critical; talk about dying; or even think about, plan, or carry out a suicide attempt. Unlike the brief outbursts of temper exhibited by a child with ODD who does not get her way, a depressed child’s irritability may be nearly constant and not linked to any clear cause. Her inability to concentrate differs from ADHD-type inattention in that it is accompanied by other symptoms of depression, such as loss of appetite or loss of interest in favorite activities. Finally, the depression itself stems from no apparent cause—as opposed to being demoralized as a result of specific obstacles posed by ADHD or becoming depressed in response to parental divorce or any other stressful situation. (In fact, research has shown that the intactness of a child’s family and its socioeconomic status have little or no effect on whether a child develops MDD.) While children with ADHD/CD alone are not at higher than normal risk for attempting suicide, children with ADHD/CD who also have an MDD and are involved in substance abuse are more likely to make such an attempt and should be carefully watched.
Talk of suicide (even if you are not sure whether it is serious), a suicide attempt, self-injury, any violent behavior, or severe withdrawal should be considered an emergency that requires the immediate attention of your child’s pediatrician, psychologist, or local hospital.
A depressed child may admit to feeling guilty or sad, or she may deny having any problems. It is important to keep in mind the fact that many depressed children refuse to admit to their feelings, and parents often overlook the subtle behaviors that signal a mood disorder. By keeping in close contact with her teacher, bringing your child to each of her treatment reviews with her pediatrician, and including her in all discussions of her treatment as appropriate to her age, you can improve the chances that her pediatrician or mental health professional will detect any signs of developing depression, and that she will have someone to talk to about her feelings.
A child with bipolar disorder and ADHD is prone to explosive outbursts, extreme mood swings (high, low, or mixed mood), and severe behavioral problems. Such a child is often highly impulsive and aggressive, with prolonged outbursts typically “coming out of nowhere” or in response to trivial frustrations. She may have a history of anxiety. She may also have an extremely high energy level and may experience racing thoughts and inflated self-esteem or grandiosity, extreme talkativeness, physical and emotional agitation, overly sexual behavior, and/or a reduced need for sleep. These symptoms can alternate with periods of depression or irritability, during which her behavior resembles that of a child with MDD. A child with ADHD/ bipolar disorder typically has poor social skills. Family relationships are often strained because of the child’s extremely unpredictable, aggressive, or defiant behavior. Early on the symptoms may only occur at home, but often begin to occur in other settings as the child gets older. Bipolar disorder is a serious psychiatric disorder that can sometimes include psychotic symptoms (delusions/hallucinations) or self-injurious behavior such as cutting, suicidal thoughts/impulses, and substance abuse. Many children with bipolar disorder have a family history of bipolar disorder, mood disorder, ADHD, and/or substance abuse. Children with ADHD and bipolar disorder are at higher risk than those with ADHD alone for substance abuse and other serious problems during adolescence.
If your child has ADHD with coexisting bipolar disorder, her pediatrician will generally refer her to a child psychiatrist for further assessment, diagnosis, and recommendations for treatment.
As with ADHD with anxiety disorders, treatment of ADHD with depression usually involves a broad approach. Treatment approaches may include a combination of cognitive-behavioral therapy, interpersonal therapy (focusing on areas of grief, interpersonal relationships, disputes, life transitions, and personal difficulties), traditional psychotherapy (to help with self-understanding, identification of feelings, improving self-esteem, changing patterns of behavior, interpersonal interactions, and coping with conflicts), as well as family therapy when needed.
Medication management approaches, as with ADHD and other coexisting conditions, include treating the most disabling condition first. If your child’s ADHD-related symptoms are causing most of her functioning problems, or the signs of depression are not completely clear, your child’s pediatrician is likely to start with stimulant medication to treat the ADHD. In cases when the depressive symptoms turn out to stem from poor functioning due to ADHD and not to a depressive disorder, they may diminish as the ADHD symptoms improve. If the ADHD and depressive symptoms improve, your child’s pediatrician will probably maintain stimulant treatment alone. If her ADHD symptoms improve but her depression remains the same, even after a reasonable trial of the type of broad psychotherapeutic approach described previously, her pediatrician may add another medication, most commonly an SSRI—a class of medications including Prozac, Zoloft, Paxil, Luvox, and Celexa. Selective serotonin reuptake inhibitors can make the symptoms of bipolar disorder worse, so a careful evaluation must be completed before starting medication. If this approach is unsuccessful, you may be referred to a developmental/behavioral pediatrician or a psychiatrist, who may try other classes of medications.