Information

How does one respond to an ADD/ADHD diagnosis of one's self or one's child?

How does one respond to an ADD/ADHD diagnosis of one's self or one's child?

I read:

Is ADHD even a thing?

This kind of question can be offensive to some. The same kind of thing can be applied to other conditions:

Is depression even a thing? Or are they just lazy? Is gender disphoria even a thing? Or have they just sexually confused? Is homosexuality even a thing? Or are they just a deviant? Is otherkin even a thing? Or are the just a teenager looking for a unique identity?

Apparently, there is much controversy over ADHD, according to Wiki (not enough reputation)

Part 1:

What is a diagnosed person to do? How does one evaluate methods used by a doctor? How does one evaluate if prescribed medicine and dosage is right or at least not severely wrong?

I'm guessing initial prescription, if any, is going to be experimental. From there we see if dosage needs to increase or decrease or if medicine needs to be changed or stopped. How then should one evaluate a doctor's decision?

Part 2:

Why not controversy over depression? Bipolar? Schizophrenia?

Some psychologists seem to believe ADD/ADHD is a myth. Is there any truth to such?

The blog also points out how homosexuality was wrongly considered a disorder. How do we know ADD/ADHD won't turn out like that?


There actually is the same kind of controversy over depression. The French documentary Dépression, une épidémie mondiale nicely summarizes how a well-meant change in diagnostic criteria (from DSM-IV to DSM-5) backfired and the pharmacoceutical industry now use this to diagnose every sadness or exhaustion as depression with the intention to sell drugs and make money.

There has also been controversy over schizophrenia for at least two hundred years. Other mental disorders are equally highly controversial. It is just that ADHD is a "fashion disorder" today and therefore covered by the media, which gives laypeople the impression that only this disorder is controversial.

As for ADHD, we live in a society that favours certain personality traits and disfavours others, and those kids that don't sit still very well, need a higher input speed, or are simply socially maladjusted, are often diagnosed with ADHD, although they are perfectly healthy and normal and would only need a different kind of learning environment or better familial support.

On the other hand, this does not mean that ADHD does not exist. If the diagnosis was given by an expert after careful investigation, then the patient will certainly profit from therapy. But the therapy cannot be deduced from the diagnosis alone. It must take into consideration the etiology (what caused the disorder?) and the circumstances (how does the patient live?), as well as the personality of the patient. Because the same symptoms of the same disorder can have widely varying causes, and you want your therapy to address those causes and not just ease the symptoms.

Therefore a meaningful diagnosis will include an analysis of the cause. ADHD can be genetic, caused by harmful substances, or psycho-social. Therapy will differ in each case.

If you want to evaluate a diagnosis and recommended therapy, I would recommend you go see another expert. Evaluating them yourself would require you study medicine and psychology to an extent probably not feasible. Be extremely careful of reading stuff on the net! Much of what you find there is published by companies who are in search of patients to sell medication to, or by laypeople.

I don't know where you live, and probably don't know how you can find trusted experts in your country. In Germany, where I live, the best path to take would be to approach therapeutic organizations or even your health insurance and ask them for whom you should turn to.

Generally, psychiatrists appear to be more likely to prescribe medication, while psychologists seem to prefer non-medical therapy. The best therapy for many mental disorders is a combination of both, with medication used to alleviate the current symptoms, and psychotherapy working mid- to long-term on changing behavior (and personality) so that medication is no longer necessary or can at least be reduced. I know people with ADHD who live well without medication, simply by creating for themselves the environment that they can flourish in.

All the best.


Tl;dr

Find a doctor you can trust, and trust them.


Treatment for ADHD

Should a youngster be diagnosed with Attention Deficit Hyperactivity Disorder, several options become available for parents, schools, and/or referring physicians. The results of your child’s evaluation will be used to develop a treatment plan that includes recommendations for addressing symptoms at home and school. Consultative services are available for schools to provide educational programming and teacher methods to deal with ADHD. Finally, should medication be view­ed as a necessary component of the treatment process, you child’s pediatrician will be contacted for medica­tion treatment options, double-blind trials, medication monitoring, and ongoing follow-up. This ADHD Diagnostic Clinic is designed to provide assessment, diagnostic and behavioral services primary medical services will be provided collaboratively with your primary care provider.


How ADHD Impacts the Daily Life of a Child

The major symptoms of ADHD are inattention, hyperactivity and impulsiveness. But, as parents of children with ADHD already know, these three symptoms are only part of the story. There is no part of a child's life that is not impacted by ADHD. At one time, ADHD was considered to be a school day disorder, affecting mostly a child's performance in school settings. As more and more is learned about this disorder, it is understood that ADHD permeates every aspect of a child's life. Characteristics such as forgetfulness and disorganization cause problems at home as well as in school. Secondary symptoms such as low self-esteem, aggressiveness and emotional immaturity play a major role in how a child and family adapt to ADHD being part of daily life.

Although children with ADHD often struggle in school, it does not have anything to do with intelligence. The range of IQ for students with ADHD has been shown to be the same as students without ADHD.

ADHD is not a learning disability however, it can cause difficulties in learning. In addition, children with ADHD have a higher incidence rate of learning disabilities and can have problems with math and reading. Some studies have indicated that as many as 50% of children with ADHD may also have a learning disability.

Disorganization, forgetfulness and losing items are also major problems for students with ADHD. Keeping track of projects, remembering homework assignments and tests are all frequent complaints of students with ADHD. They find it difficult to keep track of all the important information needed to manage their studies.

Inattention, a major symptom of ADHD, can cause students to miss details when a teacher is speaking, when homework assignments are giving or when other students are talking. A student with ADHD tends to pay attention to everything that is going on around them rather than being able to focus on one task.

Hyperactivity creates problems with sitting still through class. Students are expected to remain seated for extended periods of time and as they get older, sitting for longer periods is necessary. Hyperactivity, however, doesn't go away and this continues to cause problems throughout the school years.

Parenting children with ADHD can be a challenge. Children with ADHD require more monitoring and supervision. Their school problems may require parents to spend evenings helping with homework. Parents need to be more involved in making sure they complete their chores. If parents are not able to work together to provide consistency, they may end up arguing and being at odds with one another. Often, one parent may feel the other is too harsh, while one feels the other is too lenient. Families have been torn apart by the constant conflict within the house.

In addition, siblings can feel neglected or resentful. Children with ADHD are often impulsive, acting without thinking and possibly causing arguments with their siblings. Parents can feel guilty over the amount of attention given to the child with ADHD and the lack of attention given to the children without ADHD.

Raising children with ADHD requires parents to evaluate their parenting techniques. Their children may not respond to normal discipline methods, such as time outs or grounding. They may need to adopt a new way of parenting, instituting a system of rewards and consequences.

Days may be exhausting from constant monitoring and possibly hours of homework each night. Parents who once had certain visions of family life must re-evaluate and determine new priorities. Where once a clean and peaceful home may have been important, now making it through the day may be enough of a priority.
ADHD is also considered to be hereditary. There is a good chance that at least one of the parents has ADHD as well. This can lead to inconsistent parenting and disorganized households. Many parents have discovered and been diagnosed with ADHD after going through the diagnostic process with their children.

Often, the tension and stress in a home with at least one child with ADHD is high. Sometimes parents can feel frustration, exhaustion and the feeling that they are not going to make it through the day.

Social Skills and ADHD

Children with both ADD and ADHD can have difficulty making friends. Those with ADD are shy or introverted. They may have a hard time reaching out to other children, although once they make a friend they tend to remain friends. Children with ADHD, on the other hand, can be impulsive and hyperactive. This may make it appear as though they are outgoing and energetic and easily able to reach out to other children, but in fact it is harder for them to maintain friendships.

Whether children have ADD or ADHD, they are often emotionally immature. Their classmates could be years ahead of them emotionally, making it hard for children with ADHD to relate and connect with children their own age.

Some research has shown that children with ADHD, especially those that have emotional outbursts or have aggressive tendencies, have trouble getting along with their peers. Many children with ADHD feel "different" and feel as if they do not fit in. They can feel isolated. In school, if their classmates or teachers single out children with ADHD, they may be humiliated or embarrassed.

Children with ADHD do tend to do better in small, structured environments. Clubs such as Boy Scouts, Girl Scouts, or extracurricular classes in art, music, martial arts or sports often work well. These activities often provide structure and consistent monitoring, giving children an opportunity to interact with other children in a supervised setting

Emotional maturity in individuals continues to develop until around the age of 35. This process can be slower in people with ADHD, and they may not reach the level of emotional maturity of a 21 year old until they are in their late 20s or early 30s. For children with ADHD, their emotional maturity level may be well below that of their non-ADD counterparts.

Individuals with ADHD also suffer from low self-esteem. Years of struggling in school or not feeling adequate add to these feelings. Adults, especially those that were not diagnosed or did not receive treatment in childhood, often bring the feelings of low self-worth into their adult years.

In addition, ADHD has a high incident rate of co-existing conditions. Anxiety, depression, bipolar disorder and learning disabilities are commonly found along with ADHD. These conditions can make it more difficult to accurately diagnose and treat individuals.

Eileen Bailey is an award-winning author of six books on health and parenting topics and freelance writer specializing in health topics including ADHD, Anxiety, Sexual Health, Skin Care, Psoriasis and Skin Cancer. Her wish is to provide readers with relevant and practical information on health conditions to help them make informed decisions regarding their health care.


TREATMENT

The management of ADHD includes consideration of two major areas: non-pharmacological (educational remediation, individual and family psychotherapy) and pharmacotherapy 2 . Support groups for children and adolescents and their families, as well as adults with ADHD, provide an invaluable and inexpensive environment in which individuals are able to learn about ADHD and resources available for their children or themselves. Support groups can be accessed by calling an ADHD hotline or a large support group organization (i.e. Children and adults with ADHD-CHADD, Adults with ADHD-ADDA,), or by accessing the internet.

Specialized educational planning based on the child’s difficulties is necessary in a majority of cases 68 . Since learning disorders co-occur in one-third of ADHD youth, ADHD individuals should be screened and appropriate individualized educational plans developed. Parents should be encouraged to work closely with the child’s school guidance counselor who can provide direct contact with the child as well as serve as a valuable liaison for teachers and school administrators. The school’s psychologist can be helpful in providing cognitive testing as well as assisting in the development and implementation of the individualized education plan. Educational adjustments should be considered in individuals with ADHD with difficulties in behavioral or academic performance. Increased structure, predictable routine, learning aids, resource room time, and checked homework are among typical educational considerations in these individuals. Similar modifications in the home environment should be undertaken to optimize the ability to complete homework. For youth, frequent parental communication with the school about the child’s progress is essential.


Treatment for attention-deficit/hyperactivity disorder

Specific treatment for attention-deficit/hyperactivity disorder will be determined by your child's doctor based on:

Your child's age, overall health, and medical history

Extent of your child's symptoms

Your child's tolerance for specific medications or therapies

Expectations for the course of the condition

Your opinion or preference

Major components of treatment for children with ADHD include parental support and education in behavioral training, appropriate school placement, and medication. Treatment with a psychostimulant is highly effective in most children with ADHD.

Psychostimulant medications. These medications are used for their ability to balance chemicals in the brain that prohibit the child from maintaining attention and controlling impulses. They help "stimulate" or help the brain to focus and may be used to reduce the major characteristics of ADHD.
Medications that are commonly used to treat ADHD include the following:

Methylphenidate (Ritalin, Metadate, Concerta, Methylin)

Dextroamphetamine (Dexedrine, Dextrostat)

A mixture of amphetamine salts (Adderall)

Atomoxetine (Strattera). A nonstimulant SNRI (selective serotonin norepinephrine reuptake inhibitor) medication with benefits for related mood symptoms.

Psychostimulants have been used to treat childhood behavior disorders since the 1930s and have been widely studied. Traditional immediate release stimulants take effect in the body quickly, work for 1 to 4 hours, and then are eliminated from the body. Many long-acting stimulant medications are also available, lasting 8 to 9 hours, and requiring 1 daily dosing. Doses of stimulant medications need to be timed to match the child's school schedule to help the child pay attention for a longer period of time and improve classroom performance. The common side effects of stimulants may include, but are not limited to, the following:

Rebound activation (when the effect of the stimulant wears off, hyperactive and impulsive behaviors may increase for a short period of time)

Most side effects of stimulant use are mild, decrease with regular use, and respond to dose changes. Always discuss potential side effects with your child's doctor.

Antidepressant medications may also be administered for children and adolescents with ADHD to help improve attention while decreasing aggression, anxiety, and/or depression.

Psychosocial treatments. Parenting children with ADHD may be difficult and can present challenges that create stress within the family. Classes in behavior management skills for parents can help reduce stress for all family members. Training in behavior management skills for parents usually occurs in a group setting which encourages parent-to-parent support. Behavior management skills may include the following:

Contingent attention (responding to the child with positive attention when desired behaviors occur withholding attention when undesired behaviors occur)

Teachers may also be taught behavior management skills to use in the classroom setting. Training for teachers usually includes use of daily behavior reports that communicate in-school behaviors to parents. Behavior management techniques tend to improve targeted behaviors (such as completing school work or keeping the child's hands to himself or herself), but are not usually helpful in reducing overall inattention, hyperactivity, or impulsivity.


Parents seemed to play down girls’ hyperactive and impulsive symptoms, while playing up those of boys

Mowlem, who was PhD candidate at King’s College London at the time, found that parents, in their own ratings, seemed to play down girls’ hyperactive and impulsive symptoms, while playing up those of boys. They also found that girls who did meet the criteria tended to have more emotional or behavioural problems than girls who didn’t. This was not the case for boys.

In a similar study of 19,804 Swedish twins published last year, Mowlem and her colleagues found that girls, but not boys, were more likely to be diagnosed if they suffered from hyperactivity, impulsivity, and behavioural problems.

Girls could also be better at compensating for their ADHD symptoms than boys, similar to how girls with autism mask their symptoms.

Because of social norms, girls with ADHD are less likely to ‘bounce around the classroom’ than boys (Credit: Getty Images)

“Girls are far less likely to bounce around the classroom, fighting with the teachers and their colleagues,” says Helen Read, a consultant psychiatrist and ADHD lead for a large London NHS Trust. “A girl who did that would be so criticised by peers and other people that it is just far harder for girls to behave in that way.”

Even when they are hyperactive, girls are more likely to be over-talkative, or rebellious – a bit of a wild child, she says. That might not be recognised by parents or teachers as being caused by ADHD, especially as we expect girls to be more sociable than boys anyway.

But more research is needed before we’ll know how big a problem this is.

Symptom similarity

If girls are losing out because they have less stereotypical symptoms, they might not be the only ones: boys with purely inattentive ADHD are probably being missed, too.

It’s a commonly held belief that girls are more likely to be inattentive than boys. But that’s a myth, says Elizabeth Owens, assistant clinical professor in the department of psychology at the University of California, Berkeley. She says the current best evidence shows that rates of inattention are the same for boys and girls.


Who Diagnoses ADHD?

Attention deficit disorder (ADHD or ADD) can be diagnosed by a psychiatrist, a psychologist, a pediatrician or family doctor, a nurse practitioner, a neurologist, a master level counselor, or a social worker.

Choosing the appropriate professional to conduct an ADHD diagnosis — and oversee the subsequent treatment — can be difficult, and confusing. Each specialty has its strengths and weaknesses to consider. Here is a short list of who does what.

The Psychiatrist

A psychiatrist, an M.D. who treats the brain, may prescribe medication or other treatment.

Disadvantages

  • Cost — fees usually start at about $200 an hour and go up from there.
  • While psychiatrists can diagnose and treat, they may not be trained in counseling, especially in the areas of day-to-day life skills which may be needed by the person who has ADHD.

The Psychologist

A psychologist understands how the mind works, but is not an M.D. and cannot prescribe medications. If the psychologist feels that medications are called for, he or she will have to refer the patient to either a medical doctor or a psychiatrist.

Disadvantages

  • Cannot prescribe medications
  • Need to refer for MRI or any other testing which could assist in diagnosis.

Your Family Doctor

Most family doctors know of ADHD, but may lack the extensive knowledge of more specialized professionals.

  • Is already familiar with you and your medical history
  • Is usually easier to see for an appointment
  • Can prescribe medications if needed
  • Less expensive

Disadvantages

  • May have limited experience with ADHD, especially in adults
  • Cannot offer counseling
  • Brief office visits often mean a hurried diagnosis

The Nurse Practitioner

Often working with a general practitioner — although in many states nurse practitioners work independently in diagnosing and prescribing medication — the nurse practitioner offers many of the same benefits and drawbacks as a family doctor.

  • Is usually easier to see for an appointment
  • Can prescribe medications if needed
  • Less expensive

Disadvantages

  • May not offer counseling (although many nurse practitioners, especially psychiatric nurse practitioners, are trained equally in the medical treatment of mental health disorders as well as therapeutic interventions, including counseling)

The Neurologist

A neurologist is a doctor who specializes in treatment of the brain and central nervous system.

Disadvantages:

  • Expensive
  • EEG testing for ADHD isn’t needed for diagnosis or treatment
  • Patient must be referred for any counseling or therapy

The Master Level Counselor

A Master level counselor has a master’s degree in either psychology or counseling. They may be able to do an initial assessment if they have the appropriate training.

  • Is able to provide counseling, behavior management, and problem solving
  • Less expensive than psychiatric care

Disadvantages:

  • May have trouble with a differential diagnosis (identifying other possible problems)
  • Will need to refer patient to a doctor or other professional
  • Cannot prescribe medication

The Social Worker

A Master of Social Welfare (MSW) or a Licensed Clinical Social Worker (LCSW) is often employed by an agency (for example, public healthcare resources) to provide counseling to people served by the agency.


More than half of people diagnosed with attention deficit hyperactivity disorder (ADHD or ADD) will experience depression in their lifetime. And 30 to 40 percent of individuals diagnosed with depression also have ADHD. The comorbid connection between ADHD and depression is strong. And with that connection comes an increased risk for two common scenarios that lead to ineffective or non-existent treatment for ADHD:

  • incomplete diagnosis — when a patient with both ADHD and depression is diagnosed with only one condition, usually depression
  • misdiagnosis — when symptoms of one condition are mistaken for the other this is particularly common in women with just ADHD who are often misdiagnosed with depression

Though ADHD and depression share similar symptoms, they are separate and distinct conditions with different treatment protocols. ADHD is a lifelong neurological disorder that impairs executive functions, attention, and self-control depression is a mood disorder that causes sustained periods of unprovoked sadness, irritability, fatigue, and hopelessness.

Correctly distinguishing symptoms of depression from those of ADHD is vital. However, mistakes are common for the following reasons:

  • overlapping symptoms and diagnostic criteria for ADHD and depression
  • misunderstanding of the intense symptoms of emotional dysregulation often associated with ADHD that lead women to be diagnosed with depression instead of ADHD

Environmental influences

There have been a number of studies linking quality of parenting to ADHD diagnosis, concluding that ADHD is related to insecure attachment relationships (e.g. Reference Roskam, Stievenart and Tessier Roskam 2014). What much research makes clear (and in accordance with common sense) is that if we expect the environment to be dangerous and unpredictable, we are less relaxed and more hypervigilant and jumpy. Thus, children who grow up in difficult circumstances may be more hyperactive and less likely to settle than children who are used to a relaxed and calm environment. Research ( Reference Tronick Tronick 2007) as well as infant observation over many decades, such as in the Tavistock model ( Reference Miller Miller 1989), have shown how even young infants, when feeling less emotionally held, move around more and are less able to concentrate. Infants and children feel calm, more relaxed and stiller when their emotional and physiological states are regulated by an adult attuned to them. Studies show that having a stressful or traumatic childhood is highly predictive of being impulsive, emotionally dysregulated and having poor executive functioning ( Reference Ersche, Turton and Chamberlain Ersche 2012). In families displaying high levels of negativity, anger or aggression, children tend to struggle much more with emotion regulation ( Reference Morris, Silk and Steinberg Morris 2007). Indeed, where there is violence and aggression we see extreme sympathetic nervous system arousal together with externalising behaviours ( Reference Panzer and Viljoen Panzer 2005 Reference El-Sheikh, Kouros and Erath El-Sheikh 2009).

From the perspectives of life history theory ( Reference Belsky, Schlomer and Ellis Belsky 2012), a speeded up metabolism, less trust, less relaxation, and more suspicion and risk-taking might be adaptive for abusive homes or violent neighbourhoods. In such environments there is little emotional security or expectation that things will work out well. It is a strategy that ensures short-term survival, though at the cost of long-term physical and mental health. Our responses can therefore be seen as adaptive to our environments, triggering neurobiological patterns that have a profound effect on the rest of our lives ( Reference Belsky, Schlomer and Ellis Belsky 2012). Those born into highly stressed worlds tend to have a speeded up metabolism and more activated stress response systems and develop what some call a ‘fast’, as opposed to a ‘slow’, life history strategy. We see this in a range of other mammals as well as in humans, and it is a strategy that aids survival. Without it, any too trusting and complacent ancestors might well have met a violent end before they had time to reproduce. In many circumstances the best response is to be wary, vigilant and untrusting.

Evidence shows that ADHD symptoms increase in response to adverse social and economic as well as parenting influences. For example, Reference Mischel Mischel (2014) found that children from low-income families in violent parts of New York's Bronx tended to have below average ability to self-regulate compared with more privileged children. Early severe institutional deprivation is associated with adult ADHD ( Reference Kennedy, Kreppner and Knights Kennedy 2016). Other studies have found a link between low socioeconomic status and impaired development of the executive parts of the brain ( Reference Noble, Norman and Farah Noble 2005), even linking poverty to chronic stress and neurocognitive outcomes right into adulthood ( Reference Evans and Schamberg Evans 2009). Indeed, by the age of 6 months, infants from socioeconomically deprived environments have been shown to be less able to pay attention ( Reference Clearfield and Jedd Clearfield 2013). Childhood poverty and the associated stress levels can have a big effect on capacity for emotion regulation, the development of inhibitory brain networks ( Reference Kim, Evans and Angstadt Kim 2013) and the likelihood of increased risk-taking ( Reference Griskevicius, Tybur and Delton Griskevicius 2011). Being able to defer gratification depends on feeling sufficiently relaxed (high vagal tone) and being helped to bear and regulate one's emotions ( Reference Moore and Macgillivray Moore 2004).

ADHD can be thought of in part as a deficit in executive functioning ( Reference Barkley Barkley 2017) – although many forms of executive function disorder are unrelated to ADHD. Those diagnosed with ADHD struggle, for example, with planning, emotion regulation, focusing, concentrating, putting plans into action – all of which are aspects of executive functioning ( Reference Brown Brown 2013). People able to delay gratification have more activity in prefrontal brain regions, central to abstract thinking, planning, working memory and emotion regulation – again, all of which are aspects of executive functioning ( Reference Barkley Barkley 2012). Those with more impulsive character traits tend to lack these prefrontal ‘brakes’ on their impulsivity ( Reference McClure, Laibson and Loewenstein McClure 2004). Instead, more primitive subcortical brain areas are active. This also is seen in trauma and in stressful situations generally, which is partly why many children who display symptoms that fit with ADHD checklists for other reasons are misdiagnosed as having ADHD ( Reference DeJong DeJong 2010).


Comorbid ADHD and Depression: Assessment and Treatment Strategies

In both clinical and community settings, the clinical significance of ADHD and depressive disorders is substantial when they co-occur. 1 ADHD is a chronic disorder that often persists into adulthood it is also among the most common psychiatric disorders. In DSM-5, the more lenient criteria for age of onset and lower required number of symptoms for adult ADHD will likely increase the rates of ADHD diagnoses.

In adults, episodes of MDD cause significant morbidity and mortality, but when they occur with ADHD, such episodes are more prolonged, more likely to result in suicidal behaviors and hospitalizations, and more likely to convert from unipolar to bipolar mood disorders. 2,3 The impact of comorbid depression on ADHD response has not been assessed, but studies of patients with bipolar disorders suggest that ADHD treatment may exacerbate untreated mood disorders. 4 Because ADHD typically begins several years before the first unipolar depressive episode, earlier identification and treatment of ADHD may affect the risk of depression.

Developmental and other etiological factors

Knowing the genetic and environmental risk factors for comorbid depression in patients with ADHD could potentially help inform strategies for earlier prevention, detection, and treatment. ADHD is among the most heritable psychiatric conditions. 5 Family members of patients with ADHD are at higher risk for ADHD or depression, but environmental rather than genetic factors are the stronger predictors of which ADHD patients become depressed. Such environmental factors may include exposure to early abuse and other traumatic exposures, family or peer conflicts, and poor academic or other achievement, and may be influenced by patient behavior. 6

Earlier pharmacological treatment of ADHD is associated with a lower risk of MDD. 7 Rates of depression are equivalent across genders before adolescence but become twice as frequent in females as in males during adolescence. 8 Moreover, hyperactive-impulsive symptoms in particular have been linked with a lifetime history of suicidal behaviors in females but not in males. 9 On the other hand, pharmacotherapy for ADHD or depression may increase the risk of bipolar episodes in patients already at high risk because of factors such as a history of psychosis, medication-induced or subthreshold levels of mania, or a family history of bipolarity. 4

Assessment challenges and strategies

The evaluation of any patient for potential ADHD requires gathering information about the frequency and severity of ADHD symptoms, and verifying the age of onset of symptoms, their chronicity, and associated impairment in multiple domains of function (eg, school, work, interpersonal and family relations). Because ADHD is highly heritable, patients with ADHD will often have other family members with the disorder. 5 Ideally, evidence of symptoms and impairment is sought from collateral sources.

There are many ADHD rating scales useful for gathering collateral history regarding potential ADHD symptoms in children. Validated self-report rating scales are also available to screen for adult ADHD including the Conners’ Adult ADHD Rating Scales, the Brown Attention-Deficit Disorder Scale for Adults, the Wender Utah Rating Scale, the ADHD Rating Scale-IV, and the Adult ADHD Self-Report Scale-v1.1 Symptom Checklist.

Diagnosing ADHD and other comorbidities often requires having to weigh potentially contradictory reports. For example, while adolescents typically are more reliable reporters of depressive symptoms than their parents, the same is not true for adolescents with ADHD. 1 Parents and teachers are generally more reliable informants of ADHD and other externalizing behaviors. However, parents of children with ADHD are more likely to have depressive disorders themselves, and depressed parents tend to over-report their child’s symptoms and impairment. 5,10 Adults with ADHD often present with chief complaints of mood, anxiety, or substance use disorders, rather than ADHD. 4 The key to diagnosing ADHD in patients who have depression is to carefully consider their childhood history to determine whether symptoms of inattention, hyperactivity, and impulsivity were evident before the depression.

As seen in Table 1, another challenge in correctly diagnosing co­morbid ADHD and depression is the overlap of their symptoms. The symptoms that best discriminate a true comorbid MDD in a pediatric patient with ADHD are depressive cognitions (eg, guilt, worthlessness, hopelessness, morbid or suicidal thoughts), severe anhedonia, and psychomotor retardation. In contrast, symptoms such as irritability, poor concentration, anergia, sleep problems, and psychomotor or appetite changes are less helpful, because they overlap with ADHD, the side effects of ADHD medications, and other frequent comorbidities (eg, oppositional defiant or conduct disorders, anxiety disorders). 11

The risk of bipolar disorders, as well as the conversion from unipolar depressive to bipolar disorders, is increased with ADHD. 3 Getting an accurate history of a previous manic episode is challenging. Manic episodes in pediatric bipolar disorders are typically mixed or rapid cycling. 12 In adults they are predominantly depressive rather than mixed or manic. 4 As with depressive disorders, many mania symptoms overlap with those of ADHD, other common comorbid disorders, or side effects of ADHD medications. 4,12

Several validated measures in the public domain may also be helpful in screening for bipolar symptoms over time, including parent-reports of bipolar symptoms in their children and self-reports of such symptoms in adults. An accurate diagnosis requires a careful clinical interview and close follow-up over time to identify signs and symptoms of depression, mania, or hypomania that are clearly distinct from the patient’s usual state.

Adolescent and adult patients with ADHD are also likely to have other comorbid disorders, such as anxiety, post-traumatic stress, obsessive compulsive, intermittent explosive, personality, and alcohol or substance use disorders. The co- occurrence of multiple disorders along with the ADHD and depression is especially common in tertiary clinical settings. 13 Once again, the symptoms of these disorders overlap with those of depression or ADHD and need to be carefully considered and ruled in or out. If the primary problems are mood and/or these other disorders, verifying a suspected diagnosis of co-occurring ADHD might require observation over time to see whether the potential symptoms of ADHD persist after the other disorders improve with treatment.

Pharmacotherapy

Stimulant pharmacotherapy is generally the first-line treatment for uncomplicated ADHD. 14 Methylphenidates and the amphetamines are FDA-approved for ADHD and have formulations with varying durations of effect. Immediate-release formulations include methylphenidate, dexmethylphenidate, dextroamphetamine, and mixed amphetamine salts. Intermediate-release stimulants include methylphenidates, dexmethylphenidate, and dextroamphetamine Spansules. Several extended-release formulations are now available for methylphenidate and 2 are available for the amphetamines-mixed amphetamine salts and lisdexamfetamine.

In patients of all ages, the extended-release stimulants offer the advantage of potential once-daily dosing, and less risk of abuse or diversion. Atomoxetine is the first non-stimulant FDA-approved for ADHD in children and adults. One trial suggested atomoxetine was useful for treating ADHD that is comorbid with MDD. 15 There is also evidence for the efficacy of bupropion and tricyclic antidepressants for ADHD. 14 One open-label trial in adolescents suggested that bupropion is effective for comorbid ADHD and depression. 16 Tricyclic antidepressants and bupropion are not FDA-approved for pediatric depression or for ADHD at any age. Two extended-release alpha-agonists-guanfacine and clonidine-are FDA-approved for ADHD but have not been studied in comorbid ADHD and depression.

Regarding antidepressants, there is growing evidence for the efficacy of SSRIs for pediatric depression fluoxetine and escitalopram are both FDA-approved for pediatric MDD. 17 Sertraline, fluoxetine, and fluvoxamine are FDA-approved for treating pediatric obsessive compulsive disorder. These and other SSRIs are widely used off-label to treat other anxiety disorders and depression in children and adolescence.

Table 2 summarizes the studies that have examined these and other pharmacological treatments specifically in youths with depressive disorders and ADHD. While many of these studies are limited by their open-label designs, small sample sizes, or use of post hoc analyses, they offer preliminary evidence that monotherapy with stimulants, atomoxetine, fluoxetine, or bupropion is a reasonable treatment for ADHD and comorbid depression.

A trial of methylphenidate in pediatric patients who have subsyndromal depression and ADHD has demonstrated significant reductions in ADHD and depressive symptoms over 12 weeks of open-label treatment. 18 Improvements in depressive and ADHD symptoms were highly intercorrelated, and depressive response was inversely correlated with baseline depressive severity. This study suggests that stimulant monotherapy may be a reasonable treatment for ADHD and milder depression.

Only one study of pediatric ADHD and comorbid MDD has used a placebo-controlled design. A significant difference in atomoxetine relative to placebo for ADHD was seen, but not for depression, because of the high level of depressive response to placebo. 14

The Texas Children’s Medication Algorithm Project (CMAP) offers treatment algorithms for comorbid pediatric MDD and ADHD. 13,14 First, the clinician determines which of the 2 conditions is more severe, then step 1 for that specific condition is selected while monitoring any effects of treatment on the other. If ADHD is to be targeted first, the ADHD algorithm recommends initial treatment with a stimulant. Should only the ADHD improve but not the depression, then an SSRI can be added to target depression.

When the depressive disorder at outset is more severe or when neither condition responds to stimulant monotherapy, CMAP recommends starting or switching to the depression algorithm, respectively. The first 2 steps of the depression algorithm are separate monotherapies with 2 SSRIs, while the third step is monotherapy with a non-SSRI such as bupropion. The clinician has the option to add a stimulant if the depressive but not the ADHD symptoms respond to the antidepressant. CMAP recommends changing only one medication at a time to make it easier to interpret responses to various treatments. Considering the limited available empirical evidence informing the treatment of comorbid ADHD and depression, the CMAP algorithms offer a reasonable clinical approach for patients of all ages.

As mentioned before, adults with ADHD typically present with primary concerns about other clinical comorbidities, such as mood symptoms or anxiety. 4 Often these other conditions should be targeted first, perhaps with an SSRI or bupropion. Patients with an active substance or alcohol use disorder should also have that condition stabilized before ADHD can be safely and effectively treated. Persistent ADHD symptoms in patients with depression or other comorbidities can then be treated with an extended-release, once-daily stimulant or a non-stimulant ADHD treatment.

When the primary concern in adults with ADHD and depression is ADHD, the extended-release stimulants can be used first. Atomoxetine and bupropion are other monotherapies for such patients, especially if a stimulant trial is contraindicated or has failed, or when a non-stimulant is preferred for other reasons. Effective treatment of lifelong ADHD can improve the patient’s ability to function occupationally and interpersonally and reduce his or her depressive symptoms without the need to add an antidepressant.

Findings from an open-label study in 36 adults with bipolar disorders (mostly bipolar II) suggest that bupropion sustained-release is effective and safe for ADHD and mood symptoms. 19 Only one patient converted to hypomania, although most patients (89%) were not taking concomitant anti-manic medication.

Even so, when using pharmacotherapy in patients with comorbid ADHD and depression, clinicians should monitor closely for unexpected or serious adverse effects, worsening moods, suicidality, and emerging manic or psychotic symptoms. In such cases, diagnoses of bipolar disorders or other conditions may need to be considered and treated instead.

Psychosocial interventions

Patients with comorbid ADHD and depression have significant academic, social, and occupational impairment, which can be targeted with psychosocial interventions. Parents of youths with both problems should be encouraged to request an evaluation for an Individualized Education Plan under the Individuals’ With Disabilities Education Act, to provide accommodations and extra support in school.

Patients with ADHD and depression may also benefit from concomitant psychotherapy. Cognitive behavioral therapy (CBT) and interpersonal therapies are available for pediatric and adult depressive disorders, though none have been specifically developed or tested in patients with comorbid ADHD and depression. A post hoc analysis of the Treatment of Adolescents with Depression study (TADS) suggests that responses to fluoxetine, CBT, or their combination were superior to placebo in the subgroup of subjects with comorbid MDD and ADHD. 20 However, youths with particularly severe and more chronic depressive symptoms at enrollment did best over time on the combination of CBT and fluoxetine and had a lower risk of emerging suicidality. 21,22 Such findings suggest that complex cases of MDD and ADHD may warrant the combination of CBT and fluoxetine.

Studies of individual or group therapies for ADHD have recently shown promising results, but primarily in adults rather than in youths with ADHD. 23 Using psychosocial interventions in combination with pharmacotherapy seems a reasonable approach for patients of all ages with comorbid ADHD and depression. Treatment of any co-occurring substance use disorders is usually the first priority, given the greater risks associated with such conditions.

Depressive disorders and ADHD commonly co-occur, and when comorbid are more impairing and challenging to assess and treat. Comorbid depression in patients who first develop ADHD may be related to a chronic history of functional deficits from the ADHD, along with adverse environmental and genetic factors. Despite the relative lack of randomized controlled trials, there is increasing evidence for the role of pharmacotherapy, including stimulants, SSRIs, atomoxetine, or bupropion, to target either or both disorders. There is also some suggestion for the potential benefit of concomitant psychosocial interventions to address the patient’s depressive and ADHD symptoms and any potential environmental factors contributing to such comorbid presentations.

This article was originally posted on 8/4/16 and has since been updated.

Disclosures:

Dr. Daviss is Associate Professor of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, NH. Dr. Bond is a Psychiatric Resident at Dartmouth Hitchcock Medical Center, Lebanon, NH. They report no conflicts of interest concerning the subject matter of this article.

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