Treating Children with ADHD and Depression
When a child comes to a doctor's office with problems with attention, whether it's due to ADHD or something else, usually the child has had a lot of negative feedback from the world because they aren't finishing tests on time, doing homework well, or get into arguments with their peers or parents. This negative feedback can come in a variety of ways. A boy repeatedly told that he needs to shape up in school, even if he is very bright and trying his hardest, may start thinking something is wrong with him. This can lead to feelings of depression. It becomes challenging for the doctor, parents, and the child to determine whether problems with concentration are due to depression or due to ADHD.
The bottom line is that the inattention, if part of a disease process like depression or ADHD, should be treated. The trouble is what if the child has both? There are several guidelines that have been developed for the diagnosis and treatment of ADHD in various scenarios. One is the practice parameters for treatment of ADHD recently published by the American Academy of Child and Adolescent Psychiatry. Another useful guide for physicians is the Texas Children's Medication Algorithm Project Overview, created in part by the Texas Department of State Health Services. From these and other sources, several general principles emerge when looking at ADHD and other psychiatric conditions in children:
One point to note is that if depressive symptoms seem to be the biggest psychiatric problem in the child's life and ADHD is also present, ADHD usually came first. It's one of the few psychiatric diagnoses that actually say in its DSM-IV criteria that there should be symptoms present before the age of 7. Many times, children with both depression and ADHD usually develop depression several years after the onset of ADHD. This is different that some disorders, like anxiety disorders, which often begin before symptoms of ADHD present themselves.
A second point that repeatedly comes up in many published recommendations is the suggestion of treating the most severe disorder before treating the second. Yes, inattention can be due to depression or ADHD, but if the child is suffering much more from inattention and other symptoms of ADHD, then treatment of ADHD may be enough to improve the child's overall quality of life. If depressive symptoms continue after the symptoms of ADHD resolve, then treatment of depression should be considered.
These recommendations are of course, generalizations. Each child is an individual and a treatment plan needs to be carefully crafted by healthcare workers in conjunction with the child and his or her parents. A future blog can discuss other issues that arise when children have more than one psychiatric diagnosis.