ADHD Depression

and

Adolescent Girls

Douglas Cowan, Psy.D.
ADHD Information Library

Several studies in recent years have looked into the impact of ADHD on the lives of teenage girls. MRI studies report that teenager’s brains are rapidly maturing, but that they are not fully mature until the early 20’s in females, and perhaps the early 30’s in males. Long-term studies on behavior and emotional health report that girls with ADHD may struggle through the teen years. And other studies report that depression is common among teens with ADHD, and is so common among adolescents that the use of medications for ADHD, antidepressants, antipsychotics, and even sleep medications, is up sharply with adolescent girls. While many children and teens with ADHD also suffer from some degree of sadness, discouragement, or frustration, as many as 25% are clinically depressed. Children and teens with ADHD are as much as 300% more likely to also suffer from depression than are children or teens without ADHD. The co-morbid depression seems little associated with the ADHD symptoms such as inattention, impulsivity, hyperactivity, or academic problems. These problems might result in discouragement, sadness, or frustration, but not clinical depression. Rather, the depression seems to be most correlated to social awkwardness or interpersonal difficulties that are often a part of having ADHD. The lack of friendships, the sense of loneliness, or the sense of being a “social outcast” seemed to be behind the depression. And these feelings are, of course, much stronger in the teenage years. In girls who were diagnosed with ADHD, and were followed by long-term studies through the years, it was observed that as they moved from childhood to adolescence their “outward” symptoms of ADHD, such as hyperactivity and impulsivity, tended to decrease. We do want to note that most girls with ADHD do not have the symptoms of hyperactivity or impulsivity. Most girls with ADHD are inattentive, distracted, disorganized, or “space cadets,” which is why girls are so under-diagnosed for ADHD. Girls tend to just sit in the classroom, get distracted, and do poorly on the tests. But they don’t cause trouble in the classroom so they don’t get the attention that might lead to a diagnosis and treatment. But for those girls were did have the symptoms of hyperactivity or impulsivity, and had been diagnosed as children, their “outward” symptoms tended to decrease as they reached the teenage years. However, as these girls reached the teenage years, it was noted that their academic performance continued to be a problem, and that the academic gap between them and their non-ADHD peers continued to widen with each passing year. These researchers also noted that, while some girls with ADHD actually “out-grew it” as they reached adolescence, for the most part the girls not only continued to suffer from it but many began to get into serious trouble. Both behavioral and emotional problems began to emerge in many of these girls, and the need for specialized treatment greatly increased.

There were increased problems with friends, which led to increased levels of depression. There were increased levels of substance abuse (both alcohol and drug abuse). School delinquency increased as the academic problems got worse. And, surprisingly, eating disorders became a serious problem among many of these girls. All of these problems were at higher levels among these ADHD girls than among their nonADHD peers. As we have noted elsewhere, twice as many teens with ADHD will run away from home than teens without ADHD. About 16% of teens run away from home at some point, versus 32% of teens untreated for Attention Deficit Hyperactivity Disorder - ADD ADHD. And as many as 50% of all teenagers in juvenile facilities have Attention Deficit Hyperactivity Disorder but were untreated for ADHD. Teenagers untreated for ADHD are ten times more likely to get pregnant, or cause a pregnancy, than those without ADHD, and teenagers untreated for Attention Deficit Hyperactivity Disorder are 400% more likely to contract a sexually transmitted disease than teens without ADHD: 16% to 4%.

ADHD, and Depression With as many as 25% of teenagers with ADHD being clinically depressed, it is important to understand what depression looks like, why it is important to treat it and manage it, and the treatment options available. When we think of someone who is depressed, we usually picture a sad, tearful, lonesome person. But teenagers with depression don't look like adults with depression. Current studies show that there are about as many teenagers who are depressed as there are adults that are depressed, about 10% of the general population. And as we have noted, as many as 25% of teens with ADHD are depressed. However, depression in teenagers doesn’t always look like depression in adults. Teenagers do not commonly display gloom, self-depreciation, or talk about feeling hopeless like adults do. Teenagers with Major Depression are described as often becoming negative and antisocial. Feelings of wanting to leave home or wanting to run away will increase. There may be a strong sense of not being understood and approved of by parents, siblings, or peers. The teen often changes, and becomes more restless, grouchy, or aggressive. A reluctance to cooperate in family ventures, and withdrawing from the family by retreating into their room is pretty common. School difficulties are likely even in those few ADHD teens who were doing pretty well in school, as concentration is even more affected than from the ADHD alone. Sometimes the teen will stop paying attention to personal appearance, and sometimes they will adopt the “uniform” of social groups that profess depression or despondency as a way of life.

They often become much more emotional “at every little thing.” Often there is an increased sensitivity to rejection in love relationships as well. Which reminds me of a Cornell University study that reported that the leading cause of teenage depression was breaking up with a boyfriend or girlfriend. And that the younger the teen was in this relationship, the more likely the breakup would lead to depression. Teenage boys will often become aggressive with their parents or peers, seem more agitated around the house, and get into more trouble at home, at school, or with the law. Teenage girls will sometimes become preoccupied with themes of death or dying, and become decreasing concerned about how they look. Think black – black hair, nails, clothes, lips. Suicidal thoughts are common in depressed teens. Some studies suggest that 500,000 teens attempt suicide each year, and 5,000 are successful. That would be 10% of depressed teens. Other studies suggest that the number is 15% of depressed teens ending their life via suicide. By the way, another study notes that of all the teenagers that commit suicide each year, only seven percent were receiving mental health treatment at the time of their death. Poor self-esteem is common with teenagers, but especially with those who are depressed, and there is often an increase in “self-destructive behaviors” such as alcohol abuse, drug abuse, and sexual promiscuity. Parents are often confused and frustrated when their teens begin to act like this. Sometimes parents become stern disciplinarians, or even put the teen down, which only serves to increase feelings of guilt and depression. Other times, parents feel helpless, and stand by waiting for adulthood to arrive. Of course neither course is the right one to take. From 2001 to 2006, the use of ADHD medicines prescribed to girls was up by nearly 75%, and the use of antidepressant medications was up by nearly 10% in girls. Black Box Warning Label No doubt you have seen recent news headlines about a federal panel that recommended to the FDA that anti-depressant medications carry the strongest possible warning label for use in children and teenagers. This recommendation to the FDA shook the medical community, especially those who work with depressed young people, and now the FDA does mandate that antidepressants used to treat adolescent depression carry the “black box” warning label. The warning label reads:

Suicidality in Children and Adolescents Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation

and communication with the prescriber. [Drug Name] is not approved for use in pediatric patients except for patients with [Any approved pediatric claims here]. (See Warnings and Precautions: Pediatric Use) Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials.

The biggest problem from the treatment community's point of view was not the recommendation for the warning label, but the way that the media portrayed the panel's recommendation. The panel reported that 2% to 4% of children and teens that were given anti-depressants for the treatment of depression had suicidal thoughts, or made suicidal attempts of one kind or another. None of the 4,000 children and teens studied committed suicide. What the media did not report well is the fact that 10% to 15% of children and teens with depression that receive no treatment will commit suicide. These 10% to 15% will not just think about it, but will actually kill themselves. So what are we to do? If the media had their way it seems that no teens with depression would receive anti-depressants. As a result the suicide rate for those who could be using the medication would rise from nearly zero percent to about fifteen percent, which is the suicide rate for depressed teens who are untreated. While there actually are young people, and adults, who have become suicidal only after beginning treatment with an anti-depressant, and some have in fact gone on to take their own lives, which is absolutely tragic and heart-breaking, so is the fact that untreated depression is potentially a fatal disease. As many as fifteen out of one hundred young people with depression take their own lives unless they receive treatment. These young people should receive a treatment that will lower the suicide rate dramatically, without any stigma attached to it by the media. With proper diagnosis and treatment a depressed teen, or adult, can be greatly helped. If someone close to you is suffering from depression, first please understand that depression is a very emotionally painful condition. Please take the situation seriously. If you know of a teen whose behaviors have changed to look like what has been described above, let the parents know that there is help available, and encourage the family to seek help from a professional.

See: The ADD ADHD Information Library