The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

April 14, 2023

ADHD increases the likelihood of postpartum depression (PPD) and postpartum anxiety in more significant and impactful ways than do other well-established risks like comorbid psychiatric disorders or sociodemographic factors in women, according to a recent study published in the Journal of Affective Disorders. ¹

The research found that 25% of women with ADHD had postpartum anxiety, compared to 4.61% of women without ADHD. In addition, almost 17% of women with ADHD had PPD, compared to 3.3% without ADHD.

“ADHD is an important risk factor for depression and anxiety disorders postpartum,” the researchers wrote. “Therefore, ADHD needs to be considered in maternal care, regardless of sociodemographic factors and other psychiatric disorders.”

Using population-based registers from Sweden, the researchers identified 773,047 women who gave birth to their first or second child between 2005-2013. Of that number, 3,515 had received an ADHD diagnosis before their pregnancy. They also analyzed data on women’s depression and anxiety diagnoses before pregnancy, maternal age at delivery, highest achieved maternal education at childbirth, cohabitation status with their child’s father, and family history of depression and anxiety disorders.

The study found that the risk of PPD and postpartum anxiety was lower for women diagnosed with a psychiatric disorder before pregnancy and those with a history or family history of depression or anxiety. The researchers suggested that women diagnosed before pregnancy with ADHD and depression or ADHD and anxiety may have received greater support and treatment during and after their pregnancies compared to women diagnosed with ADHD alone.

Women with ADHD Become Pregnant Younger

Women diagnosed with ADHD were more likely to have a lower education level and less likely to live with the father of their child compared to women without ADHD, according to the researchers.

The study also reported that women with ADHD gave birth to their first child at a younger age (15–24 years) than did women without ADHD (25–34 years), supporting previous research. A study published in the Journal of Attention Disorders of more than 7,500 adolescents with ADHD and 30,000 adolescents without ADHD in Taiwan found that participants with ADHD became pregnant younger, more frequently, and had a higher risk of early pregnancy than did their neurotypical peers.² A large Danish study published in the Journal of the American Academy of Child & Adolescent Psychiatry reported that girls with ADHD were more than three and a half times as likely as their peers to become pregnant between the ages of 12 and 15.³

“It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD,” said Ellen Littman, Ph.D., in discussing how hormonal fluctuations impact women in the ADDitude webinar titled Why ADHD is Different for Women: Gender Specific Symptoms & Treatments.

In addition, the Swedish study found that 59% of the women diagnosed with ADHD had an additional psychiatric disorder compared to only 5% of the women without ADHD.

“The combination of being diagnosed with ADHD and being pregnant at a young age could increase the vulnerability and therefore the risk of being diagnosed with a psychiatric disorder postpartum, such as depression and anxiety,” researchers wrote. “However, results from the present study also show that women diagnosed with ADHD have an increased risk of depression and anxiety disorders regardless of age. This highlights the importance of health care providers to evaluate women diagnosed with ADHD across the lifespan.”

Postpartum Depression and ADHD

In a recent ADDitude survey of 2,027 women with ADHD, one-third of mothers reported that they experienced PPD, including the following symptoms:

• crying spells: 76%
• feelings of worthlessness, shame, guilt, or inadequacy: 76%
• mood swings: 66%
• irritability: 62%
• lack of concentration: 58%
• sleep problems: 57%
• withdrawing from friends and family 55%
• restlessness 46%
• appetite changes (increase or decrease) 37%
• thoughts of harm to self or others 31%
• other 24%
• extreme mood disorder or psychosis 13%
• self-harm 6%

“My ADHD got significantly worse postpartum,” said a survey respondent. “I felt overwhelmed and was not supported by my husband. He’d say things like, ‘Sarah next door has four children, and she copes. I don’t understand why you can’t even manage to keep things organized when you only have one!’”

“Something in me definitely changed after giving birth,” said an ADDitude reader from Ontario, Canada. “My doctors told me it was ‘anxiety’ and hormones. Although tired and sleep-deprived from the baby, I could not shut down my racing mind. I was constantly irritable, impatient, and a complete space cadet. I did suffer from postpartum depression after the birth of my second child. That is when I looked deeper into the root of my troubles. I have always wondered if I had PPD after my first child, or was my ADHD so out of control that I didn’t even notice?”

ADDitude survey respondents reported that their PPD symptoms lasted:

• 1-3 months 13.14%
• 4-6 months 18.63%
• 7-13 months 21.63%
• 14-24 months 13.63%
• Longer than two years 14.14%

Women Lack Treatment for Postpartum Depression

Almost half of ADDitude survey respondents said their healthcare providers did not offer treatment for their postpartum depression or anxiety.

“The medical community didn’t take baby blues seriously when my children were born,” said one ADDitude reader. “I just ‘needed to exercise, lose the rest of the baby weight, and focus on my family.’ Then I would be all better.”

“No one talked about it, and my doctor never asked how I was doing. So, I assumed I was weak,” said another survey respondent.

One ADDitude reader found the help she needed on her own. “No doctor cared,” she said. “So I self-treated by researching natural treatments and took several supplements that helped.”

According to the ADDitude survey, 41% of respondents received prescriptions for antidepressants, and 20% received therapy for PPD.

“PPD made it hard to get through anything without going into a guilt-depression spiral,” an ADDitude reader said. “It was awful. Antidepressants changed everything so I could function without spiraling or wanting to disappear.”

Postpartum Depression with Undiagnosed ADHD

Many ADDitude readers who experienced postpartum depression or postpartum anxiety were unaware of their ADHD diagnoses at that time.

“I had depression, anxiety, and just went into full paralysis,” an ADDitude reader said. “I didn’t know I had ADHD. I thought I sucked at everything, so I might as well add motherhood to the list.”

“I lost all sense of myself and pretended to cope,” said an ADDitude reader from Edmonton, Canada. “It wasn’t until I was diagnosed and looked back on my pregnancy that I realized how much ADHD and hormones played a role in my lack of coping. I wish I could go back and talk to that frightened, overwhelmed, and so very sad me and let her know there was a reason for it all.”

ADHD and Maternal Care: Next Steps

The Swedish researchers recommended that primary healthcare providers assess women with ADHD for the risk of PPD and postpartum anxiety beginning with the first prenatal visit. In addition, they said, women with ADHD should receive parental education before conception, psychological surveillance during pregnancy, and social support after childbirth.

According to Littman, women should find a doctor who understands the impact of hormones on ADHD and the interplay with medication. “Finding this professional is perhaps the most important and most difficult thing to do,” she said. “Be sure to ask about their experience treating ADHD in women.”

Sources

¹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

²Hua, M.H., Huang, K.L., Hsu, J.W., Bai, Y.M., Su, T.P., Tsai, S.J., and Chen, M.H. (2020). Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study. Journal of Attention Disorders. https://doi.org/10.1177/1087054719900232

³Østergaard, S.D., Dalsgaard, S., Faraone, S., Munk-Olsen, T., and Laursen, T, (2017). Teenage Parenthood and Birth Rates for Individuals with and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study.  Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2017.05.003

What is MDD?

Major Depressive Disorder (MDD) is a mood disorder that impacts millions of Americans every year. According to the Substance Abuse and Mental Health Services Administration¹:

• 21 million adults in the U.S. had at least one major depressive episode over the past year. (8.4% of all adults). Of those, 66% received treatment.
• 4 million adolescents aged 12 to 17 had at least one major depressive episode over the past year (17% of all teens). Of those, 41.6% received treatment.

Among people diagnosed with ADHD, however, rates of MDD are far higher. It’s estimated that half of people with ADHD will experience a depressive episode in their lives. Because symptoms of ADHD and depression often overlap, one or the other condition commonly goes undiagnosed. For this reason, it’s critical to debunk myths and clear up misconceptions about what depression looks like. To that end, here are six unexpected and/or misunderstood signs of depression.

1. People with depression aren’t always sad.

The word “depressed” is often used casually to refer to a state of being sad, blue, or down in the dumps. In reality, only about 60% of people with depression actually report any sadness. You don’t have to be sad to be depressed.

Most people with depression report a marked inability to experience pleasure from things that used to be pleasurable. Life just feels empty and unfulfilling. Nothing is engaging. This leads to a tremendous amount of futility. When faced with the prospect of doing something that might make them feel better, people with depression feel like: “Why bother? Nothing’s going to feel good.” They think only of negative outcomes, which is a serious obstacle to beginning treatment.

[Read: Depression – When It’s More Than a Symptom of ADHD]

2. Depression moves slowly and sticks around.

All of us have good days and bad days for no particular reason. In some cases, our “mood thermostat,” which typically allows only a fairly narrow range, breaks down and our mood just keeps going up, with increased energy, decreased need for sleep, and wonderful feelings. This is called mania. When the bottom end of the thermostat gives way, we have no energy, we become negative, and we can’t experience pleasure. We call this depression. The change in mood usually happens slowly and imperceptibly over weeks to months and then stays for years-long episodes. If one of these down episodes hits suddenly and lasts less than two weeks, it is probably not depression.

3. The most common emotional symptom of depression is irritability.

Only 60% of people with depression report sadness, but 95% of them report feeling exceedingly, but uncharacteristically, irritable. Little things get under their skin and they have explosive outbursts. This is especially true for children under the age of 12. These children present with a lot of irritability, and tend to experience what’s called “affective storms.” When they explode, it goes on for hours sometimes. Often, you’ll find that everybody in the family walks on eggshells, for fear of setting off the child. Irritability is also a common symptom of ADHD, which helps to explain how and why sadness may be masked by irritability that isolates the individual and pushes away people who might be helpful.

4. If you’re feeling bad because of a bad situation, it’s “reactive depression.”

In MDD, the depressed mood has no trigger and isn’t related to a situation. People will search for some cause, but usually there’s no event, scenario, or relationship that would cause the depth of impairment seen with depression. This is very different from “reactive depression” or “situational depression,” wherein someone feels bad because bad things are happening in their life.

Feeling down because you’ve had a setback or loss is sadness, and it is normal. Reactive depressions don’t respond to medication, but they do respond to steps taken to improve the situation. Counseling can help to make that process go faster.

[Read: Is it ADHD, Depression, or Both?]

5. Depression in teens often looks completely different.

Most people with MDD experience their first depressive episode in late high school or early college, between the age of 16 and 19. That said, depressive episodes in children and adolescents don’t look like depressive episodes in adults. Whereas most people stop eating, teens will eat everything in sight. Where most people sleep more, an adolescent will sleep less. Where most people lose an interest in sex, adolescents will become hypersexual. It’s critical to understand the difference in the way MDD manifests in teens, so as not to miss an important diagnosis.

6. There is no such thing as a “minor” depression.

The term Major Depressive Disorder was coined in the 1970s, with the idea that we might find minor depression, but we never have. What we have found, instead, is that every depression is a major one. The World Health Organization ranks depression as the single largest contributor to global disability.² Half of all depressive cases are rated both by the patient and by the clinician as being severe to extreme. MDD affects every aspect of a person’s life and makes it seem as though life is not worth living. It’s a serious problem that needs to be addressed.

Thankfully, it is highly treatable. About 70% of people get a good response to practically any antidepressant out there, and for the 30% who don’t, the solution is to try another class of medication. Adding in cognitive therapy to the treatment is important, too, as we know that a combination of medication and therapy is the most effective course of action, by far.

Signs of Depression: Next Steps

• Read: What Is a Mood Disorder? Recognizing and Treating Depression
• Self-Test: Depression in Adults
• Read: The ADHD – Depression Link: Symptom Parallels and Distinctions
• Read: Treatment for Depression and ADHD – Treating Comorbid Mood Disorders Safely]

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Delphin-Rittmon, M.E. (July, 2020). The National Survey on Drug Use and Health (NSDUH), Substance Abuse and Mental Health Services Administration,
https://www.samhsa.gov/data/sites/default/files/reports/slides-2020-nsduh/2020NSDUHNationalSlides072522.pdf

²Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017, https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf

Register to reserve your spot for this free webinar and webinar replay ►

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Adults with ADHD are up to six times more likely than are their neurotypical peers to have Major Depressive Disorder (MDD), which is characterized by extreme sadness, loss of interest, and mania. Not only is MDD more prevalent in adults with ADHD, but the disorder can have an outsized effect on women and girls who have both conditions. MDD is associated with an earlier age of onset, a longer duration, more severe impairment, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization in girls with ADHD.

When treating depression in patients with ADHD, it is critical for clinicians to recognize a patient’s feelings of worthlessness, which, as one study points out, were directly related to suicidal thoughts and planning in adolescents.

In this webinar, you will learn:

• About MDD and other mood disorders that are highly comorbid with ADHD, including bipolar disorder, disruptive mood dysregulation disorder, and emotional dysregulation
• About symptoms of mood disorders and how they co-exist with ADHD
• About new and alternative treatments for MDD, including medication, neurofeedback, and neuromodulation therapy, trans-cranial magnetic stimulation (TMS), and esketamine treatments
• Which therapies are in clinical trials that may hold promise
• About strategies to help people with depression and mood disorders

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meet the Expert Speaker:

Nelson Handal, M.D., DFAPA, is the Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic (DBMC) & Harmonex Neuroscience Research (HRX). As a practicing Board Certified Child, Adolescent and Adult Psychiatrist, Dr. Handal has dedicated much of his career to developing and implementing technologies that elevate the quality of patient care.

Dr. Handal participates in extensive clinical research and has been primary investigator in over 85 clinical trials. In the late 1980s, Dr. Handal was president of one of the first telemedicine referral services in the world. This system was featured in Business Week. CliniCom® is an online psychiatric assessment tool Dr. Handal has been developing for the past 10 years and which has been used by over 54,000 patients. In May 2009 Dr. Handal was invited to testify before the United States House Committee on Veterans’ Affairs regarding innovative technologies and treatments for veterans; he spoke about CliniCom®.

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February 21, 2023

Teen girls in the U.S. are “engulfed in a growing wave of sadness, violence and trauma,” according to a report released last week by the Centers for Disease Control and Prevention (CDC) that found alarming increases in rates of rape, depression, suicidality, and cyberbullying among adolescents.¹ “The numbers are unprecedented,” said Kathleen Ethier, director of the CDC’s Division of Adolescent and School Health. “Our young people are in crisis.”

The CDC report echoes findings from a 2022 ADDitude survey of 1,187 caregivers, which found that an astounding 75% of adolescent girls with ADHD also have anxiety, 54% suffer from depression, more than 14% have a sleep disorder, and nearly 12% report an eating disorder — more than three times the national average for neurotypical women.

“The kids are not alright. Not at all,” wrote one ADDitude reader who works as a youth therapist.

[The ADHD Symptom Test for Teen Girls]

The CDC report, based on the most recent Youth Risk Behavior Survey, included a nationally representative sample of students in public and private high schools, and it found that adolescent health risks have ballooned to levels never seen before—especially for girls. Its findings include the following:

• Nearly 60% of teen girls reported persistent feelings of sadness and hopelessness during the past year, double the rate reported 10 years ago, and twice the rate in boys. For LGBTQ+ teens, this number jumped to a startling 70%.
• 1 in 3 of girls seriously considered attempting suicide during the past year, up nearly 60% from a decade ago.
• At least 1 in 10 girls attempted suicide in the past year. Among LGBTQ+ youth, the number was more than 1 in 5.

Girls with combined type ADHD are 3 to 4 times more likely to attempt suicide than are their neurotypical peers, and they are 2.5 times more likely to engage in non-suicidal self-injuring behavior, said Stephen Hinshaw, Ph.D., in an ADDitude webinar titled, “Girls and Women with ADHD.” The 2022 ADDitude survey found that 18% of girls with ADHD had engaged in self-harm in the past two or three years, as opposed to 9% of boys; it did not specifically ask about suicidality, however anecdotal reports from caregivers are both frequent and frightening.

“A few years ago, I would have been shocked by these numbers,” said one mom of a teen daughter recently diagnosed with ADHD. “But in 2021 my girl was admitted to a clinic for suicidal ideation. She is still here and working on her mental health daily.”

Only 6% of caregivers rated their adolescents’ mental health as “very good” in the ADDitude mental health survey. Contributing to elevated rates of depression, self-harm, and suicidality among teen girls with ADHD are poor response inhibition and peer victimization, as well as a history of maltreatment, such as physical abuse, sexual abuse, or neglect, Hinshaw said.

“I can’t tell you how many mums are holding their girls tight as they self-harm their way through adolescence,” wrote one ADDitude reader in Canada.

[ADHD and Self-Harm: How to Help the Girls Who Suffer Most]

“We are gaslighted, misdiagnosed, or expected to suck it up,” wrote an ADDitude reader on Instagram. “The wait times for help are not OK, and once you finally do get ‘help,’ they barely listen or dismiss your concerns.”

Sexual Violence at an All-Time High

Among the CDC report’s more distressing findings was a stark increase in sexual violence among teen girls. It found the following:

• 1 in 5 girls recently experienced sexual violence
• 14% have been forced to have sex, an increase of 27% over the past 2 years
• For American Indian or Alaska Native girls, that number jumped to 18%, and for LGBTQ+ teens, it was 20%

“For every 10 teenage girls you know, at least one of them, and probably more, has been raped,” Ethier said during a press briefing.

The prevalence of sexual violence causes significant and understandable anxiety. According to the ADDitude survey, 20% of girls expressed anxiety about physical or sexual assault, as opposed to 7% of boys.

The CDC’s study reflects this anxiety, reporting that:

• 10% of girls did not go to school in the past 30 days because of safety concerns, nearly double the rate from 10 years ago; the same was true for 7% of boys.
• School avoidance rates were higher among LGBTQ+ students, at 14%; American Indian and Alaska students, at 13%; and Black students at 12%.

The prefrontal cortex in a developing brain is especially sensitive to the effects of stress and “children with ADHD may be even more sensitive to the effects of traumatic stress,” said Cheryl Chase, Ph.D., in her ADDitude webinar, “How Stress and Trauma Affect Brain Development.” In other words, the trauma of sexual violence leaves lasting scars.

The mother of a girl with ADHD explained the long-term implications of a sexual assault on her daughter’s health and well-being four year after the attack: “When she was a freshman in college this past year, she was re-triggered while in public talking to a boy who touched her inappropriately without her consent.”

Cyberbullying Twice as Likely for Girls

Whether in school or online, girls are more likely to be victims of bullying, according to the CDC report.

• 1 in 5 girls said they were bullied through texting and social media, almost double the percentage of boys who were cyberbullied
• In school, 17% of girls and 13% of boys reported experiencing bullying in school over the past year

Among teens with ADHD, the rates of bullying are much higher. According to ADDitude survey respondents, 60% of girls with ADHD have been bullied at school, 58% on social media and 44% in text messages.

“We know that kids who are neurodiverse are often seen as peculiar and different,” explained Sharon Saline, Ph.D. “You miss social clues, you blurt things out, and chances are you’re more likely to experience bullying and be socially excluded.”

This was the case for the daughter of an ADDitude reader in Wisconsin: “Bullying has been around my daughter’s lack of age-appropriate social insight and her emotional reactivity. Girls exclude her from group texts. Friends screenshot the negative posts others create about her, and she then ruminates until her mood totally plunges.”

Bullying is a widespread problem, and so is the response (or lack thereof) from most schools;  72% of ADDitude survey respondents who reported that their kids were the victims of bullying also said they were dissatisfied with the school’s response.

“The lack of help in the public school system is so disappointing,” wrote an ADDitude reader on Instagram. “They claim to not be tolerant of bullying, yet anytime you seek help you’re met with nothing but rotating doors and promises of help that go undone.”

Substance Use Higher in Girls

Teen girls are more likely to use alcohol, marijuana, vaping, and illicit drugs, according to the CDC.

• Alcohol: 27% of teen girls reported drinking in the last month vs 19% of boys
• Vaping: 21% of girls reported vaping in the last month vs 15% of boys
• Illicit drugs: 15% of girls reported ever using illicit drugs vs 12% of boys
• Misuse of prescription opioids: 15% of girls reporting ever misusing opioids vs 10% of boys

“ADHD affects substance abuse in both children and adults,” explained Walt Karniski, M.D., in a recent ADDitude webinar on ADHD medication. “Children with ADHD are more likely to smoke and to begin smoking at younger ages. They’re more likely to use alcohol at younger ages and more likely to abuse alcohol as adults.”

“A Level of Distress that Calls on Us to Act”

In the introduction to its 89-page report, the CDC authors clearly state its takeaway: “Young people in the U.S. are collectively experiencing a level of distress that calls on us to act.”  The CDC urges schools to act swiftly and thoughtfully for maximum impact.

“Schools play an integral role in promoting wellness and connectedness, and facilitating protective factors among students,” said Anna King, president of the National PTA. Specifically, the report highlights the importance of implementing quality health education, connecting young people to needed services, and making school environments safer and more supportive.

“It’s about time someone noticed, besides all the struggling parents and kids,” wrote one ADDitude reader in New York.

How Can Parents Protect Their Kids?

Keep lines of communication open

“As girls reach the teen years, they naturally want to emancipate from adult control,” Chase says. “But teens’ brains have more ‘accelerators’ than ‘brakes,’ so they need a loving, interested adult to guide them.” This is doubly true for teens with ADHD, whose executive function weaknesses may exacerbate impulse control. So, how do you stay connected with a teen who seems intent on pushing you away?

• Prioritize a positive relationship

Sources for conflict between adolescents and parents abound, but Saline advises that parents pick their battles. “Your Number One agenda item as the parent of a teen is maintaining a positive connection,” Saline says. “So that they will come and talk to you if they need help.”

To build that connection, Chase emphasizes the importance of unstructured time together. “Going for walks, grabbing a smoothie together, playing a game,” she suggests. “Time just to ‘be’ and if they want to talk, they can.” Don’t wait for your teen to reach out to you. Be proactive, and invite them to do something low-key and stress-free every week or two.

• Make communication routine

When teens push back against their parents, seeking autonomy and space, anxious parents often ask a lot of questions, which can make teens feel hounded, Saline says. Keep communication open without putting teens in the hot seat by making conversations routine. Saline suggests instituting a family-wide practice of sharing one “happy” and one “crappy” thing that happened during the day — at dinner or in the car ride home. If it’s a daily practice in which everyone participates, your daughter won’t feel singled out.

• Actively listen, rather than offer unsolicited advice

When your child share experiences with you, practice active listening to ensure the communication continues. Allow your child tell their story, uninterrupted, and follow up with reflective statements, like “I think I’m hearing you say…”  Avoid swooping in with unsolicited advice — that’s the fastest way to get a teen to shut down, according to Chase and Saline.

Help your daughter find treatment

Depression, anxiety, trauma, and self-harm are all treatable, and a mental health professional can help you figure out what avenue of treatment to pursue. If you sense something’s persistently troubling your teen, Chase urges you not to wait to find them a therapist. “It’s like going to the dentist with a toothache,” she explains. “It doesn’t mean they are broken.”

Cognitive behavioral therapy, dialectical behavior therapy, and medication are among the most common interventions. If trauma is involved, consider somatic therapy, which increases awareness of the sensations in the body as a form of healing.

If your child has ADHD, consider that ADHD treatment may decrease their risk for other challenges. Hinshaw says that treating ADHD can decrease rates of suicidality in teens. “Treatment is a huge antidote to internalization, self-stigma, and the belief that there’s something wrong with you,” he explains. In addition, multiple research studies have indicated that children and adults with ADHD who are taking stimulant medication are less likely to engage in substance use than are their untreated peers.

Get Help

Suicide &Crisis Lifeline: Call or Text 988
988lifeline.org

National Sexual Assault Helpline: 1-800-656-HOPE

National Substance Abuse Helpline: 1-800-662-HELP

Stop Bullying

Mental Health in Teens: Next Steps

• Read: Special 2022 Mental Health Report from ADDitude
• Read: Compare & Despair: Social Media & Mental Health Concerns in Teens with ADHD
• Self-Test: Signs of Depression in Teens
• Learn: Nearly One in Four Women with ADHD Has Attempted Suicide

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Source

¹Centers for Disease Control and Prevention (2023). U.S. Teen Girls Experiencing Increased Sadness and Violence. Youth Risk Behavior Survey cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

“Depression” is used casually and colloquially to refer to a fleeting experience, as in “Oh, I’m so depressed by the rain and gloom today.” Or “I’m super depressed that I couldn’t get Taylor Swift tickets.”

It’s important to understand, however, that depression is a serious mental illness — and one that is far more common in people with ADHD than it is in the rest of the population. About 30% of people with ADHD will experience a depressive episode in their lifetime.

Major Depressive Disorder (MDD) is one of the most common mental health conditions in the United States, affecting 6.7% of adults. Despite its casual usage in the popular vernacular, depression is something beyond simply feeling sad. In fact, many people with depression will tell you that their experience has less to do with sadness and more to do with feeling the absence of all emotions — the absence of everything, really, that makes them feel human. Depression is isolating and terrifying, but with medication, psychotherapy, and other treatments, most people who experience depression notice an improvement in symptoms.

The first step toward getting help is diagnosing the problem — which can be a challenge when symptoms of depression overlap with symptoms of ADHD.

ADHD is a stronger predictor of depression and anxiety in adults than is autism spectrum disorder, according to a new study that suggests patients with attention deficit hyperactive disorder are more likely that autistic patients to experience “internalizing problems” like mood disorder. The study, led by researchers at the University of Bath and published in Scientific Reports, underscores the importance of screening for comorbid conditions in adults with ADHD. ¹

As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder.² According to a recent ADDitude survey of 1,500 readers, anxiety and depression are the two most common comorbid conditions diagnosed alongside ADHD in adults, with co-diagnosis rates of 72% and 70%, respectively.

Despite this high rate of comorbidity, researchers said, “ASD has often been prioritized over ADHD in both research on internalizing problems and clinical practice, particularly for anxiety.”³

Notably, approximately 28% of autistic individuals have ADHD, making it difficult to determine which disorder — ASD or ADHD — more significantly impacts mental health outcomes.² (The ADDitude reader survey found that 9% of adults with ADHD have ASD.)

Researchers aimed to clarify the associations between self-reported ASD traits and ADHD traits with mental health conditions like anxiety and depression using a general population sample, which included 504 adults from the U.K. (49% male, 51% female) aged 18–79 years.

While the results linked both ASD and ADHD with anxiety and depression, ADHD was a stronger statistical predictor of both mental-health conditions than was ASD. Further analysis confirmed that ADHD traits were associated with more severe anxiety and depression symptoms in adults than were ASD traits.

Researchers “speculate that response inhibition difficulties, which appear to be a cognitive feature of ADHD, may also potentially underpin the stronger association between ADHD traits and internalizing problems.”

To the researchers’ knowledge, this is the first study showing ADHD more strongly predicts mental health outcomes in adults than do other neurodevelopmental conditions, like ASD.

“Our finding that ADHD traits dominated ASD traits in predicting internalizing disorder symptoms could inform strategies to identify individuals who are at an increased risk of internalizing problems,” researchers said. “This might allow preventative measures and interventions to be implemented at an earlier age, which, for example, could focus on managing ADHD symptoms for a greater impact on ameliorating internalizing problems and improving mental wellbeing in adults.”

Recognizing complex ADHD (attention deficit plus one or more co-occurring conditions) is of “high clinical importance,” said Theresa Cerulli, M.D., of Beth Israel Deaconess Medical Center and the Neuroscience Education Institute, in the ADDitude webinar titled, “Complex ADHD: The New Approach to Understanding, Diagnosing, and Treating Comorbidities in Concert.”

“The presence of co-occurring conditions almost always muddles the diagnosis, treatment, and prognosis of ADHD,” she said. “ADHD and comorbidities may also influence the presentation and severity of one another, which can complicate the detection and treatment of symptoms, and impair overall quality of life.”

Researchers hope the study’s findings will encourage more research probing whether genetics help explain why ADHD traits are more strongly associated with internalizing problems than are autistic traits.

Sources

¹Hargitai, L.D., Livingston, L.A., Waldren, L.H. et al. (2023). Attention-Deficit Hyperactivity Disorder Traits Are a More Important Predictor of Internalising Problems Than Autistic Traits. Sci Rep. 13, 31. https://doi.org/10.1038/s41598-022-26350-4

²Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC psychiatry. 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

³Bishop, D. V. M. (2010). Which Neurodevelopmental Disorders Get Researched and Why? PLoS ONE 5, e15112/

⁴Young, S. et al. (2021). Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement. Front. Psychiatry 12, 324.

Physical activity can significantly reduce depressive symptoms in children and adolescents, according to a recent study published in JAMA Pediatrics. ¹

The meta-analysis of 21 studies involving 2,441 participants (47% boys and 53% girls) between the ages of 11-19 found that physical activity may help alleviate depressive symptoms in young patients. Twelve of the studies also demonstrated the benefits of physical activity for participants with a somatic or psychiatric disorder such as depression, obesity, ADHD, and diabetes.

The findings revealed that physically active teenagers experienced more notable reductions in depressive symptoms than did younger participants. “It is possible that younger children are sufficiently active to be desensitized to additional physical activity, whereas their older and more sedentary counterparts might be more responsive to the intervention,” researchers said.

After analyzing the frequency and duration of physical activity, researchers determined that engaging in three sessions of physical activity lasting at least 30 minutes yielded the greatest improvement in depressive symptoms.

“Depression is the second most prevalent mental disorder among children and adolescents, yet only a small proportion seeks or receives disorder-specific treatment,” researchers said. “Physical activity interventions hold promise as an alternative or adjunctive approach to clinical treatment for depression.” ²

Benefits of Physical Activity for Comorbid Conditions

The study suggests that physical activity may also alleviate comorbid symptoms of anxiety and ADHD, which impact 75% and 57% of children with depression, respectively.³,⁴

This finding echoes that of a 2017 ADDitude survey, which found that 37% of children with ADHD manage their symptoms with daily exercise. Roughly half of the respondents rated exercise as an “extremely” or “very” effective treatment — the highest rating of any ADHD treatment included in the survey.

“Any aerobic activity, especially outdoors, helps our daughter,” said one ADDitude reader recently surveyed on the impact of exercise. “Within a day or two of not doing anything, she gets depressed.”

“We see great improvements in our son after physical activity,” said another parent. “The depression can really take hold, even though he is only 10. We homeschool, so our son and I both have YMCA memberships and attend at least three times per week. He enjoys the elliptical, rower, spin bikes, automatic stepper, and treadmill.”

Most ADDitude reader panelists called exercise an effective form of treatment, but many said that inducing their children to participate in physical activity is challenging.

“My teenage daughter has depressive symptoms, and we see her mood improve when she is active, but it took her a long time to start exercising,” said one parent. “She used to play tennis and soccer and ski, but when she went to college, she stopped exercising.”

Physical activities must be regular and consistent to maintain their mental-health benefits, according to ADDitude readers. “In just a few short months, I see the absence of physical activity in his life magnifying all his depressive symptoms,” one parent said.

“I see an improvement in her behavior with more physical activity, but I could not say I’ve noticed any direct correlation with her mood,” said another parent. “However, I notice that her mood and behavior deteriorate when she’s less active or getting too much screen time. She does martial arts once a week and seasonally participates in soccer or t-ball. We’re adding family yoga in a few weeks.”

“My son always does better when he moves but, unfortunately, it is very difficult to get him going,” wrote another parent. “I notice after shooting hoops he is much calmer and in a better mood, so I try to encourage him to get out and do it.”

However, exercise is not a universal cure. Of ADDitude survey respondents, 5% found exercise “not very” or “not at all affective” in addressing ADHD symptoms.

“Physical activity does not have a sustained effect on his depression or intense feelings,” said one ADDitude reader panelist. Said another, “The positive results of physical activity last as long as the activity occurs, then fade fast.”

One parent explained that physical activity negatively impacted her child’s symptoms. “Physical activity does not help her — it actually makes it worse. She needs more mental activities to help her, such as puzzles, card games, or workbooks. Those are things that help regulate and reduce her symptoms.”

Sources

¹Recchia F., Bernal J.D.K., Fong D.Y., et al. (2023). Physical Activity Interventions to Alleviate Depressive Symptoms in Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Pediatr. https//doi.org/10.1001/jamapediatrics.2022.5090

²Erskine H.E., Baxter A.J., Patton G., et al. (2017 ). The Global Coverage of Prevalence Data for Mental Disorders in Children and Adolescents. Epidemiol Psychiatr Sci. 26(4):395-402. https://doi.org/10.1017/S2045796015001158

³Angold, A., Costello, E.J. (1993). Depressive Comorbidity in Children and Adolescents: Empirical, Theoretical, and Methodological Issues. Am J Psychiatry. 150(12):1779-1791. https://doi.org/10.1176/ajp.150.12.1779

⁴Birmaher, B., Brent, D., Bernet, W.,  et al. (2007). AACAP Work Group on Quality Issues. Practice  Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders.  J Am Acad Child Adolesc Psychiatry. 46(11):1503-1526. https://doi.org/10.1097/chi.0b013e318145ae1

The risk of developing depression is three to six times higher in girls and young women with ADHD who take oral hormonal contraceptives (HCs) than it is among their neurotypical peers on similar birth control, according to a population-based cohort study published in the Journal of the American Academy of Child & Adolescent Psychiatry. ¹

Women with ADHD were three times more likely to develop depression than women without ADHD, regardless of HC use, according to the research. However, the risk for depression increased substantially for women on a combined oral contraceptive (COC) or progestogen-only pill (POP). Women with ADHD who used oral combined HC were five times more likely to develop depression than were neurotypical women not using hormonal birth control. The risk increased sixfold for women with ADHD on a COC compared with neurotypical women using a COC.

Overall, 42% of women with ADHD developed depression or were prescribed antidepressants during the study period; the same was true for only 11% of subjects without ADHD.

The Swedish study was based on data from national population-based registers and included 29,767 girls and young women with ADHD aged 15 to 24 years, plus 763,146 controls without ADHD. Seven hormonal birth control groups were analyzed. These included women using any HC, COC, combined non-oral contraceptives (i.e., patch or vaginal ring), POP, progestogen implants, progestogen injection, and the hormonal IUD.

The study found that medical reasons for taking hormonal contraceptives, such as menstrual bleeding, irregular menses, dysmenorrhea, and acne, were more common in women with ADHD, further placing them at risk for depression. ¹ Women with ADHD who used non-oral HCs, such as progestogen implants or hormonal IUD, had a moderate risk of developing depression no different than that for women without ADHD.

Women with ADHD at Risk for Unplanned, Unwanted Pregnancies

Researchers noted that women with ADHD face an elevated risk of becoming teenage mothers. In Sweden, women with ADHD are six times more likely to give birth as teenagers than women without the disorder.²

“Adverse effects of hormonal contraception, including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD,” researchers said. “To prevent subsequent unplanned pregnancies and to overcome health disparities among women, health care providers need to identify women at risk and provide them with the most-effective contraceptive methods that are easily available and that do not confer unnecessary risk of depression.”

Additional research has confirmed the risk for unplanned pregnancies among women with ADHD. Stephen P. Hinshaw, Ph.D., professor of psychology at the University of California, Berkeley and principal investigator of the ongoing Berkeley Girls with ADHD Longitudinal Study, told ADDitude: “By the time they reached their mid to late 20s, about 43% of the BGALS participants in the ADHD group had one or more unplanned pregnancies compared to about 10% of individuals in the comparison group.”

Ellen Littman, Ph.D., discussed why women with ADHD are more likely to engage in risky sexual behaviors than women without ADHD during the ADDitude webinar titled, “Why ADHD Is Different for Women: Gender-Specific Symptoms & Treatments.”

“One theory for this is the early recognition of sexuality as a shortcut to social acceptance,” she explained. “It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, sexually transmitted infections, and more unplanned pregnancies in women with ADHD than women without ADHD.”

While researchers hope the study’s findings provide clinicians with guidance in contraception counseling, they also recognize several limitations, including “selection bias and residual confounding due to a lack of intact information on exposures, outcome variables, and missing covariates.”

“Given the increased risk of depression in women with ADHD, which may be further increased by oral HC use, future clinical trials on contraception need to include women with mental health problems, including ADHD, to guide prescribers on the best available choices for these women,” they said.

Sources

¹Lundin, C., Wikman, A., Wikman, P., Kallner, H.K., Sundström-Poromaa, I., Skoglund, C. (2022). Hormonal Contraceptive Use and Risk of Depression Among Young Women with Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. S0890-8567(22)01894-9. https://doi.org/10.1016/j.jaac.2022.07.847

²Skoglund C., Kopp Kallner H., Skalkidou A., et al. (2019). Association of Attention-Deficit/Hyperactivity Disorder with Teenage Birth Among Women and Girls in Sweden. JAMA Network Open.  https://doi.org/10.1001/jamanetworkopen.2019.12463

This is what psychologists call post-traumatic growth (PTG) — positive psychological changes that occur as part of a healing process. Researchers discovered that people who experience profound difficulties are more likely to experience PTG than they are to face post-traumatic stress disorder (PTSD), which often brings intense anxiety, sleeplessness, depression, or intrusive thoughts.

After a traumatic situation, people need time to heal physically, mentally, and emotionally. The process of rebuilding changes how people perceive the world around them. PTG happens when people resist being debilitated by trauma and lean into their strengths. By shifting their baseline perceptions of self and others, they allow something beneficial to develop.

[Get This Free Download: Mindful Meditation for ADHD]

Developing PTG begins with managing PTSD symptoms. Start by learning about trauma and seeking effective treatments for mind-body healing. You can’t focus on growth if you’re sleepless, depressed, or suffering from physical pain. Follow these five steps to foster PTG:

Post-Traumatic Growth: 5 Steps

1. Start by working through your feelings. Talk with a caring, licensed mental health professional and, if needed, get assistance in setting realistic goals for daily living, for recovery, and for moving forward.
2. Avoid the temptation to withdraw or use substances to cope with your distress. Find reputable support groups; sharing your experience with other trauma survivors offers comfort. Spend time with family and friends who support you.
3. Choose healthy self-care options. Manage intense emotions by noticing and naming them while practicing mindfulness and other interventions.
4. Spend time doing activities that bring you joy. Your goal is to build physical and mental well-being now and in the future.
5. Design a life that feels consistent with your changed self. Examine how your priorities have shifted. Your new narrative not only benefits you, but it can help others. Consider how to use your experience to serve others. Join an organization dedicated to a cause that moves you or start one of your own.

Post-Traumatic Growth: Next Steps

• Watch: “Mental Health Out Loud: How Stress & Trauma Affect Brain Development”
• Download: 5 Mindfulness Exercises
• Read: ADHD & PTSD: Fear Circuit Deficits Link Conditions
• Treatment: Somatic Therapy – Understanding the ADHD Brain, Body & Trauma

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Intravenous ketamine infusions could effectively reduce symptoms in patients with treatment-resistant depression (TRD), suicidal ideation (SI), and anxiety, according to a new study published in the Journal of Clinical Psychiatry. The study analyzed data from 424 TRD patients who received ketamine injections from November 2017 to May 2021. ¹

Patients received six ketamine infusions at a starting dose of 0.5 mg/kg, each one lasting around 40 minutes. Half of the patients responded to treatment within six weeks, and 20% reported remission of their depression symptoms. (After 10 infusions, response and remission rates for depression were 72% and 38%, respectively.) During the same period, 50% of patients with self-harm/suicidal ideation reported entering remission or had fewer symptoms. One-third of patients reported decreased anxiety symptoms.

“The high rates of response and remission were similar to those for interventional treatments in community samples of TRD,” researchers wrote. However, they acknowledged several limitations of the study, which included no control group and used self-reported patient data. “Comparative efficacy trials with other interventions and randomized controlled trials of racemic ketamine infusion as the primary treatment for SI are needed,” researchers said.

Roberto Olivardia, Ph.D., clinical psychologist and clinical instructor of psychology at Harvard Medical School, discussed ketamine treatment for depression in the 2019 ADDitude webinar titled “The ADHD-Depression Connection in Adults: Understanding the Link, Distinct Symptoms, and First-Line Treatments.”

“Ketamine is a hallucinogenic drug with properties that can be very useful in treating depression,” Olivardia said. “The drug affects glutamate and GABA — excitatory and inhibitory neurotransmitters of the brain. Ketamine promotes synaptic connections within the brain for learning and memory, but it can also block other receptors, leading to rapid antidepressant action. Studies have shown that the drug reduces or eliminates very acute or distressing symptoms of depression, including suicidal thoughts. Other studies show that 60% or more of patients find relief from depressive symptoms with these infusions.

“The drug, still considered experimental, is used for severe cases of treatment-resistant depression,” he continued. “When other antidepressant medications have failed, or if there’s acute suicidality, ketamine infusions may be appropriate.”

The U.S. Food and Drug Administration has not approved ketamine to treat psychiatric disorders. However, the “S” form of ketamine, which is derived from ketamine and known as Spravato (esketamine), is a Schedule III controlled substance that was approved by FDA in 2019 as a nasal spray for treatment-resistant depression in adults and depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior, in conjunction with an oral antidepressant.²

Sources

¹ Oliver, P. A., Snyder, A. D., Feinn, R., Malov, S., McDiarmid, G., & Arias, A. J. (2022). Clinical Effectiveness of Intravenous Racemic Ketamine Infusions in a Large Community Sample of Patients with Treatment-Resistant Depression, Suicidal Ideation, and Generalized Anxiety Symptoms: A Retrospective Chart Review. The Journal of Clinical Psychiatry. 83(6), 21m14336. https://doi.org/10.4088/JCP.21m14336

²U.S. Food and Drug Administration. (February 2022). FDA Alerts Health Care Professionals of Potential Risks Associated with Compounded Ketamine Nasal Spray. https://www.fda.gov/drugs/human-drug-compounding/fda-alerts-health-care-professionals-potential-risks-associated-compounded-ketamine-nasal-spray

Social distancing and remote learning have largely vanished. The same cannot be said of the pandemic’s mental health challenges. In a recent ADDitude survey, 72 percent of caregivers said their child has experienced anxiety, depression, and other mental health effects in the last two to three years. Many attributed this to the pandemic and cited new or aggravated challenges like mood changes, sleep issues, and anger.

Several parents reported an improvement in their child’s symptoms, which seemed to subside with a return to school and social activities. Others said they have learned how to cope with long-term social, emotional, and behavioral challenges. Still, many are at a loss with how to help their child acclimate to an almost-post-pandemic world.

Below, ADDitude readers describe the lingering impact of the pandemic on their child’s everyday life. What are some challenges your child has faced over the past few years, and have you found effective interventions? Let us know in the comments section.

“My son’s anxiety has increased exponentially. He always struggled in school, but distance learning for third and fourth grade — two very critical learning years — caused him to fall even further behind, both socially and academically. He’s come so far, but there’s so much ground to make up. He knows he isn’t like other kids and it has made him anxious and depressed.” — An ADDitude reader

“My child avoids all relationships even though he states how alone he feels.” — An ADDitude reader

“My son’s behavior has been difficult, but it worsened during COVID. He became visibly depressed, stopped making an effort in school (even when he knew answers), did not want to maintain any friendships, and became frightened of things that were previously common to him (like his bedroom at night). A decrease in his medications helped, but getting a neuropsychological exam that highlighted his anxiety and resulted in new medication changed the picture entirely.” — An ADDitude reader

[Download: Friendship Guide for Kids with ADHD]

“When COVID hit, we had to stay home for more than a year. Now, [our son] prefers to stay home most of the time.” — An ADDitude reader

“My son’s life changed drastically in 2020 after an already difficult fifth grade year. He has never recovered from loss of math skills, has lost many of his friends, uses food as comfort, and his picking disorder has increased tenfold. This past year was the worst we have ever had, and I hope that some changes made this summer make his eighth grade year better. I hope for happiness, if nothing else.” — An ADDitude reader

“We’ve noticed that over the last two years, our son started and continues to chew and bite on his nails and other non-food items to deal with anxiety. He has also developed a worry about going to the doctor. His concern seems to be around having to get tests, particularly nasal swabs, and shots.” — An ADDitude reader

“A lack of opportunity to socialize and isolation affected [my son’s] well-being during the pandemic. Since returning to class, he’s doing much better and is no longer having these concerns.” — An ADDitude reader

[Read: Safeguarding Youth Against Depression in the Pandemic]

“The pandemic and subsequent online learning has dug my child further into depression and anxiety. After two years of trying to succeed at school and failing enormously, she is finally taking a gap year to put her life back together through counseling. She is also being assessed for ADHD, which would explain so many of the symptoms that she has experienced since childhood.” — An ADDitude reader

“My daughter always had ADHD symptoms, but before the pandemic, she did well in school and functioned relatively normally in social settings. Once the pandemic hit, she was isolated and had to learn at home. She experienced severe depression, and her ADHD symptoms became more apparent without the structure of school.” — An ADDitude reader

“[My daughter] is combative and easily angered by family. She stopped taking her antidepressants and turned to smoking marijuana to cope with anxiety. Now that she’s 21, she’s buying alcohol.” — An ADDitude reader

“[My daughter] graduated from college in 2020 and moved to a large city with a new job and new responsibilities. The inevitable overwhelm swallowed her and magnified her symptoms to the point of taking action. She just recently got diagnosed with ADHD and has started taking stimulant medication. The good news is that, like so many of us twice exceptional women who have been diagnosed late in life, stimulant medication has made a big difference for her. The challenges remain, but now she has discovered and embraced the tools that help her meet and manage them. I’m grateful she is finally on ‘the journey’ now.” — An ADDitude reader

“My child has unofficially dropped out of school due to his inability to leave his bed on most days. He doesn’t eat, doesn’t practice self-care or personal hygiene, and has trouble maintaining and keeping track of material items. As he becomes more antisocial, his OCD, autism, and ADHD symptoms become more detrimental and debilitating.” — An ADDitude reader

“[My son] had sleep issues at the beginning of the pandemic and struggled to adjust to virtual school work and online classes. He did adjust after a few months and is now much better. He still worries and has started biting his nails, but overall, he is exhibiting much more ‘normal’ behavior than he did three years ago.” — An ADDitude reader

“My son has been homeschooled for five years and had a good social network in that community. COVID broke up our groups, some people left, and playmates went online. Friendships faded with struggles to solve online gaming disputes remotely, disagreements over wearing masks, and becoming a teen with big changes during isolation. Now I’m trying to return to work with the higher cost of living and get our son into an Early Intensive Developmental and Behavioral Intervention (EIDBI) program. Due to the shortage of qualified supervising professionals (QSP), he is still isolated and lonely.” — An ADDitude reader

Steps to Support Your Child’s Mental Health

Health experts have sounded the alarm on concerning youth mental health trends of recent years – undoubtedly worsened by the pandemic – and the need for all of society to step up for children and teens. Below are parent-focused strategies to support youth mental health.

1. Be on the lookout for signs of distress in your child.

Contact your child’s pediatrician if the following behaviors persist for more than a week, as they could indicate that your child or teen is struggling and needs help, according to Sharon Saline, Psy.D.

• Excessive worry, sadness, crying, irritation or withdrawal
• Inability to enjoy activities they previously liked
• Poor eating or sleeping habits
• Avoiding responsibilities they were previously able to meet
• Greater trouble with focus and concentration than you would expect
• Unexplained headaches or other physiological complaints
• Evidence of drug, alcohol or tobacco use
• Giving away belongings

2. Take care of your own mental health.

Put on your own oxygen mask first. Practicing self-care will help you regulate your own emotions and be present for your child. By prioritizing your mental health – through maintaining routines, taking breaks, getting enough sleep, eating nutritious meals, etc. –  you are also modeling healthy habits for your child.

3. Validate and acknowledge your child’s feelings.

According to Caroline Buzanko, Ph.D.: “Anxious children need to learn that overcoming anxiety is about doing what we’re afraid of in spite of – not without – fear. That means that even well-meaning reassurances like, ‘It’s not so bad’ and ‘It’s OK, nothing bad is going to happen’ minimize your child’s feelings.” Practice active listening as you validate.

4. Teach your child to externalize anxiety.

Externalizing anxiety will help your child separate themselves from their worries. Anxious teens especially tend to believe that anxiety is an ingrained, unchangeable personality trait. Encourage your child to think of anxiety as an outside force trying to infiltrate their brain.

5. Remain calm to de-escalate anger and meltdowns.

Shouts and arguing will only fuel your child’s anger. Temporarily walk away if you sense your child has lost control. As you walk away, be sure to communicate to your child that you need space to calm down, and that you are giving them a chance to do the same. Clearly indicate that you’ll be back after a certain number of minutes.

Learn more about de-escalating explosive reactions here.

6. Think of meaningful ways your child can connect with peers.

• Does your child have a hobby? Could they join an online group for teens interested in that activity?
• What steps, if any, is your child’s school taking to connect students with one another? Ask about extracurriculars and after school programs your child might be able to attend.
• If your child struggles with social anxiety or making friends, try setting up a couple of “have-tos” during the week (like calling grandma every Friday).

7. Foster resilience

The above strategies all serve to strengthen your child’s resiliency – the ability the cope and bounce back from difficult experiences – as do the following:

• Give your child responsibilities. Entrusting your child with important tasks (chores count) conveys trust, builds their self-esteem, and boosts their sense of purpose.
• Help your child focus on what they can control. According to Robert Brooks, Ph.D., resilient people focus their time and energy on what they can impact and influence, while those are not resilient often lead with defeatist attitudes.
• Teach your child that change and discomfort are part of life, and that it’s vital, nonetheless, to maintain a hopeful outlook despite setbacks. (More resiliency strategies here.)

ADHD and Youth Mental Health: Next Steps

• Download: Emotional Control Strategies for Kids with ADHD
• Read: Youth Mental Health Care Is Vital. And Hard to Access.
• Read: A COVID Timeline of ADHD Brains in Distress

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

All adults under age 65, including pregnant and postpartum people, should be routinely screened for anxiety and depression, according to new and groundbreaking draft recommendations from the U.S. Preventive Services Task Force (USPSTF). ¹

The task force, which comprises independent medical experts, has never before called for routine mental health screenings for adults ages 19 to 64. The group’s draft recommendations intend to help clinicians identify and treat symptoms of anxiety and depression, in particular, before they intensify and possibly interfere with a patient’s everyday life.

“We know that anxiety is such a common disorder,” said John Piacentini, Ph.D., a professor of psychiatry and biobehavioral sciences at UCLA. “If left untreated, it can increase the risk for depression, substance abuse, self-harm, and other negative health outcomes. This recommendation is a really important step toward helping people get treatment.”

Elizabeth Hovis, M.D., an assistant professor at the Medical College of Wisconsin, called the USPSTF draft recommendations for routine anxiety and depression screenings for pregnant and postpartum women—a demographic at higher risk for these disorders—long overdue.

“Depression and anxiety are leading and preventable causes of maternal morbidity and mortality, with one in five pregnant or postpartum women experiencing a mental health condition,” she said. “Unfortunately, 75% of these go untreated. Because of this, universal screening for depression and anxiety in the perinatal period is critical.”

Earlier this year, the task force recommended routine mental health screenings for children ages 8 to 18 as well.

According to the draft recommendation, U.S. data collected from 2001 to 2002 found that the lifetime prevalence of anxiety disorders in adults was 26.4% for men and 40.4% for women. Generalized anxiety disorder has an estimated prevalence of 8.5% to 10.5% during pregnancy and 4.4% to 10.8% postpartum. ², ³

The public may comment on the draft recommendation through Oct 17, 2022.

Sources

¹ U.S. Preventive Services Task Force. (2022) Screening for Anxiety in Adults. www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/anxiety-adults-screening

² Kessler, R.C., Petukhova, M., Sampson, N.A., et al. (2012) Twelve-Month and Lifetime Prevalence and Lifetime Morbid Risk of Anxiety and Mood Disorders in the United States. Int J Methods Psychiatr Res. 21(3):169-184. https://doi.org/10.1002/mpr.1359

³ Misri, S., Abizadeh, J., Sanders, S., et al. (2015) Perinatal Generalized Anxiety Disorder: Assessment and Treatment. Journal of Women’s Health. 24(9):762-70. https://doi.org/10.1089/jwh.2014.5150

Mood swings. Sleep disturbances. Deteriorating relationships. Worsening grades. Total lack of interest in recreational activities. These are among the troubling behaviors observed by more than half of caregivers since the start of the pandemic, according to a new ADDitude survey on the mental health of youth with ADHD.

Our 1,187 survey responses mirror reports by the U.S. Surgeon General with one important caveat: The mental health crisis plaguing today’s youth appears even more severe for adolescents with ADHD.

The mother of a 14-year-old in Michigan put it this way: “My daughter has developed social anxiety and sometimes has difficulty going to school or to stores where other teens might be present. She is overly obsessed with her looks, so much so that she covers our mirrors. She went from an honor roll student to Ds and Es.”

[ADDitude Special Project: Mental Health Out Loud]

Many high school students, as we now know, weren’t doing well before the pandemic: One in three reported a persistent feeling of sadness or hopelessness between 2009 and 2019, according to U.S. Surgeon General Vivek Murthy. And one in five children aged 3 to 17 reportedly had a mental, emotional, developmental, or behavior disorder during that time period.

But in the last two to three years, mental health challenges grew even more troublesome for high school students with ADHD, according to the caregivers who responded to the ADDitude survey: An astounding 67% of teens have now been diagnosed with anxiety and 46% with depression. Among children ages 3 to 17 with ADHD, the survey also revealed above-average levels of oppositional defiant disorder (11%), sleep disorders (6.75%), and eating disorders (5.32%), not to mention the learning differences that impact more than one in five students with ADHD.

The Social Media Effect

Less than 6% of parents surveyed said their adolescents with ADHD have “very good” mental health today. On a 4-point scale, this group’s average mental health rating was 2.27.

The most alarming signs of a mental health crisis revealed by the survey data involved adolescent girls with ADHD who use social media. The rate of anxiety among this group is a startling 75%, and the rate of depression is 54%, according to the survey. More than 14% have a sleep disorder, and nearly 12% report an eating disorder—more than three times the national average for neurotypical women. Though the survey cannot demonstrate causality with social media use, it does reveal that this demographic has the most severe mental health challenges.

The most “pervasive and troubling” emotions impacting all adolescents with ADHD today include anxiousness (66%), irritability (60%), apathy (59%), withdrawal (47%), and anger or aggression (45%).

[Free Resource: Too Much Screen Time? How to Regulate Your Teen’s Devices]

Among adolescent girls with ADHD, the most common sources of anxiety were school (76%); COVID-19 (54%); finances (31%); gun violence in schools and social media use (28% each). Among teens with ADHD who are not cisgender, 38% report feeling anxiety over political violence.

“Sometimes my son goes through acute depression,” said a caregiver of a transgender adolescent with ADHD, anxiety, and depression. “When this happens, the entire world goes dark for him, and we just do what we can to get him through.”

If your child is experiencing troubling symptoms of anxiety, depression, or self-harm, call or text 9-8-8 to access mental health services in the United States.

How to Protect Your Teen’s Mental Health

Talk to your child’s pediatrician if you are concerned about your child’s mental health. Learn about the signs of anxiety and depression (and other signs of distress) and ask your child’s doctor if screenings for these conditions are warranted. If your child has been diagnosed with anxiety, depression, and/or other conditions, ensure that they are adhering to treatment plans.

1. Model emotional regulation at home.

Practice self-care and prioritize your well being. Even if it doesn’t seem like it, your behaviors serve as a guide for your teen.  Keeping calm will help your teen do the same – or at least prevent emotions from escalating. Make sure you aren’t enabling your child’s anxiety.

2. Try to minimize exposure to negative news.

Avoiding discussing potentially stressful subjects – finances, marital problems, etc. – around your child, as these topics could undermine your child’s sense of safety and stability. Limit your family’s exposure to distressing news events. Learn more about navigating conversations around gun violence and school shootings here.

3. Encourage healthy social media use.

Have ongoing conversations about online experiences, and watch for warning signs of problematic Internet use. Listen to our conversation with Linda Charmaraman, Ph.D., on social media and youth mental health for more strategies. If unhealthy social comparison over social media is a problem for your teen, read this article.

4. Encourage healthy habits.

Consistency and routine ground us, as do sufficient sleep, nutritious meals, and physical activity. Social connection is also vital for teens. Take steps to ensure that your child’s life has all these elements.

5. Prioritize a good relationship with your child above all else.

A stable, supportive environment does wonders for fostering resiliency and confidence. Bond with your child over things they enjoy (don’t come in with an agenda), and really listen to your child’s concerns without judgment. (Check your immediate reactions and unsolicited advice at the door.)

ADHD & the Mental Health Crisis: Next Steps

• Join Us! Mental Health Out Loud Event on Eating Disorders in Teens
• Read: Special 2022 Mental Health Report from ADDitude
• Read: Compare & Despair: Social Media & Mental Health Concerns in Teens with ADHD
• Listen: “Mental Health Out Loud – The Mental Health Fall Out from Social Media Use”
• Free Resource: Social Anxiety Facts & Falsehoods
• Read: A Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth  

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

The mental health of adults with attention deficit hyperactivity disorder (ADHD) garners a passing grade — but barely.

In an exclusive ADDitude survey, 1,542 adults assigned their mental health status a rating of 2.27 out of 4 — a C-minus average. One contributing factor: Nearly three-quarters of respondents with ADHD also reported diagnoses of anxiety, depression, or both. This sky-high level of comorbidity is four to eight times greater than the national average.

This self-rating reflects the fact that, over the last 2 and a half years, ADDitude survey respondents said they have…

• …felt depressed (68%)
• …suffered with sleep problems (67%)
• …felt unmotivated (62%)
• …experienced mood changes (61%)
• …worried excessively (55%)
• …lost friendships or other relationships (54%) over the last three years.

More than half blamed the pandemic, and the issues it raised, for these and other mental health struggles.

“I worked face-to-face with customers who refused to wear masks,” said a mother of two in North Carolina. “This led to thoughts and feelings of anger, depression, and worthlessness because I didn’t understand why someone would think that my health wasn’t worth protecting by simply wearing a mask.”

In the survey, only about 7% called their mental health “very good” and fewer than 4% said they had no mood changes in the last three years.

[Get This Free Download: 9 Conditions Often Linked to ADHD]

The Burden of Anxiety

More than three-quarters of people reported feeling debilitating anxiety that impaired their daily living. The top reasons they cited were as follows:

• finances and money (61%)
• access to health care (38%)
• the pandemic (37%)
• political violence (33%)

Social isolation, once a pandemic requirement and now a complicated choice for many, has led to feelings of apathy, irritability, withdrawal, and sadness for more than half of respondents with ADHD. A whopping 86% said they used social media, though 60% of those individuals said it harms their mental health and even contributes to addiction issues, headaches, and eating issues for up to 24%.

The Scars of Trauma

An astounding 82% of ADDitude survey respondents said they have experienced trauma, a rate that is significantly higher than the national average compiled by the U.S. Department of Veteran Affairs: 50% for women and 60% for men. Sexual assault, the death of a loved one, car accidents, and bullying were among the traumatic incidents cited by ADDitude readers.

[Read: Does Trauma Cause ADHD? And Vice Versa?]

“I endured childhood emotional neglect and traumatic events (car accident, parents separating, violence, and bullying),” said a women diagnosed with ADHD and autism. “As an adult, I experienced sudden bereavements (my best friend and mother), and trauma based on supporting my bereaved father.”

The ADDitude survey captured many stories like these, suggesting that trauma is the rule rather than the exception for people with ADHD. The primary treatment for trauma is psychotherapy, namely, cognitive behavioral therapy (CBT), and other approaches. Yet only 25% of survey respondents said they were receiving CBT for trauma and only 57% reported receiving therapy of any kind. Almost 82% said they were taking medication, which most deemed “helpful” or “very helpful.”

“Finding a therapist who fit my schedule, was in my insurance network, and was seeing new patients was nearly impossible,” said a woman in Washington with ADHD, anxiety, and an eating disorder. “My health insurance does not cover my therapy, so I pay out of pocket. It’s been a nightmare.”

Strategies for Adults Living with Anxiety, Depression, or Trauma

A combination of ADHD medication and therapy has been found to be the most beneficial for adults with ADHD and anxiety, according to J. Russell Ramsay, Ph.D. He also offers the following daily coping mechanisms for ADHD and anxiety:

• Develop strict routines with space blocked out for downtime
• Exercise daily for at least 30 minutes, ideally outdoors
• Sleep at least 7 hours each night
• Fill your calendar with task- or time-based items that are clearly defined
• Maintain consistent treatment for ADHD
• Accept negative thoughts for what they are: just thoughts

“Sometimes we’re so caught up in our daily routines that we fail to step back and analyze sources of stress,” adds Kathleen Nadeau, Ph.D. “Whenever it starts to affect your moods, get out paper and pen and list the biggest stresses in your day. Then look for ways to reduce or eliminate them.”

She also recommends combatting anxiety and depression by cutting down on carbohydrates, which offer a quick energy hit but also a long crash and, often, weight gain. She urges adults with ADHD to create a chart where they can track progress against sleep, exercise, nutrition, green time, and stress reduction every day.

Edward Hallowell, M.D. recommends reaching out to friends, family, or a support group to avoid worrying alone.

For patients who have experienced trauma, Kerry J. Heckman, LICSW, uses somatic therapy, which “increases awareness of the sensations in the body to give the patient a roadmap to understand what they mean,” she says. “Focusing on the body’s response to the trauma — instead of the trauma itself — reduces the possibility of re-traumatizing the individual and starts the healing process. Through the body, we have more access to the traumatic residue, which may not be available in memories.”

Somatic therapy is a long-term treatment (lasting a year or more) that requires a licensed mental health practitioner trained in somatic therapy who also has experience treating people with ADHD. Since somatic therapy is a modality used by licensed therapists, most insurance policies that cover traditional talk therapy will cover somatic therapy as well.

5 Ways to Practice Somatic Therapy at Home

Though working with a trained therapist is the best treatment, Heckman says patients with trauma and ADHD can follow these simple rules to increase awareness of the nervous system.

#1. Note body sensations throughout the day. Noting and amplifying good experiences can be especially helpful when treating both ADHD and trauma, both of which carry a history of negative experiences.

#2. Find safety in structure. Structure — knowing consistently what to expect — can foster a sense of safety and decrease chronic stress-related activation or vigilance.

#3. Build a strong foundation. Diet, exercise, and sleep are the foundations of a healthy nervous system function.

#4. Notice agency. Paying attention to the areas of life where there are choices brings awareness to what can be controlled, rather than what feels uncertain.

#5. Communicate with the nervous system to calm it down. One way to quiet activation in the body is the gentle reminder that this is not a survival situation. To do this, slow down your movement and speech; check for muscle tension; and check in periodically with your body to see what movement it craves.

Learn more about somatic therapy here.

Trauma, Mental Health, & Adult ADHD: Next Steps

• Get 5 Daily Rituals to Reduce Stress
• Free Download: Make Mindfulness Work for You
• Read: The Relationship Between PTSD and ADHD
• Read: Treating Traumatic Stress Alongside ADHD

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.