Get More Help in NevadaAttention-Deficit/Hyperactivity Disorder (ADHD) & Mood Disorders
A number of mood disorders in children, including depressive disorder, seasonal affective disorder, bipolar disorder, dysthymia, disruptive mood dysregulation disorder (DMDD), may be comorbid with ADHD in children and adolescents, complicating their diagnosis and treatment. Children and adolescents with ADHD and mood disorders are at risk of having more severe and harder to treat symptoms. [Daviss: 2008] Meta-analysis reveals that 16-26% of children with ADHD develop depression during their youth. [Clemow: 2017] Major depression is present in 3.2% of adolescents at any given time, and suicide is the third leading cause of death in adolescents 12 to 19 years old. [Ghandour: 2019] [Miniño: 2010] A 2014 meta-analysis of comorbid ADHD and depression indicates a “medium” strength association between the 2 conditions, meaning that more youth with ADHD have depression than their counterparts without ADHD. [Meinzer: 2014] Children with ADHD and mood disorders are also at increased risk of suicidal attempts due to their impulsivity. [American: 2013]
DMDD, a condition defined by chronic, severe irritability and severe temper outbursts, was identified as a comorbid condition in 21.8% of children ages 6-8 years diagnosed with ADHD in a 2016 Australian study. [Mulraney: 2016] Of the children with both ADHD and DMDD, 89.7% had comorbid oppositional-defiant disorder (ODD) and 41% had anxiety (any type). See Missing link with id: b46586ee.xml for more information.
Bipolar disorder (BD) in children and adolescents is now thought to be less common than previous rates of diagnosis suggest. [Mulraney: 2016] Based on 10-year-old US data, prevalence was calculated at 1.8-3% in adolescents, whereas a 2019 meta-analysis based on international diagnostic information found a prevalence of 0.6-3.9%. [Marangoni: 2015] [Merikangas: 2010] [Van: 2019] Prominent mood problems, sleep problems, and aggressive behaviors in youth, with impulsive behaviors around money, sex, and substance use, tend to arise more in BD, whereas fidgeting, restlessness, and disorganization related to distractibility and inattention point to ADHD. [Marangoni: 2015] Children with ADHD tend to have more consistent symptoms. A review of previous studies found rates of children and adolescents with ADHD developing bipolar disorder between 0% and 22%; however, the latter may be an over-estimate as rates of bipolar diagnosis in children have declined since the introduction of DMDD with DSM-V. [Clemow: 2017] [Le: 2020]
A child or adolescent with ADHD may not have a mood disorder at the time of the ADHD diagnosis, as depressive symptoms often emerge several years after ADHD symptoms. [Meinzer: 2014] [Daviss: 2008]Therefore, repeated screening for depressive symptoms is indicated for children with ADHD. [Meinzer: 2013]
Etiology
A 2020 study underscores that children with ADHD are at increased risk (odds ratio 1.27) of later developing depression when compared to children without symptoms of ADHD. [Powell: 2020] Their research identified problematic peer relationships and impaired academic achievement as contributors to development of depressive symptoms. In a separate study from 2020, low educational attainment in parents strongly increased the risk of ADHD, depression, and academic problems in offspring with shared genetic factors, while the environmental effects of lower parental education were strongly correlated with depressive symptoms. [Torvik: 2020] Prenatal factors are associated with ADHD and increased risk of childhood depression, which are thought to be related to changes in the uterine environment that impact brain development and shared genetic factors. [Kim: 2020] [Upadhyaya: 2020]
Distinguishing Mood Disorders and ADHD
Inattention can occur in both ADHD and mood disorders. In ADHD, distraction is typically caused by external stimuli, whereas in mood disorders, the distraction is internal. Suspect a mood disorder or depression when the child displays:
- Irritability
- Depressed mood/sad (not always evident)
- Decreased interest in usual activities
- Appetite changes
- Unintended weight changes
- Sleep problems
- Changes in energy level, fatigue
- Feelings of worthlessness
- More difficulty concentrating
- Suicidal ideation or behavior
Diagnosis
Untreated mood disorders can make it harder to effectively treat ADHD, and it can be challenging to differentiate some behaviors seen in ADHD from those in mood disorders.
When diagnosing mood disorders, consider the following types of questions:
- Family history
- Changes in the child's usual affect and temperament. Note that DMDD is often present in childhood with severe, persistent irritability and temper outbursts, whereas depression is more likely to emerge once puberty has started. [Eyre: 2017]
- Decreased involvement with friends or activities that are usually enjoyable for the child
- Changes in sleep (sleeping more or less)
- Decreased or dramatically increased energy level
- Threatened or actual self-harm or suicidal ideation
- Appetite changes
- Increased outbursts of temper
- Impact of symptoms on functioning
Information from the child's teacher is also important in sorting out the
degree of symptomatology. The Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) (
1.1 MB), frequently used to assist in diagnosis and monitoring response to treatment for
children and youth with ADHD, include several questions about mood disorders in the
initial evaluations. A high score on mood-related questions, along with impaired
function, should raise concern for a mood disorder.
As part of the ongoing assessment of children with ADHD, separate screens for mood disorders may periodically be used. For assistance clarifying a diagnosis or presence of suspected comorbid conditions, consult psychiatry. For more information, see the Clinical Assessment sections of the Portal's Depression and Attention-Deficit/Hyperactivity Disorder (ADHD) modules.
Treatment
Having ADHD and a comorbid mood disorder can complicate treatment of both conditions. For example, the medical home provider needs to consider whether inadequately treated ADHD symptoms are increasing the child’s depressive symptoms, or if inadequately treated mood disorders are contributing to the child’s inattentive or impulsive symptoms. Sudden worsening of ADHD symptoms when they had previously been controlled may indicate the onset of a mood disorder. On a good note, there is evidence that treatment of ADHD in childhood may protect against later depression. [Biederman: 2009] [Daviss: 2008] [Cubero-Millán: 2014] Initial pharmacologic treatment should be targeted towards the dominant symptoms. [Barbaresi: 2020] Strongly consider psychiatric referral for complicated treatment plans, such as needing 2 or more psychoactive medications, or multiple comorbid conditions.
Treatment with selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors (SNRIs) and psychological interventions, such as cognitive-behavioral therapy (CBT), have been shown to be helpful in treating children/youth with depression. Psychotherapy, in conjunction with medication, generally was found to have the strongest effect [Strawn: 2017], but the most recent Cochrane review did not find one better than the other. [Cox: 2014] In mild-moderate cases of depression, primary care clinicians are generally advised to start with referral to psychotherapy if readily accessible and the family is open to that approach. [Cheung: 2018] All patients with depression should be monitored closely (e.g., monthly) with phone calls or visits.
For children and adolescents with DMDD, treatment includes behavioral therapy as well as medications. A wide range of medications have been used to treat DMDD: antidepressants/selective norepinephrine reuptake inhibitors, mood stabilizers, psychostimulants, antipsychotics, and alpha-2 agonists. [Tourian: 2015] While data are limited, there is evidence to support the treatment of ADHD with comorbid DMDD symptoms with psychostimulants (methylphenidate) or alpha agonists. Consult a psychiatrist for treatment of youth with bipolar disorder and comorbid ADHD. See Psychiatry > … (see NV providers [101]).
Behavioral Therapy
Medications
SSRIs and SNRIs
Among the numerous available SSRIs, the FDA approved fluoxetine and escitalopram for treatment of major depressive disorder in children/adolescents [Strawn: 2017]; however, many providers prescribe alternative SSRIs/SNRIs to children as off-label use. Although these medications carry an FDA black box warning for suicidal ideation and behavior, studies suggest that the benefits of treatment for depression in children/youth may outweigh these risks. [Hetrick: 2012] SSRIs and SNRIs are increasingly used to treat irritability and anger as well, [Bruno: 2019], but there is no good evidence currently of concurrent benefits for symptoms of ADHD.
In children and adolescents, antidepressants can cause activation, with symptoms including impulsivity, hyperactivity, restlessness, disinhibition, giddiness, and/or insomnia. Little is known about the likelihood of children with ADHD treated with stimulant medications developing activation with the addition of an antidepressant, although it appears to be low. [Luft: 2018] Consider starting at a lower dose if an autism spectrum disorder is also present as activation is more likely to occur in this population.
Medical home providers who prescribe medications for depression should ensure that the family understands the risks involved, the patient is monitored closely, and a plan is in place should the child/youth have increasing suicidal ideation or behavior. See Suicidality & Self-Harm.
Atomoxetine
Atomoxetine, generally considered a second-line ADHD treatment, has SNRI properties but is not generally prescribed as an antidepressant and has not been shown to consistently improve depressive symptoms in children with ADHD. [Clemow: 2017] Although it has a black box warning for suicidality due to its medication class, studies seem to show that it does not increase the risk of suicidality when prescribed for treatment of ADHD. [Linden: 2016] Paroxetine, duloxetine, and venlafaxine are associated with higher rates of side effects in youth than the other SSRI/SNRIs, so they are not advised as first-line antidepressants. [Cheung: 2018]
Bupropion
Bupropion, a dopamine and norepinephrine reuptake inhibitor, is occasionally used in the treatment of ADHD, although it is not considered a first-line intervention. It is thought to have a smaller effect on symptoms of ADHD but may be considered in children with comorbid mood disorders. More study is needed to understand the medication’s potential benefits and risks in pediatrics. [Ng: 2017]
Psychostimulants
Limited research on stimulant medications for children/adolescents with ADHD and DMDD generally demonstrates positive effects on both the core symptoms of ADHD and externalizing and aggressive symptoms of DMDD, but inconsistent improvement on the depressive symptoms of DMDD. Stimulant monotherapy may be reasonable to try for children with ADHD and DMDD with high irritability, significant aggression, and explosiveness and may decrease depressive symptoms. Be aware that amphetamine derivatives have been associated with increased risk of irritability, whereas methylphenidate class stimulants may decrease risk of irritability. [Luft: 2018]
In contrast to DMDD, stimulants are not recommended to treat symptoms of major depression in children with comorbid ADHD. [Blader: 2016]
Alpha-2 Agonists
Very limited information is available on pharmacologic treatment for both DMDD and ADHD. Both clonidine and guanfacine can be used to help treat ADHD. Studies in children with ADHD and severe mood dysregulation or irritability have shown improvement in both sets of symptoms when treated with alpha agonists. [Tourian: 2015]
Atypical Antipsychotics
Risperidone and aripiprazole are approved for treatment of irritability in children with autism spectrum disorder but have not been widely studied for treatment of irritability in children with DMDD and ADHD. One open-label study demonstrated improved irritability, attention, externalizing behaviors, depression, and anxiety in children treated with aripiprazole and methylphenidate. [Pan: 2018]
Atypical antipsychotics, which may be used to treat bipolar disorder, are not generally used to treat core symptoms of ADHD.
Role of the Medical Home Provider
- Provide routine screening for mood disorders in all children and adolescents.
- Remain vigilant for the emergence of a mood disorder among children and adolescents with a known diagnosis of ADHD, particularly if there is a family history of mood disorders.
- When a mood disorder is present, screen for thoughts of self-harm and suicidal ideation.
- Work with both the patient and family to establish treatment goals and priorities.
- Provide a referral to behavioral health to clarify a diagnosis and/or help with treatment and family training.
- Prescribe and monitor medication when indicated.
- Encourage good sleep hygiene, regular physical activity, and nutrition. [Cheung: 2018]
- Obtain consultation from a psychiatrist when there are severe symptoms, failing interventions, or concerns about medication interactions.
- Provide families and patients with information about all of their medical conditions.
Resources
Information & Support
Attention-Deficit/Hyperactivity Disorder (ADHD), Anxiety Disorders and Anxiety Disordershave further clinical information for these related conditions.
For Professionals
Child and Adolescent Mental Health (NIMH)
Information about mental health conditions in children and adolescents, including a list of warning signs, featured videos,
and health hotlines; National Institute of Mental Health.
ADHD Resource Center (AACAP)
Includes excellent provider and parent resources; American Academy of Child & Adolescent Psychiatry.
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research,
and getting help for depression; American Academy of Child & Adolescent Psychiatry.
For Parents and Patients
ADHD (HealthyChildren)
Links to more than 90 articles that discuss aspects of ADHD evaluation and management; developed by the American Academy of
Pediatrics.
ADHD Resource Center (AACAP)
Includes excellent provider and parent resources; American Academy of Child & Adolescent Psychiatry.
Spence Children’s Anxiety Scale (SCAS) ( 115 KB)
Child (45-question) and parent (39-question) forms for school-aged children. Scores for overall anxiety disorder plus scores
for separation anxiety, social phobia, obsessive-compulsive problems, panic/agoraphobia, generalized anxiety/overanxious symptoms,
and fears of physical injury. Based on DSM-IV, with free access to downloadable PDFs and online scoring versions. Available
in many languages.
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, “Facts for Families,” books, videos, practice parameters, research,
and getting help for depression; American Academy of Child & Adolescent Psychiatry.
Practice Guidelines
Barbaresi WJ, Campbell L, Diekroger EA, Froehlich TE, Liu YH, OʼMalley E, Pelham WE Jr, Power TJ, Zinner SH, Chan E.
The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children
and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms.
J Dev Behav Pediatr.
2020;41 Suppl 2S:S58-S74.
PubMed abstract
Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein REK.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.
Pediatrics.
2018.
PubMed abstract
Wolraich ML, Hagan JF Jr, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann
CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W.
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children
and Adolescents.
Pediatrics.
2019;144(4).
PubMed abstract / Full Text
This guideline revision provides incremental updates to the 2011 guideline on ADHD, including the addition of a key action
statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying
process of care algorithm has also been updated to assist in implementing the guideline recommendations; American Academy
of Pediatrics (AAP).
Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment,
and Initial Management.
Pediatrics.
2018.
PubMed abstract
Tools
Brown Stanley Patient Safety Plan Template ( 57 KB)
A template outlining 6 steps to help those considering suicide to first self-help, then reach out to others for help when
a crisis may be developing. Template may be reproduced.
Services for Patients & Families in Nevada (NV)
| Service Categories | # of providers* in: | NV | NW | Other states (3) (show) | | NM | RI | UT |
|---|---|---|---|---|---|---|---|---|
| General Counseling Services | 210 | 1 | 10 | 30 | 298 | |||
| Psychiatry | 101 | 5 | 90 | 72 | ||||
| Psychiatry/Medication Management | 37 | 3 | 80 | 53 | ||||
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Helpful Articles
Eyre O, Langley K, Stringaris A, Leibenluft E, Collishaw S, Thapar A.
Irritability in ADHD: associations with depression liability.
J Affect Disord.
2017;215:281-287.
PubMed abstract / Full Text
This study aims to establish levels of irritability and prevalence of DMDD in a clinical sample of children with ADHD and
examine their association with anxiety, depression, and a family history of depression.
Strawn JR, Dobson ET, Giles LL.
Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety.
Curr Probl Pediatr Adolesc Health Care.
2017;47(1):3-14.
PubMed abstract / Full Text
Tourian L, LeBoeuf A, Breton JJ, Cohen D, Gignac M, Labelle R, Guile JM, Renaud J.
Treatment options for the cardinal symptoms of disruptive mood dysregulation disorder.
J Can Acad Child Adolesc Psychiatry.
2015;24(1):41-54.
PubMed abstract / Full Text
The objective of this article is to provide a thorough review of peer-reviewed studies on the subject of pharmacological treatment
options for children and adolescents with the cardinal symptoms of DMDD.
Marangoni C, De Chiara L, Faedda GL.
Bipolar disorder and ADHD: comorbidity and diagnostic distinctions.
Curr Psychiatry Rep.
2015;17(8):604.
PubMed abstract
This article reviews recent relevant findings and highlights epidemiological, clinical, family history, course, and treatment-response
differences that can aid the differential diagnosis of these conditions in an outpatient pediatric setting.
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and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms.
J Dev Behav Pediatr.
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Irritability in ADHD: associations with depression liability.
J Affect Disord.
2017;215:281-287.
PubMed abstract / Full Text
This study aims to establish levels of irritability and prevalence of DMDD in a clinical sample of children with ADHD and
examine their association with anxiety, depression, and a family history of depression.
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risk of suicidal events in pediatric patients treated with atomoxetine compared with stimulants in 26 Medicaid programs.
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Bipolar disorder and ADHD: comorbidity and diagnostic distinctions.
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2015;17(8):604.
PubMed abstract
This article reviews recent relevant findings and highlights epidemiological, clinical, family history, course, and treatment-response
differences that can aid the differential diagnosis of these conditions in an outpatient pediatric setting.
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Primary pediatric care psychopharmacology: focus on medications for ADHD, depression, and anxiety.
Curr Probl Pediatr Adolesc Health Care.
2017;47(1):3-14.
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Treatment options for the cardinal symptoms of disruptive mood dysregulation disorder.
J Can Acad Child Adolesc Psychiatry.
2015;24(1):41-54.
PubMed abstract / Full Text
The objective of this article is to provide a thorough review of peer-reviewed studies on the subject of pharmacological treatment
options for children and adolescents with the cardinal symptoms of DMDD.
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2019;80(3).
PubMed abstract
This updated meta-analysis confirms that rates of bipolar spectrum disorders are not higher in the United States than in other
Western countries, nor are rates increasing over time. Nonstandard diagnostic criteria result in highly variable prevalence
rates, as does focusing on narrow definitions of PBD to the exclusion of the full spectrum.
Wolraich ML, Hagan JF Jr, Allan C, Chan E, Davison D, Earls M, Evans SW, Flinn SK, Froehlich T, Frost J, Holbrook JR, Lehmann
CU, Lessin HR, Okechukwu K, Pierce KL, Winner JD, Zurhellen W.
Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children
and Adolescents.
Pediatrics.
2019;144(4).
PubMed abstract / Full Text
This guideline revision provides incremental updates to the 2011 guideline on ADHD, including the addition of a key action
statement related to diagnosis and treatment of comorbid conditions in children and adolescents with ADHD. The accompanying
process of care algorithm has also been updated to assist in implementing the guideline recommendations; American Academy
of Pediatrics (AAP).
Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D.
Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment,
and Initial Management.
Pediatrics.
2018.
PubMed abstract