ADHD, Clinical Depression, and Teenage Girls: Recent Research

Several research projects in recent years have looked into the impact of ADHD on the lives of adolescent girls. MRI studies report that the adolescent brain is rapidly maturing, but is not fully mature until the early twenties in women, and perhaps the early thirties in males. Long-term research on behavior and emotional health report that girls with ADHD may struggle through the teen years. And other studies report that depression is common among teens with ADHD, and is so common among adolescent students that the use of medications for ADHD, antidepressants, anti-psychotics, and even sleep medications, is up sharply with adolescent females.

While many children and teens with ADHD also suffer from some degree of sadness, discouragement, or frustration, as many as 25% are clinically depressed. Children and teens with ADHD are as much as 300% more likely to also suffer from depression than are children or teens without ADHD.

The co-morbid depression seems little associated with the ADHD symptoms such as inattention, impulsivity, hyperactivity, or academic problems. These problems might result in a young person being discouraged, sad, or frustrated, but probably not clinically depressed.

Rather, the depression seems to be most associated with social awkwardness or interpersonal difficulties that are sometimes a part of having ADHD. The lack of friendships, the sense of loneliness, or the sense of being a social outcast are most likely behind the depression. And these feelings are, of course, much stronger in the teenage years.

In girls who were diagnosed with ADHD, and were followed by long-term studies through the years, it was observed that as they moved from childhood to adolescence their outward symptoms of ADHD, such as hyperactivity and impulsivity, tended to lessen.

We do want to note that most girls with ADHD do not have the symptoms of hyperactivity or impulsivity. Most girls with ADHD are inattentive, distracted, disorganized, or space cadets, which is why girls are so under-diagnosed for ADHD. Young women tend to just sit in the classroom, get distracted, and do poorly on the tests. But they don't cause trouble in the classroom so they often do not get the attention that might lead to a diagnosis and appropriate treatment.

But for those girls were did have the symptoms of hyperactivity or impulsivity, and had been diagnosed as children, their outward symptoms tended to decrease as they reached the teenage years.

However, as these girls reached the teenage years, it was observed that their academic performance continued to be a problem, and that the academic gap between them and their peers without ADHD continued to widen with each passing year.

These researchers also noted that, while some girls with ADHD actually out-grew it as they reached adolescence, for the most part the girls not only continued to suffer from their ADHD, but many began to get into serious trouble. Both behavioral and emotional problems began to emerge in many of these girls, and the need for specialized treatment grew.

There were growing problems with friends, which led to increased levels of depression. There were increased levels of substance abuse (both alcohol and drug abuse). Behavior problems at school increased as the academic problems worsened. And, surprisingly, eating disorders became a serious problem among many of these girls.

All of these problems were at higher levels among these ADHD girls than among their non-ADHD peers.

As we have noted elsewhere, twice as many teens with ADHD will run away from home than teens without ADHD. About 16% of teens run away from home at some point, versus 32% of teens untreated for ADHD. And as many as 50% of all teenagers in juvenile facilities have Attention Deficit Hyperactivity Disorder but were undiagnosed or never treated.

Adolescents undiagnosed or never treated for ADHD are ten times more likely to get pregnant, or cause a pregnancy, than those without ADHD, and teenagers undiagnosed or never treated for Attention Deficit Hyperactivity Disorder are 400% more likely to contract a sexually transmitted disease than teens without ADHD: 16% to 4%.

ADHD, and Depression

With as many as 25% of teens with ADHD being clinically depressed, it is important to understand what depression looks like, why it is so important to treat it and manage it, and understand the treatment options available.

When we think of someone who is depressed, we usually picture a sad, tearful, lonesome person. But teens with depression don't look like adults with depression.

Current studies show that there are about as many teens who are depressed as there are adults that are depressed, about 10% of the general population. And as we have noted, as many as 25% of teens with ADHD are depressed.

However, depression in teens does not typically look like depression in adults. Teenagers do not commonly display gloom, self-depreciation, or talk about feeling hopeless like adults do. Teenagers with Major Depression are described as often becoming negative and antisocial. Feelings of wanting to leave home or wanting to run away will increase. There may be a strong sense of not being understood and approved of by parents, siblings, or peers.

The young person often changes, and becomes more restless, grouchy, or aggressive. A reluctance to cooperate in family ventures, and withdrawing from the family by retreating into their room is pretty common. School difficulties are likely even in those few ADHD teens who were doing pretty well in school, as concentration is more affected by the depression than from the ADHD alone.

Sometimes the teen will stop paying attention to personal appearance, and sometimes they will adopt the uniform of social groups that profess depression or despondency as a way of life. They often become much more emotional at even small things. Often there is an increased sensitivity to rejection in love relationships as well.

This reminds me of a Cornell University report that showed that the leading cause of teenage depression was breaking up with a boyfriend or girlfriend. The study further reported that the younger the teen was in this relationship at the time of the breakup, the more likely the breakup would lead to depression.

Teenage boys will often become aggressive with their parents or peers, seem more agitated around home, and get into more trouble at home, at school, or with the law.

Teenage females will sometimes become preoccupied with themes of death or dying, and become decreasing concerned about how they look. Think black - black hair, nails, clothes, lips.

Suicidal thoughts are common in depressed teens. Some studies suggest that 500,000 teens attempt suicide each year, and 5,000 are successful. That would be 10% of depressed teens. Other studies suggest that the number is fifteen percent of depressed teens ending their life via suicide.

By the way, another study notes that of all the teenagers that commit suicide each year, only seven percent were receiving mental health treatment at the time of their death.

Poor self-esteem is common with teenagers, but especially with those who are depressed, and there is often an increase in self-destructive behaviors such as alcohol abuse, drug abuse, cutting, and sexual promiscuity.

Parents are often confused and frustrated when their teens begin to act like this. Sometimes parents become stern disciplinarians, or even put the teen down, which only serves to increase feelings of guilt and depression. Other times, parents feel helpless, and stand by waiting for adulthood to arrive. Of course neither course is the right one to take.

From 2001 to 2006, the use of ADHD medicines prescribed to girls was up by nearly seventy-five percent, and the use of antidepressant medicines was up by nearly ten percent in girls.

Black Box Warning Label

No doubt you have seen recent news headlines about a federal panel that recommended to the FDA that anti-depressant medicines carry the strongest possible warning label for use in children and teenagers. This recommendation to the FDA shook the medical community, especially those who work with depressed teens, and now the FDA does mandate that antidepressants used to treat adolescent depression carry the black box warning label.

The warning label reads:

Suicidality in Children and Teenagers:

Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and teenagers with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or teen must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. [Drug Name] is not approved for use in pediatric patients except for patients with [Any approved pediatric claims here]. (See Warnings and Precautions: Pediatric Use)

Pooled analyses of short-term (4 to 16 weeks) placebo-controlled trials of nine antidepressant drugs (SSRIs and others) in children and teenagers with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders (a total of 24 trials involving over 4400 patients) have revealed a greater risk of adverse events representing suicidal thinking or behavior (suicidality) during the first few months of treatment in those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials.

The biggest problem from our point of view was not the recommendation for the warning label, but the way that the media portrayed the recommendation. The panel reported that 2% to 4% of children and teens that were given anti-depressants for the treatment of depression had suicidal thoughts, or made suicidal attempts of one kind or another. None of the 4,000 children and teens studied committed suicide.

What the media did not report well is the fact that 10% to 15% of children and teens with depression that receive no treatment will commit suicide. These 10% to 15% will not just have suicidal thoughts, but will actually kill themselves.

So what are we to do? If the media had their way it seems that no teenagers with depression would receive medication for treatment. As a result the suicide rate for those who could be using the medication would rise from nearly zero percent to about fifteen percent, which is the rate of suicide for young people with depression who receive no treatment.

While there actually are young people, and adults, who have become suicidal only after beginning treatment with an anti-depressant, and some have in fact gone on to take their own lives, which is absolutely tragic and heart-breaking. But so is the fact that if left untreated depression is potentially a deadly disease. As many as fifteen out of one hundred teenagers with depression take their own lives if they do not get treatment. These young people should be able to get treatment that will lower the suicide rate dramatically, without any stigma attached to it by the media. With proper diagnosis and treatment a depressed teen, or adult, can be helped significantly.

Over 350,000 parents and school teachers visit the ADD ADHD Information Library at http://newideas.net each year to find accurate and helpful insights on helping children with ADHD. Dr. Douglas Cowan is the clinical editor.