Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Comorbid Depression and ADHD in Children and AdolescentsSeptember 01 2008 | ADHD [1] Attention Deficit Disorders [2] Bipolar Disorder [3] Comorbidity InPsychiatry [4] Dysthymia [5] Major Depressive Disorder [6]By Gavin L Brunsvold MD [7] Godehard Oepen MD PhD [8] Edward J Federman PhD [9] and Richard Akins MD MBA [10]

ADHD the most common diagnosis in child psychiatry appears to be more challenging to diagnoseand treat when there is a comorbid depressive disorder

Attention deficit hyperactivity disorder (ADHD) the most common diagnosis in child psychiatry

appears to be more challenging to diagnose and treatwhen there is a comorbid depressive disorder In community samples estimates of the prevalence ofdepression among patients with ADHD range from 13 to 27 while clinical sample reports haverun as high as 601-3 Conversely among children and adolescents with depression various studieshave reported widely varying rates of ADHD (from less than 5 to more than 50) a recent study invery young children reported a rate of 4245 Nevertheless ADHD and depressive disorders areoften difficult to separate in clinical practice

Depressed children often show more irritability and inattention than sadness which may lead to amisdiagnosis of ADHD6 Various algorithms and evidence-based treatment recommendations forcomorbid ADHD and depression point in somewhat differing directions378 In clinical practicemoderating factors that include age and sex as well as additional comorbid conditions add

Page 1 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

complexityIn this article we review key issues in the diagnosis treatment and outcome of comorbid ADHD anddepression We also highlight the importance of moderating variables and consider the validity of thedistinction between internalizing and externalizing disorders Our review of academic studies iscomplemented with new naturalistic findings from 3419 patients who were routinely assessed atbaseline and 4-month follow-up in private practiceDiagnostic controversiesSome conditions such as thyroid disease drug abuse sleep disorders learning disabilities bipolardisorder or attachment disorders may easily be misdiagnosed as ADHD if not screened for69 Sourcebias in the diagnosis of ADHD remains a concern parent and teacher ratings of schoolchildren arefrequently inconsistent and the validity of the most widely used instrument to diagnose ADHDmdashtheConnersrsquo Rating ScalendashRevisedmdashhas been seriously questioned310 DSM-IV split the ADHD diagnosispresented in DSM-IIIR into inattentive and hyperactiveimpulsive subtypes and more recent researchsuggests other ways of subtyping ADHD11-13

With and without antisocial disordersADHD alone ADHD with oppositional defiant disorderconduct disorder (ODDCD) ADHD withanxiety and ADHD with ODDCD and anxietyPersistent versus nonpersistent ADHD

Turning conventional wisdom on its head research findings suggest that from a familial perspectivethe assessment of ADHD may be more valid in adults than in children14 Such findings can lead topolarized conclusions including hypotheses that ADHD is genetically heterogeneous or that ADHD isnot a disease but rather a group of symptoms that represents a common behavioral pathway for arange of emotional psychological and learning problems313

Similarly the diagnosis of depression in children is not without concerns Historically cliniciansmaintained that young children have difficulty naming affect and considered the diagnosis of mooddisorders in children controversial315 However recent studies show more typical presentations ofmajor depressive disorder (MDD) in children5 In addition there have been widely discrepant reportsof the prevalence of depression among children with ADHD The Multimodal Treatment Study ofChildren With ADHD (MTA) found mood disorders in only 4 of study participants which is far lowerthan other studies and suggests that instruments used in that study may have been insensitive todepressive symptoms16 Carefully controlled academic studies (mostly with boys) suggest thatdepression and ADHD are indeed distinct entities and not simply the product of overlappingsymptoms rater bias or demoralization9Internalizing and externalizing disordersAlthough ADHD is often considered an externalizing (overtly disruptive) disorder (as are ODD andCD) and depression is often considered a (nondisruptive) internalizing disorder (as is anxiety) thedistinction between these 2 ldquosuper categoriesrdquo is less clear than the names suggest Externalizingdisorders are related to a range of anxiety disorders Findings from studies of patients with ADHDalone with ADHD and dysthymia and with dysthymia alone indicate that the rates of externalizingsymptoms or ODD are not significantly different1718 Other research shows that the association ofdepression with ODDCD (one an internalizing and one an externalizing disorder) was almost asstrong as that of depression and anxiety (2 internalizing disorders)4Complementing these academic studies we collected data from our clinic at Alabama PsychiatricServices (APS)mdasha private practice group with 11 offices 38 psychiatrists 45 nurses and 34therapistsmdashthat routinely integrates baseline and follow-up assessments into its inpatientoutpatient and partial hospital services to adults children and adolescents Our findings shed lighton the relationship between the internalizing and externalizing disorders19 We administered theChild and Adolescent Symptom Checklist (CAS) to parents of 3419 outpatients The CAS is a fullyautomated psychometrically sound rating scale (E J F unpublished data 2005) with 5 subscalesthat assess for ADHD

ADHD-inattentive (ADHD-I)ADHD-hyperactiveimpulsive (ADHD-H)Generalized anxiety disorderODDMDD

Page 2 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

The items on each subscale parallel the criteria for DSM-IV Category A of the correspondingdiagnosis and responses are on a 4-point scale of frequency A factor analysis (principal componentswith varimax rotation) of CAS data reveals that 2 factors account for 77 of the varianceThe correlation between the factor and the underlying variablesmdashfactor loadingmdashis shown in the Table The 5 common childhood disorders may be represented by 2 factors that do not neatly followthe internalexternal dichotomy On factor 1 (a distress factor) anxiety and depression load heavilyand ODD loads moderately on factor 2 (an attentional factor) ADHD-I and ADHD-H load heavily andODD loads moderately In short anger and acting out are components of both the distress andattentional factors These findings align with clinical reality and indicate that irritability is oftenpresent in anxiety depression and ADHDUnderlying factorsThe relationship between depression and ADHD may vary as a function of moderating variables (sexage comorbid ODD) ADHD subtype and data source (doctor child parent teacher) For examplewhen we look at our entire sample depression scores have a significantly higher correlation (P lt001) with ADHD-I than with ADHD-H However if we look at these same correlations within agegroups (younger than 10 years 10 to 14 years older than 14 years) the highly significant differencesin the correlations between depression and ADHD subtypes remain only for the youngest group (P lt0001) and there is merely a trend in the 2 older groups Clinically this highlights the importance ofconsidering behaviors that are normed by ageAs another example of the power of moderating variables our data showed that by controlling forODD symptoms a clear distinction emerged between depression and ADHD-H symptoms while therelationship between depression and ADHD-I symptoms was significantly attenuated Thisunderscores the relative independence of depressive and ADHD syndromes when angryirritablefeatures are not present suggested by the factor analysis in the Table More generally these resultsindicate that failing to sufficiently account for moderating variables and ADHD subtype may helpexplain why different investigators have reached different conclusions about whether thecomorbidity between depression and ADHD is an epiphenomenon (accounted for by a thirdvariable)420

The relationship between ADHD and depression symptoms can be refined even further by looking atthe results by sex On the CAS the relationship between ADHD-I and depression scales wassignificantly stronger (P lt 001) for boys than for girls (whether controlling for ODD or not) Whencontrolling for ODD the correlation for girls (r = 06) was clinically meaningless while stillstatistically significant in our large sample This finding suggests that when ODD features are absentdepression and ADHD-I are less closely related in girls and thus more clearly distinguishable than inboys in whom significant overlap remains and differential diagnosis may be more difficultGenetic research suggests that MDD with ADHD is an etiologically distinct subtype in females but notin males21 Biederman and colleagues22 found that girls with ADHD were less likely than boys withADHD to have MDD This is an interesting finding because the prevalence of depression in thegeneral population is higher in girls than in boys These lines of evidence converge to indicate aclearer distinction between ADHD and depression in girls than in boysIt remains unclear whether a clinically easier differential diagnosis in females produced a cleanerproband sample that led to a familial distinction or conversely whether a true etiological distinctionleads to an easier differential diagnosis in girls than in boys Clinically it appears that a morerigorous assessment procedure is indicated whenever features of ODD are present with ADHD anddepression and that differential diagnosis may be more complicated in boys than in girlsA strong relationship was found between ADHD and depression that was modified by age andcomorbidity23 This relationship was intensified when ODDCD was present in older but not youngerchildren In general ADHD appears at a younger age and depression at an older age and asexpected the strength of the association between the 2 disorders increases from childhood throughadolescence2324

The importance of considering moderating variables and ADHD subtype is underscored by ourfindings (Figure) which show levels of depression as a function of sex age and ADHD subtype TheFigure shows that

Children and adolescents with ADHD-combined (ADHD-C) subtype generally have higherlevels of depression than do youths with ADHD-IDepression increases with age and the rate of increase is greater in girls than in boysGirls older than 10 years generally have higher levels of depression than boys whereas thereverse appears true in children younger than 10 years

Page 3 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

The items on each subscale parallel the criteria for DSM-IV Category A of the correspondingdiagnosis and responses are on a 4-point scale of frequency A factor analysis (principal componentswith varimax rotation) of CAS data reveals that 2 factors account for 77 of the varianceThe correlation between the factor and the underlying variablesmdashfactor loadingmdashis shown in the Table The 5 common childhood disorders may be represented by 2 factors that do not neatly followthe internalexternal dichotomy On factor 1 (a distress factor) anxiety and depression load heavilyand ODD loads moderately on factor 2 (an attentional factor) ADHD-I and ADHD-H load heavily andODD loads moderately In short anger and acting out are components of both the distress andattentional factors These findings align with clinical reality and indicate that irritability is oftenpresent in anxiety depression and ADHDUnderlying factorsThe relationship between depression and ADHD may vary as a function of moderating variables (sexage comorbid ODD) ADHD subtype and data source (doctor child parent teacher) For examplewhen we look at our entire sample depression scores have a significantly higher correlation (P lt001) with ADHD-I than with ADHD-H However if we look at these same correlations within agegroups (younger than 10 years 10 to 14 years older than 14 years) the highly significant differencesin the correlations between depression and ADHD subtypes remain only for the youngest group (P lt0001) and there is merely a trend in the 2 older groups Clinically this highlights the importance ofconsidering behaviors that are normed by ageAs another example of the power of moderating variables our data showed that by controlling forODD symptoms a clear distinction emerged between depression and ADHD-H symptoms while therelationship between depression and ADHD-I symptoms was significantly attenuated Thisunderscores the relative independence of depressive and ADHD syndromes when angryirritablefeatures are not present suggested by the factor analysis in the Table More generally these resultsindicate that failing to sufficiently account for moderating variables and ADHD subtype may helpexplain why different investigators have reached different conclusions about whether thecomorbidity between depression and ADHD is an epiphenomenon (accounted for by a thirdvariable)420

The relationship between ADHD and depression symptoms can be refined even further by looking atthe results by sex On the CAS the relationship between ADHD-I and depression scales wassignificantly stronger (P lt 001) for boys than for girls (whether controlling for ODD or not) Whencontrolling for ODD the correlation for girls (r = 06) was clinically meaningless while stillstatistically significant in our large sample This finding suggests that when ODD features are absentdepression and ADHD-I are less closely related in girls and thus more clearly distinguishable than inboys in whom significant overlap remains and differential diagnosis may be more difficultGenetic research suggests that MDD with ADHD is an etiologically distinct subtype in females but notin males21 Biederman and colleagues22 found that girls with ADHD were less likely than boys withADHD to have MDD This is an interesting finding because the prevalence of depression in thegeneral population is higher in girls than in boys These lines of evidence converge to indicate aclearer distinction between ADHD and depression in girls than in boysIt remains unclear whether a clinically easier differential diagnosis in females produced a cleanerproband sample that led to a familial distinction or conversely whether a true etiological distinctionleads to an easier differential diagnosis in girls than in boys Clinically it appears that a morerigorous assessment procedure is indicated whenever features of ODD are present with ADHD anddepression and that differential diagnosis may be more complicated in boys than in girlsA strong relationship was found between ADHD and depression that was modified by age andcomorbidity23 This relationship was intensified when ODDCD was present in older but not youngerchildren In general ADHD appears at a younger age and depression at an older age and asexpected the strength of the association between the 2 disorders increases from childhood throughadolescence2324

The importance of considering moderating variables and ADHD subtype is underscored by ourfindings (Figure) which show levels of depression as a function of sex age and ADHD subtype TheFigure shows that

Children and adolescents with ADHD-combined (ADHD-C) subtype generally have higherlevels of depression than do youths with ADHD-IDepression increases with age and the rate of increase is greater in girls than in boysGirls older than 10 years generally have higher levels of depression than boys whereas thereverse appears true in children younger than 10 years

Page 3 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

This distinction underlies the finding that symptoms of depression are more highly correlated withinattentive symptoms than with hyperactiveimpulsive symptoms yet a diagnosis of ADHD-C inchildren is more likely to be comorbid with depression than a diagnosis of ADHD-IThe main limitation of this study is the anomalous finding indicating that girls who are older than 14years with ADHD-C have a slightly lower rate of depression than boys Although the data are basedon a sample of 920 patients with ADHD by taking sex age and ADHD subtype into account theresults for the oldest girls may have limited reliability because of a rather small sample sizeThese considerations help clarify some variable findings in the literature For example Biedermanand colleagues22 found that boys with ADHD have higher rates of depression than girls which ingirls older than age 10 is at variance with our findings However without understanding the mix ofADHD subtypes and ages of their study samples it is not possible to directly compare their resultswith ours Moreover because their study was well resourced and in an academic center itmaximized specificity by requiring that 3 elements be satisfied for inclusion in the study

The clinical diagnosisConfirmed by a telephone questionnaire with the motherAn in-person structured interview

Because the criteria required multiple screens there may be questions of generalizability Forexample while the ADHD CAS scores for our sample were comparable to those of patients in theMTA we found higher ODD scores in our sample than those found in the MTA participants1625

Perhaps the demanding protocol required for inclusion in the MTA selected a specialized subsamplein which the families were more compliant with requests and the children had lower levels of ODD Ifso the degree to which the results of the MTA study could be generalized remains an open questionOutcomesAlthough comorbidity in ADHD generally leads to worse outcome the impact of comorbid depressionremains unclear While Rostain9 highlights parental depression as a predictor of poor outcome inADHD in his report on the MTA study he does not list the childrsquos depression as a moderator ofoutcomeFindings from our clinic show that patients with ADHD-C and comorbid depressive disorders havehigher scores on both ADHD-I and ADHD-H scales than patients without comorbid depression Wealso found that those without depressive comorbidity at baseline had a higher probability of beingrelatively free of ADHD symptoms at the 4-month follow-up (P lt 05) However patients withoutdepressive comorbidity had lower ADHD scores to begin with so they had less ldquodistancerdquo torecoveryWhen we controlled for the degree of initial severity of ADHD there was not a true difference in thedegree of relative improvement between patients with and patients without depressive comorbidityat either the 4- or 8-month follow-up By contrast high scores on ODD predicted significantly lessrelative improvement at both the 4- and 8-month follow-ups (P lt 05 for each) Moreover patientswith ADHD-C who initially scored high on both ODD and depression scales did worse at 4 months (P= 08) and significantly worse at 8 months (P lt 05) These findings suggest that one reason thatcomorbidity has affected outcome differently in various studies in child and adolescent psychiatry isthe failure to account for the full range of comorbid conditions26-29 In this case differing resultsemerge depending on whether ODD was consideredTreatment issuesGenerally it appears best to treat the depression first because it is clinically the most limitingcondition and depressed patients show worse cognitive impairment30 Unfortunately most clinicianstreat the ADHD first usually at the insistence of the parents (and because it is possible to get a quickresponse) However the depression may persist and then one is forced to add to the treatmentregimenLooking at individual medications may help fine-tune clinical decisions Bupropion although not astimulant per se may improve both ADHD symptoms and comorbid depression it is as effective asmethylphenidate3132 Findling33 reported that patients with ADHD and depression treated withfluoxetine or sertraline monotherapy were less depressed but showed no improvement in ADHDsymptoms Additional treatment with a psychostimulant was necessary to effectively address chronicADHD Conversely the psychostimulants may not provide observable antidepressant effects forwhich additional serotonin reuptake inhibitor treatment is required In a Lilly-funded study ofadolescents with ADHD and MDD atomoxetine was an effective and safe treatment for ADHD butshowed no efficacy in treating MDD34 Consistent with these findings the Texas Childrenrsquos

Page 4 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Medication Algorithm Project protocol for treatment of comorbid ADHD and depression recommendstreating the more severe disorder first and if the other disorder does not respond treating it aswell8In ADHD with bipolar depression stimulants alone may destabilize bipolar disorder and should beavoided as monotherapy Using a mood stabilizer both bipolar and ADHD symptoms may improveand the cautious addition of a stimulant may further benefit both conditions35

On the other hand Goodwin and Jamison36 hypothesize that ldquo many children with purportedADHD develop bipolar disorder in adulthood raising the possibility that the ADHD-like presentation inchildhood may have represented an early manifestation of bipolar illnessrdquo They add ldquoWe wouldurge caution in the diagnosis and treatment of adult ADHD always giving preference to initiallydiagnosing and treating mood disorders until euthymia is achieved before making the ADHDdiagnosis or seeking to treat it with stimulantsrdquoConclusionComorbid depression in patients with ADHD suffers from an ldquoattention deficitrdquo by both researchersand clinicians compared with other comorbidities (eg ODD anxiety) Based on academic studiesand data from APS depression in ADHD appears to be a distinct comorbidity increasingly prevalentin children as they get older with a higher rate of increase in girls than boys By consideringmoderating variables our data illustrate why findings in the field are often contradictory to those inacademic studiesFully accounting for moderating variables is a formidable task even with our large database somestudy cohorts were underpowered Externalizing and internalizing disorders as traditionallyconceptualized appear to be overlapping rather than exclusive categories with anger and acting out(ie ODD features) cutting across both categoriesDepression alone does not seem to worsen the outcome of ADHD Although this counterintuitivefinding illustrates the controversial nature of the debate about diagnosis of and comorbidity inADHD our data also suggest that ODD may worsen the outcome of comorbid ADHD and depressionShould this suggestion be confirmed by further research it would indicate the need for moreaggressive intervention for this nonresponding subgroupOur findings highlight the necessity for a careful assessment of children and adolescents with ADHDand depression with special attention to comorbid ODD as well as other moderating variablesContradictory find-ings in treatment outcome may result from a failure to assess carefully

TableFigure

Disclosures Dr Brunsvold is staff psychiatrist Dr Oepen is assistant medical director and Dr Akins is CEO andmedical director of Alabama Psychiatric Services in Birmingham Dr Federman is an instructor in thedepartment of psychiatry at the Boston University School of Medicine The authors report no conflictsof interest concerning the subject matter of this article References References

1 Kessler RC Adler LA Barkley R et al Patterns and predictors of attention-deficithyperactivitydisorder persistence into adulthood results from the national comorbidity survey replication BiolPsychiatry 2005571442-1451

Page 5 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Medication Algorithm Project protocol for treatment of comorbid ADHD and depression recommendstreating the more severe disorder first and if the other disorder does not respond treating it aswell8In ADHD with bipolar depression stimulants alone may destabilize bipolar disorder and should beavoided as monotherapy Using a mood stabilizer both bipolar and ADHD symptoms may improveand the cautious addition of a stimulant may further benefit both conditions35

On the other hand Goodwin and Jamison36 hypothesize that ldquo many children with purportedADHD develop bipolar disorder in adulthood raising the possibility that the ADHD-like presentation inchildhood may have represented an early manifestation of bipolar illnessrdquo They add ldquoWe wouldurge caution in the diagnosis and treatment of adult ADHD always giving preference to initiallydiagnosing and treating mood disorders until euthymia is achieved before making the ADHDdiagnosis or seeking to treat it with stimulantsrdquoConclusionComorbid depression in patients with ADHD suffers from an ldquoattention deficitrdquo by both researchersand clinicians compared with other comorbidities (eg ODD anxiety) Based on academic studiesand data from APS depression in ADHD appears to be a distinct comorbidity increasingly prevalentin children as they get older with a higher rate of increase in girls than boys By consideringmoderating variables our data illustrate why findings in the field are often contradictory to those inacademic studiesFully accounting for moderating variables is a formidable task even with our large database somestudy cohorts were underpowered Externalizing and internalizing disorders as traditionallyconceptualized appear to be overlapping rather than exclusive categories with anger and acting out(ie ODD features) cutting across both categoriesDepression alone does not seem to worsen the outcome of ADHD Although this counterintuitivefinding illustrates the controversial nature of the debate about diagnosis of and comorbidity inADHD our data also suggest that ODD may worsen the outcome of comorbid ADHD and depressionShould this suggestion be confirmed by further research it would indicate the need for moreaggressive intervention for this nonresponding subgroupOur findings highlight the necessity for a careful assessment of children and adolescents with ADHDand depression with special attention to comorbid ODD as well as other moderating variablesContradictory find-ings in treatment outcome may result from a failure to assess carefully

TableFigure

Disclosures Dr Brunsvold is staff psychiatrist Dr Oepen is assistant medical director and Dr Akins is CEO andmedical director of Alabama Psychiatric Services in Birmingham Dr Federman is an instructor in thedepartment of psychiatry at the Boston University School of Medicine The authors report no conflictsof interest concerning the subject matter of this article References References

1 Kessler RC Adler LA Barkley R et al Patterns and predictors of attention-deficithyperactivitydisorder persistence into adulthood results from the national comorbidity survey replication BiolPsychiatry 2005571442-1451

Page 5 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

2 Thakkar V Adler L Depression and ADHD what you need to know MedScape httpwwwmedscape comviewarticle549018_print Accessed August 13 2008

3 Furman L What is attention-deficit hyperactivity disorder (ADHD) J Child Neurol200520994-1002

4 Angold A Costello EJ Erkanli A Comorbidity J Child Psychol Psychiatry 19994057-87

5 Luby JL Heffelfinger AK Mrakotsky C et al The clinical picture of depression in preschool childrenJ Am Acad Child Adolesc Psychiatry 200342340-348

6 Alston JF The complex issue of attachment disorders Psychiatric Times October 1 2007 httpwww psychiatrictimescomdisplayarticle1016854326 Accessed August 13 2008

7 Compton SN March JS Brent D et al Cognitive-behavioral psychotherapy for anxiety anddepressive disorders in children and adolescents an evidence-based medicine review J Am AcadChild Adolesc Psychiatry 200443930-959

8 Pliszka SR Crismon ML Hughes CW et al The Texas Childrenrsquos Medication Algorithm Projectrevision of the algorithm for pharmacotherapy of attention-deficithyperactivity disorder J Am AcadChild Adolesc Psychiatry 200645642-657

9 Rostain AL Treatment resistance in youths with ADHD and comorbid conditions Psychiatric TimesOctober 1 2007 httpwwwpsychiatrictimescomdisplayarticle1016854501 Accessed August 132008

10 Crystal DS Ostrander R Chen RS August GJ Multimethod assessment of psychopathologyamong DSM-IV subtypes of children with attention-deficithyperactivity disorder self- parent andteacher reports J Abnorm Child Psychol 200129189-205

11 Faraone SV Biederman J Monuteaux MC Attention-deficit disorder and conduct disorder in girlsevidence for a familial subtype Biol Psychiatry 2000 4821-29

12 Jensen PS Hinshaw SP Kraemer HC et al ADHD comorbidity findings from the MTA studycomparing comorbid subgroups J Am Acad Child Adolesc Psychiatry 200140147-158

13 Faraone SV Genetics of childhood disorders XX ADHD Part 4 is ADHD geneticallyheterogeneous J Am Acad Child Adolesc Psychiatry 2000391455-1457

14 Faraone SV Biederman J Feighner JA Monuteaux MC Assessing symptoms of attention deficithyperactivity disorder in children and adults which is more valid J Consult Clin Psychol200068830-842

15 Ryan ND Diagnosing pediatric depression Biol Psychiatry 2001491050-1054

16 Swanson JM Kraemer HC Hinshaw SP et al Clinical relevance of the primary findings of theMTA success rates based on severity of ADHD and ODD symptoms at the end of treatment J AmAcad Child Adolesc Psychiatry 200140168-179

17 Marmorstein NR Relationships between anxiety and externalizing disorders in youth theinfluences of age and gender J Anxiety Disord 200721420-432

18 Sanders M Arduca Y Karamitsios M et al Characteristics of internalizing and externalizingdisorders in medication-naive clinically referred children with attention deficit hyperactivity disordercombined type and dysthymic disorder Aust N Z J Psychiatry 200539359-365

19 Oepen G Federman EJ Akins R Measuring outcome in psychiatric private practice usingoutpatient self-reports Psychiatric Times June 1 2006

Page 6 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

httpwwwpsychiatrictimescomdisplayarticle1016851451 Accessed August 13 2008

20 Blackman GL Ostrander R Herman KC Children with ADHD and depression a multisourcemultimethod assessment of clinical social and academic functioning J Atten Disord20058195-207

21 Mick E Biederman J Santangelo S Wypij D The influence of gender in the familial associationbetween ADHD and major depression J Nerv Ment Dis 2003191699-705

22 Biederman J Mick E Faraone SV et al Influence of gender on attention deficit hyperactivitydisorder in children referred to a psychiatric clinic Am J Psychiatry 200215936-42

23 Ostrander R Crystal DS August G Attention deficit-hyperactivity disorder depression and self-and other-assessments of social competence a developmental study J Abnorm Child Psychol200634 773-787

24 Biederman J Monuteaux MC Mick E et al Young adult outcome of attention deficit hyperactivitydisorder a controlled 10-year follow-up study Psychol Med 200636167-179

25 MTA Cooperative Group A 14-month randomized clinical trial of treatment strategies forattention-deficithyperactivity disorder The MTA Cooperative Group Multimodal Treatment Study ofChildren With ADHD Arch Gen Psychiatry 1999561073-1086

26 Doss AJ Weisz JR Syndrome co-occurrence and treatment outcomes in youth mental healthclinics J Consult Clin Psychol 200674416-425

27 Jensen PS Martin D Cantwell DP Comorbidity in ADHD implications for research practice andDSM-V J Am Acad Child Adolesc Psychiatry 1997361065-1079

28 Jensen PS Hinshaw SP Kraemer HC et al Introduction ADHD comorbidity and treatmentoutcomes in the MTA J Am Acad Child Adolesc Psychiatry 200140134-136

29 Kazdin AE Whitley MK Comorbidity case complexity and effects of evidence-based treatmentfor children referred for disruptive behavior J Consult Clin Psychol 200674455-467

30 Diler R Daviss W Birmaher B et al Differentiating major depressive disorder in youths withADHD Paper presented at University of Pittsburgh Medical Center Seventh Annual Research DayJune 2007

31 Barrickman LL Perry PJ Allen AJ et al Bupropion versus methylphenidate in the treatment ofattention-deficit hyperactivity disorder J Am Acad Child Adolesc Psychiatry 199534649-657

32 Solhkhah R Wilens TE Daly J et al Bupropion SR for the treatment of substance-abusingoutpatient adolescents with attention-deficithyperactivity disorder and mood disorders J ChildAdolesc Psychopharmacol 200515777-786

33 Findling RL Open-label treatment of comorbid depression and attentional disorders withco-administration of serotonin reuptake inhibitors and psycho-stimulants in children adolescentsand adults a case series J Child Adolesc Psychopharmacol 19966 165-175

34 Bangs ME Emslie GJ Spencer TJ Atomoxetine ADHD and Comorbid MDD Study Group et alEfficacy and safety of atomoxetine in adolescents with attention-deficithyperactivity disorder andmajor depression J Child Adolesc Psychopharmacol 200717 407-420

35 Scheffer RE Concurrent ADHD and bipolar disorder Curr Psychiatry Rep 20079415-419

36 Goodwin FK Jamison KR Diagnosis In Goodwin FK Jamison KR Manic-Depressive Illness 2nded New York Oxford University Press 200789-118

Page 7 of 8

Comorbid Depression and ADHD in Children and AdolescentsPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Source URL httpwwwpsychiatrictimescomadhdcomorbid-depression-and-adhd-children-and-adolescents

Links[1] httpwwwpsychiatrictimescomadhd[2] httpwwwpsychiatrictimescomattention-deficit-disorders[3] httpwwwpsychiatrictimescombipolar-disorder[4] httpwwwpsychiatrictimescomcomorbidity-psychiatry[5] httpwwwpsychiatrictimescomdysthymia[6] httpwwwpsychiatrictimescommajor-depressive-disorder[7] httpwwwpsychiatrictimescomauthorsgavin-l-brunsvold-md[8] httpwwwpsychiatrictimescomauthorsgodehard-oepen-md-phd[9] httpwwwpsychiatrictimescomauthorsedward-j-federman-phd[10] httpwwwpsychiatrictimescomauthorsrichard-akins-md-mba

Page 8 of 8