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Anxiety and Mood Disorders in Children and Adolescents With ADHD

October 19, 2020


In this video, neurodevelopmental pediatrician Frank Lopez, MD, of Pediatric Neurology PA, Winter Park, Florida, addresses the myth that anxiety and mood disorders do not co-occur with attention-deficit/hyperactivity disorder (ADHD).

This is Part 3 of a 4-part video series marking ADHD Awareness Month, which is held in October.

Part 1: The Importance of Using Multiple Approaches When Treating Pediatric ADHD
Part 2: Dr. Theresa Cerulli Discusses the Complexity of ADHD 

Read the transcript:

I'm Dr. Frank Lopez. I'm a neurodevelopmental pediatrician working in Orlando, Florida. I'm presently associated to Pediatric Neurology PA, where we see children with all kinds of neurodevelopmental disabilities.

Today, I'm going to talk to you a little bit about myths and a fact. The myth is that ADHD and anxiety disorders and mood disorders really don't coexist. That's really not true. The fact is that ADHD, anxiety, and mood disorders are very frequent companions. I like to tell people that ADHD doesn't travel by itself, that it usually has one or two friends along for the ride.

It's a well‑known fact that about 60 percent or so of individuals have more than one coexisting condition. That is really, really critical in terms of the type of children that we see and what we tend to do.

Roughly about 40 percent of individuals who have ADHD have oppositional defiant symptomatology. Back in the MTA [Multimodal Treatment Study of Children with ADHD] trial, that was reported, I believe, at a little bit higher number, closer to 60 percent. As you know, oppositional defiant disorder involves a pattern of arguing and losing temper, refusing to follow rules. It's very difficult but very common with ADHD individuals.

More importantly is the fact that these children who have oppositional behavior deliberately do things to annoy others. That really is what brings the child many times to see physicians.

When you look at individuals who have ADHD, conduct disorder may also be present. That's about 27 percent of children and about 45 to 50 percent of adolescents and about 20 to 25 percent or so of adults with coexisting ADHD.

Mood disorders in adults is approximately 38 percent. It varies from study to study, but it's typically significantly elevated. The mood disorders are characterized by extremes and changes in mood. Children with mood disorders, many times, frequently cry. They're irritable. They have difficulty with transitioning. For the most part, you can't really find a reason for it.

When you look at a spread of individuals who have ADHD, obviously the most frequently diagnosed early on in life and in adolescence is oppositional defiant behavior. But as we get going, maturing a little bit more, say, between 13 and 18 years of age, we see a surge in anxiety. That's followed by an increment in the symptomatology for anxiety disorders in young adult and adult life.

Depression is another concern. Roughly somewhere between 17 to 20 percent of children will have some depression. In later years, that increases to over 50 percent, in particular looking at greater than 18 years of age.

What's important here is that we need to make sure that we realize that there is a significant problem with ADHD and coexisting mood disorders. We can't let that go by. In fact, many times in early childhood, if you don't think about it, the child may end up just getting partially treated.

According to the most recent guidelines that have been developed not only by the American Academy of Pediatrics but also by the Society for Developmental and Behavioral Pediatrics, we need to co‑treat the disorders together rather than as we did before, where we do what's the most significant presentation and treat that first and then treat whatever else was there.

The recommendation now is to co‑treat, to go at it simultaneously as much as possible. It's important that we understand that many times, we're in a position where the only history that we can get is one‑sided. That really doesn't help us. In childhood and early adolescence, we need to get as much information as we can from as many different sources.

At the end of the day, the studies that have looked at ADHD and the way it's assessed by those of us who are in the field have found that a large majority of clinicians struggle with assessment procedures. We tend to rely on what we've read, what we know, but there are many tools that we can use to augment the way we make our diagnosis.

It's important that we try to avoid a misdiagnosis. Think of the co‑occurring conditions, whether they are anxiety... Anxiety is really probably a very common issue in childhood and early adolescence.

Many times, the kids come in. The parents tell you that they're as wound up, as tight as a spring. When you actually start interacting with them, what you see is a person who is like they're on edge. They can't really settle down. They're irritable. Those are features that we tend to see across all the age groups.

In childhood, what really may be causing this could be academic performance. Think about it. If you are being blasted with a lot of stimulus and your neurotransmitters and your amygdala are firing into that fight and flight situation, you may know your information. You may know your spelling words or your math problems. Then you're sitting there, taking the test, and you blank out. We hear this quite frequently in childhood and early adolescence as well.

Later on in life, it could be a health issue. It could be financial issues, relationships. The bottom line is we have to be aware that these things are frequently seen together.

Moreover, we really need to look at how much effort these kids and young adults put into their work. I recently had a child come into the office. He's a preteen, very bright boy, very verbal. He essentially told me, he says, "I'm working two to three times harder to get half the amount of work done."

What he meant by that was that he was coming home and he would have 3 to 4 hours' worth of homework to complete what his friends would finish in 20 to 30 minutes and were able to go out and play. He was not able to do that.

This was a big concern. He was evaluated. We found out he had a significant generalized anxiety disorder. We started co‑treating him for his ADHD and the anxiety. It's a totally different kid. It's important to always keep these things in mind.

At the end of the day, what we want to do is once we identify the individual as having ADHD and a mood disorder or a generalized anxiety disorder, how can we approach them? One of those things that I really like to propose to parents and to those children who are receptive and can work through this is mindfulness.

I want them to stay in the here and now. I want them to really look at what's going on in their life, take deep breaths, essentially work through it, try and calm yourself down. It's important that there is a group of individuals that have the same set of goals for this patient so that we can have a team approach.

Medication by itself is just a Band‑Aid. We need to understand all those other pieces that go into supporting our children, adolescents, and adults. Medications are critical as well, but I don't like to rely just on medicine.

I'd like to bring together a group of people—therapists, parents obviously, grandparents if they're available. I want to build a support network for our patient. Then we end up really improving their overall lot.

The combination of medication, mindfulness, therapy. Even, in some instances, supplements can be helpful. There are some reports using omega‑3s. It really doesn't help a heck of a whole lot for the attention, but it may actually help the individual settle down a little bit. That needs to be further proven.

Another area is that we really don't have one solid, truly efficient physiologic method of identifying ADHD. We have to rely on history. We have to rely on our physical examination, interaction with the patient, with the family, and use whatever tools we can in terms of gathering more data so that we can improve the quality of their life and have them be truly functional members of society.

Thank you for taking the time and listening to us. Hopefully, we can make a dent and make sure that instead of myths, we deal with facts. Thank you.

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