Depressive Symptoms and Associated Factors in Children With Attention Deficit Hyperactivity Disorder

Journal of Child and Adolescent Psychiatric Nursing, Apr-Jun 2004 by LeBlanc, Nancy

PROBLEM. To compare depressive symptoms in children with attention deficit hyperactivity disorder (ADHD) to those in healthy children, and to explore the influence of individual and family factors on level of depression.

METHODS. Individual interviews with 68 children, ages 7 to 12 years, in order to complete the Children's Depression Inventory.

FINDINGS. Children with ADHD reported significantly more depressive symptoms than did children without ADHD; 14.7% of children with ADHD reached the threshold of a 19 point score, which suggests clinical depression. No significant effects of individual and family factors on level of depression were found.

CONCLUSIONS. Children with ADHD are more inclined to experience depressive symptoms than are healthy children. To plan appropriate interventions, nurses evaluating and working with children with ADHD should always consider a possible coexistence of depressive symptoms.

Search terms: ADHD, depression, depressive symptoms, Roy's adaptation model

ADHD is one of the most frequent developmental problems in children. It is also one of the main reasons for consultation in pedopsychiatrie clinics. Epidemiological studies from the United States and Canada suggest that the prevalence of ADHD in children ages 6 to 12 years is approximately 5%, and that it occurs in boys almost three times as often as in girls (Barkley, 1998). The Quebec Health Survey sets the prevalence of ADHD near 6% for children ages 6 to 11 years (Breton, 1993).

In recent years, evidence has been accumulating regarding the frequent presence of comorbid disorders with ADHD, including depression. Different clinical studies in the United States indicate that depression occurs in 29% to 38% of children with ADHD ages from 5 to 17 years (Butler, Arredondo, & McCloskey, 1995; Jensen, Shervette, Xenakis, & Richters, 1993; Milberger, Biederman, Faraone, Murphy, & Tsuang, 1995). The U.S. Agency for Health Care Policy and Research concluded that there are lower levels of co-morbidity (18.2%) in the general population (Green, Wong, & Atkins, 1999). Furthermore, follow-up data on children with ADHD strongly suggest that the coexistence of ADHD and depression may be associated with poorer treatment outcomes.

Some authors (Biederman et al., 1996; Jensen et al., 1993) report that children with ADHD and depression receive significantly more intense interventions, experience higher levels of stress, and are at greater risk of developing bipolar disorder, oppositional defiant disorder, agoraphobia, and psychosocial and familial problems than are children with ADHD who are not depressed. Moreover, Schmidt, Stark, and Carlson (1998) found that self-perception is more negative in children who have both depression and ADHD than it is in children who have ADHD only.

Up to now, many researchers have examined associations between individual factors such as age, sex, and severity of depression in children who have been recruited in clinical or normal settings, but there is still controversy as to whether age and sex are associated with severity of depression. Some results indicate no association (Brown, Borden, Clingerman, & Jenkins, 1988; Lefkowitz & Tesiny, 1985; Saint-Laurent, 1990), while others suggest a significant relationship among age, sex, and depression. For example, results from a study conducted by Desbiens (1993) show that third-grade children reported more depressive symptoms than fifth-graders, and that boys expressed higher levels of depression than did girls. Nolen-Hoeksema, Girgus, and Seligman (1991) found that young boys reported more feelings and ideas of depression than did young girls. But, in general, research has found no sex differences in prevalence of depressive disorders in clinical and nonclinical samples of children.

On the other hand, among adolescents the prevalence is greater in females than in males. It seems that sex differences in severity of depression appear in early adolescence and then increase over the years (Kuehner, 2003). The association between family factors and severity of depression in childhood has also been explored, but in few studies. McCauley et al. (1993) reported no significant relationships between maternal anxiety and depression or severity of depression in children. Also, the study conducted by Brown et al. (1988) showed that children with ADHD of divorced parents are not more depressed than are children living with both parents.

Considering that few studies to date have examined the association between individual and family factors and depression in children with ADHD, it is difficult to draw conclusions on the general effect of these factors. Moreover, reported results have been inconsistent throughout the studies. To better understand depression in children with ADHD, the present study compared depressive symptoms in children with ADHD to those in healthy children, and explored the influence of individual and family factors on level of depression.

Methods

In this study, Roy's Adaptation Model (Roy, 1976) served as the conceptual framework. This nursing model is based on the concept of adaptation, which is defined as a positive individual response to a changing environment. It is a model in which patients are considered as biopsychosocial beings in constant interaction with focal, contextual, or residual stimuli, and where health and illness are viewed as parts of a same continuum (Hoch, 1987). Roy's model serves as an anchor for individual or family factors that are viewed as focal and contextual stimuli.