500- Identifying Depression and Anxiety in Teens with ADHD

Annie Rogers
Welcome to the Attention Deficit Disorder Expert podcast series by Attitude magazine.

Hello everyone. My name is Annie Rogers and on behalf of the Attitude team, I am pleased to welcome you to today's ADHD experts presentation titled identifying depression and anxiety in teens with ADHD. Today's presentation marks the 500th episode for Attitudes ADHD Experts podcast. Since 2012, Attitude has hosted free live webinars on all aspects of ADHD and related conditions. This free educational program would not be possible without the generous contributions of our experts, our sponsors, and our listeners.

So thank you all for helping to make us reach this milestone. And joining us today to market is doctor Roberto Olivardia. Doctor Olivardia is a clinical psychologist and clinical instructor of psychology at Harvard Medical School. He maintains a private psychotherapy practice in Lexington, Massachusetts, where he specializes in the treatment of ADHD, executive functioning, and learning differences. He also specializes in the treatment of body dysmorphia, eating disorders, and OCD.

Roughly three quarters of people with ADHD have at least one co occurring condition. Sometimes the condition is caused by ADHD, and other times it operates sort of independently. This can create a complicated clinical picture, especially for teenagers who, as we know, experience major emotional and physical changes as they go through puberty. In today's webinar, we will learn about depression and anxiety, two of the most common psychiatric comorbidities in teens with ADHD. We'll discuss the interplay and distinctions between these conditions and how to devise an effective treatment plan.

Finally, the sponsor of today's webinar is play attention, ADHD, and executive function challenges can lead to anxiety, and this anxiety can further impair executive functioning by affecting the brain's processing and decision making abilities. That's why play attention offers a personalized program designed to enhance executive function and improve self regulation. Regulation. Backed by research from Tufts University School of Medicine, play attention empowers individuals to improve attention, emotion regulation, and overall performance. Their NASA inspired technology ensures tailored support for every aspect of life.

Click the link on your screen to take play attention's ADHD test, or schedule a consultation to start your journey toward improved executive function and emotion regulation. Call 828-676-2240 or visit playattention.com to learn more. Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content. Okay, without any other further ado, I'm so pleased to welcome doctor Roberto Oliverdia.

Thank you so much for joining us today and leading this really critical discussion on anxiety, depression, and ADHD in adolescents. Thank you so much for having me and really happy to be part of this 500th webinar podcast is amazing and so supportive of all the great work that attitude does. And one of the things that should be mentioned in my bio, too, is I am somebody with ADHD, and I have two teenagers. I have a 19 and almost 19 and almost 17 year old son and daughter with ADHD and dyslexia. So I'm going to get right into it because I want to leave some time for questions.

Roberto Olivardia
Q and A. We're going to start with depression, and studies show that about 30% of people with ADHD will experience a depressive episode or have a mood disorder. So, as mentioned at the beginning of the webinar, ADHD rarely travels alone, that you'll often see a comorbid condition, and mood disorders and anxiety disorders are the most common. Having ADHD places someone at four times the risk of developing a depressive episode. And studies, even looking at different presentations of ADHD, find that the inattentive type, you'll see a higher risk for depression, the hyperactive, impulsive type, you see higher risk of depression and a higher risk of suicide, which I'll talk about later.

What are the symptoms of depression? How do we sort of distinguish them from ADHD, as well as just being a teenager in 2024? So I'll just sort of go through the criteria just to kind of give a little bit of some differential, what we call differential diagnosis. So with depression, you have persistent, sad or irritable mood. Now, when it comes to a depressive episode that cuts through all contexts, that even if somebody is in their environment, that's sort of their happy place.

With people that they typically really enjoy, they're still feeling down, they're still feeling sad, they're irritable in that way. So it's, I think of depression as being more the internal that just is spilling out. With ADHD, I think of it more from the external and how it informs the internal. So a lot of times this, people with ADHD could be misdiagnosed with depression when they might not have depression. It could just be aspects of the ADHD.

Having ADHD, sometimes we could see that sadness or irritability, but it's often very contextual. So if you have, let's say, a child in a classroom who might be really down or might be really irritable, that may not be a depression, that might be that that child needs maybe more scaffolding, more support, maybe they're overstimulated, and you put that child maybe in a different classroom or with certain modifications on IEP, they're a happy, less irritable, less sad kid in that way. Now, in terms of normative development, that particularly with puberty and all those wonderful hormones that circulate through our body during puberty, sometimes you'll see some mood dysregulation, but it won't be this sort of, again, consistent cutting across all different contexts. In those kinds of cases, you'll typically see them in, like, different developmental bursts, so to speak, where a lot of times, even with adolescents, when it's just puberty and hormones, they might feel irritable and then later say something like, oh, I'm so sorry, I was irritable. I don't know what came over me.

Whereas with depression, sometimes they're so in it that they might not even realize how they're even coming across to other people. With depression, you see a loss of interest in activities that were once enjoyed. So these are activities that people really enjoy and are finding just no color in the world. The world is very gray all around, again, across the board. So the internal affecting just how everything is seen externally.

Whereas with ADHD, and I had a client once who was misdiagnosed depression, because they would just always find themselves getting bored with things, but then once they found something that was interesting, they'd be all into it, and then they get bored from it, you know, very easily. But it's always important to determine, are you just, you know, feeling like you have no interest, no zest for anything, or do you feel like you just are looking for the thing to connect to? You just haven't found that thing. That's where we hear typically with ADHD folks, it's like, oh, this is boring, and this is boring. But people with ADHD generally feel like they're just searching for something to connect to and plug into.

They feel they're like, it's almost like having a plug that, you know, the electricity's working, you just need a socket. With depression, you don't feel like you have any plug. You don't feel like you don't even care that you have a plug. It feels just very like there's almost no energy or no zest, no desire to even want to connect to something. Sometimes with depression, it's almost people who are getting depressed that they're depressed about that and that there isn't.

They see other people that might be enjoying things and they just don't really connect to it. You'll often see significant changes in appetite and body weight with depression. And these are, again markedly different than what you would typically see. So somebody who generally really might have a great appetite suddenly is not hungry a lot, again, throughout the various contexts. Whereas with ADHD, sometimes you'll see dysregulations of appetite and body weight, which is an area that I specialize in with ADHD, in eating and eating disorders, sometimes it could be just related to current activities and hyper focus.

Certainly the use of stimulants can sometimes be appetite suppressants, but you'll often see once the stimulants wear off, the person is like ravenously hungry. That's not depression, that's sort of aspects of ADHD. If somebody, you have a teen that's playing video games, they might not eat for 14 hours because they're getting their dopamine fix through the video games. Once that dopamine fix is removed, then you'll often see the hunger. With depression, you'll either see just no appetite or someone who's constantly eating in a way that is clearly not around hunger and not around even the taste or the liking of the food.

It's just sort of almost filling like a hole, so to speak. Sleeping too little, sleeping too much. And we see that with depression. And again, this is where it's significantly different than how somebody typically their sleep patterns would be during a depressive episode. Someone who typically was sleeping 7 hours a night is now sleeping 14 hours and they're still tired afterwards.

Or someone who was sleeping seven to 8 hours is only able to sleep three, and they're waking up at two in the morning and can't get back to sleep. Despite with depression, these are individuals that want sleep. They want to consistently be able to fall asleep, but they find it. There's too restless and it's not due to external activities or distractions or anything that's pulling them away. It's literally like the body is not able to either settle down or in the case of sleeping too much, is not able to adequately arouse itself.

Now, having said that, with ADHD, sleep issues go hand in hand with ADHD. So we will sleep poor, we will see sleep habits that are poor, whether it's a difficulty falling asleep, difficulty waking up, and sometimes that can be based with stimulant medication. But usually people with ADHD will say, oh, I'm just. It's just hard for me to, like, quiet my mind down. But the thoughts could be things that they're excited about.

Sometimes it's just thinking about the day. Whereas with depression, they're either just feeling nothing. It's almost this internal agitation, or they're ruminating on very negative self talk that's making it very hard to fall asleep. That agitation, you'll either see a physical agitation, and by agitation, it's different than anxiety, and anxiety and agitation sometimes get mixed up for each other. Agitation is something we'll often see more in the mood disorders or even a bipolar spectrum disorder at its more severe form.

It's somebody who literally feels like they just want to jump out of their skin. It's just this internal tremoring feeling of just discomfort in their body, and it's not related necessarily to a certain thought, like, oh, I'm anxious about this thing, and my heart is racing. It's almost like the whole. It's this full body experience that people often feel, and it feels also like their mind doesn't feel settled. It doesn't feel grounded, but in a very dysphoric way, whereas an ADHD mind doesn't often feel very settled.

But sometimes we can welcome that in terms of vivid imagination and things like that. So you'll even see that agitation, or you see a real slowing in fatigue, with depression. And again, it feels more internal, whereas with ADHD, people will report feeling that way, but only when there's a lack of external stimulation. And certainly if they're not sleeping well or if they're bored, but you provide them the stimulation, you won't see that slowing, that fatigue, that physical agitation. Feelings of worthlessness or inappropriate guilt are very common in depression.

And it's this global sense of feeling inadequate that is unrelated to accomplishments. In fact, with depression, it's the kind of diagnostic entity that can literally have somebody feel like nothing, despite the fact that objectively, you can say, well, what are you talking about? You have these relationships, and you have these friends, and you have this career, and you have all of these accomplishments. It almost just doesn't matter. And that's why.

And I'm not gonna get too much into suicide, we could do a whole presentation on that. But what's so mind boggling to people about people who die by suicide, who on the outset could be like, how does that person think they have all of these things? But the illness of depression takes all. It's almost like those accomplishments are like Teflon, like, it just doesn't stick to the person. Now, with ADHD, you can have these kinds of feelings of worthlessness, but they're very related to the ADHD in terms of unactualized intentions.

The executive functioning issues that people with ADHD struggle with can be very frustrating and can absolutely limit people and get in the way of their potentials, which can lead them to feel inadequate and worthless. Now, that doesn't mean, as I'm going through all of these, to keep in mind that having. This is why having ADHD can put somebody at risk for depression, but somebody with ADHD can struggle with these issues without necessarily having a clinical depression. And the treatment obviously would be different because here, if it's more ADHD related, as I'll get into later, managing the ADHD, then is the solution. That is the treatment.

In a sense. If you get, let's say, better executive functioning skills, you're not going to be as limited and you're going to be actualizing your intentions more and make you happier and not have you feel so worthless, difficulty concentrating that with ADHD, we know that that's an executive functioning deficit that a lot of people with ADHD have, and being able to fluidly think through things without impulsively moving around or getting distracted. With depression, though, it's a little bit different. That lack of concentration is not a associative thinking that you'll see with ADHD, it's often that people feel like their thoughts are sort of mangled together or jumbled, like, it's like noise, as opposed to, oh, here are three thoughts that are going on at the same time, but I can identify them, or like having ADHD. I definitely have a very fast mind, but I know I can tell you what I.

What those thoughts are as they pass through my mind. Whereas with depression, as we would see also with mania and bipolar disorder, people, they're not able to even identify that. It just feels like a mass, like a Jell O, is sort of how one of my patients described it. Psychosis is uncommon in ADHD. In fact, it's not a symptom of ADHD.

We don't see that really as anything that has related to ADHD per se. Whereas depression can have psychotic features to it, particularly when people are in very severe stages of depression. So when you see psychosis and the absence of substances, because substances can also create psychotic symptoms, that's not common in ADHD and recurrent thoughts of death and suicide. Depression is obviously a clinical diagnosis in which we have one of the highest suicide rates, and with ADHD alone, that it's less common. However, as I've given talks about suicide before, having ADHD alone, not just ADHD, with depression does carry a higher risk of suicide based on all of these factors, but it's definitely higher with depression.

Now, other signs of depression that you often don't hear about in the DSM, the diagnostic statistical manual are the feeling of nothingness. Actually, that depression is not just a feeling of sadness. In fact, for a lot of my patients, feeling sad is a welcome relief to feeling a numbness or a nothingness, and really feeling completely disconnected. I mean, one of my favorite bands, I'm a big music fan, is the cure. And a lot of their early stuff was around very dark.

And they have a song called fear of ghosts, which has this couplet which I think is so indicative of depression. And it says, the further I get from the things that I care about, the less I care about how much further away I get. And that is what depression is. It's like you sort of move so far from your humanity that you feel like just a hollow shell. And so a lot of times with depression, it's not even somebody who's presenting crying, being emotional.

They're just flat, feeling misunderstood, withdrawing socially. Anxiety can be a symptom to some people of depression, that depression can manifest in different ways, and particularly for boys and men, might experience depression or express depression through being very angry or irritable, having temper tantrums. And these are things that are not, again, in adolescence. Someone might be having a short fuse over getting like, a need unmet. You know, you're putting a curfew at 11:00.

They want to stay out till 01:00. They are emotionally dysregulated. As we know, having ADHD puts us at higher risk for any emotional dysregulation. With depression, it can really come out of the blue. And oftentimes with parents, they know it.

Anytime a parent says, I was totally. I had no idea that that was even coming. And it was scary. The temper tantrums or the explosiveness, that's usually. I start to wonder whether there's a mood disorder, very regressive behavior, somatic complaints like stomachaches and headaches and nausea.

Some kids and young people and adults have a hard time expressing and don't have the vocabulary for it. It might just express itself physically, acting out self harm behaviors like cutting and thoughts that they might repeat or ruminate on. I hate myself. I wish I was dead. I wish I was never born.

Those can be signs, as I mentioned before. I mean, there are a lot of. We are at higher risk of having ADHD for developing depression. And we know there are different factors involved in that. The ADHD brain.

There are different neurochemistry in the ADHD brain. Dopamine deficiencies. GabA, which is dopamine which is implicated in reward. GAbA, which is implicated in inhibition. So if we have appropriate levels of gaba, we're appropriately inhibited.

And that means we can regulate our emotions better. It means we don't act out on our emotions. ADHD brains have lower levels of GABA, so we're less inhibited. And serotonin dysregulation and serotonin is implicated in mood and sleep regulation. We know that emotional regulation is an executive function of which ADHD individuals have difficulty with.

And there's neurological factors that show that certain parts of the brain that would get activated in a neurotem typical brain that allow for more soothing and grounding of negative affect or excitable emotions. There's a delay for people with ADHD and with emotions. A lot of damage can happen in 10 seconds of an uninhibited emotion. Comorbid disorders. People with ADHD are more likely to have comorbidity.

And the way comorbidity works, it's not one plus one equals two, it's one plus one equals five. So if you have two, you know you have a comorbid disorder. The whole becomes greater than the sum of its parts. Many people with ADHD will have more than one comorbid disorder, and then low self esteem and negative self concept. Of course, all the executive functioning issues that can lead people to feeling like failures, learning disabilities.

50% of people with ADHD have a learning disability. And that could cause a lot of issues, particularly academically negative messaging from others, peers, authority figures, social issues. And children with ADHD are also at higher risk for trauma, physical sexual abuse, and other forms of trauma, which obviously can play a risk factor for depression. We know, and it's so important for clinicians to understand the importance of always keeping an eye on the ADHD, that a lot of times when we think of comorbidity, we think, okay, what's the primary disorder? What do we treat first?

I always say when ADHD is in the mix, you have to be treating the ADHD. It's never a, that can't ever take a vaccine because not treating the ADHD undermines the treatment of any comorbid disorder. So studies show that the increased severity of ADHD symptoms are going to be correlated with higher depressive symptoms. Very important to make sure we're managing the ADHD. And the symptoms are worse when people have both disorders than with one condition alone.

And having ADHD. And I should stress. Having untreated ADHD is associated with earlier signs of depression. With more frequent hospitalizations due to depression, more recurrent episodes and higher suicide risk. Now I'm going to shift to anxiety, which is when we talk about anxiety, we're talking about a feeling of unease, of nervousness, of distress.

It can express itself physically, our racing heart. We're sweating cognitively of, oh, my gosh, I'm going to fail that test behaviorally, where we're restless and sort of moving around. Sometimes we can't specify the specific cause or reason for anxiety, but if you think of anxiety as almost being. It's an attentional disorder in a way. Our attentional bias, though, is towards threat related stimuli.

So the anxious person may walk into a room thinking, what here is going to threaten me? That's sort of the cognitive web that people who struggle with anxiety can fall under. So people who are anxious think in terms of possibilities, too much over probability. So if we thought of possibilities and ruled our lives through possibilities, we would never step on an airplane because that airplane could crash. Is it a possibility that that plane could crash?

Absolutely. I would never tell a patient, no, it's impossible for that airplane to crash. Is it probable? No, it's very, very, very low probability a plane is going to crash. Statistically, given all the planes that fly and land every single day, we just hear about all the plane crashes.

But people with anxiety, they're leaning towards those. If it's possible, then I don't know if I want to do it. It's different from fear. Anxiety. Fear is something that we're relating to in the concrete moment, the stimuli that we're in the present moment with.

With anxiety, it's often we're not present to it. It's something we fear could happen. We might ruminate about the consequences of something that already happened. Anxiety is rarely in the present moment. If anything, that's what fear is.

It can be related to stressful events and sometimes a lot of uncertainty. It can elicit that flight or fight response. And we know about 30% of people with ADHD have anxiety or an anxiety disorder. Now, it's important, though, and I always think, you know, anytime I'm working with patients to destigmatize this sort of condition and help them understand that even with a lot of mental health issues, that there are evolutionary reasons that are built into us as to why these issues might be at play. And with anxiety, there is an evolutionary benefit to anxiety.

Anxiety we are wired to keep ourselves alive and keep us away from danger. That amygdala, that fight or flight, primitive part of our brain is meant to be activated to have us either kill the danger or get away from the danger as much as possible. And the amygdala will activate with any kind of whiff of danger, which surges our oxygen levels, increases adrenaline, dilates our pupils so we can see better, so we can kill, you know, the danger. Or, again, find that exit door. It provides energies to our arms and legs to run away.

It decreases our appetite because nobody's in the mood for a good meal. If a building's on fire, you need to just get out. It heightens our senses and it communicates with memory circuits in our brain to never forget that. Now, with the exception of some cases of trauma, where sometimes memory formation is very fragmented, but for the most part, we are meant to not only remember that thing that made us feel really anxious, but to over generalize it. So, meaning that if, let's say, somebody was in a car accident, it's not just to.

Maybe that amygdala might get activated the next time it's in a car. It might get activated the next time it's even walking on a street when it's even thinking about going into a car, because it's trying to keep us sort of safe. Now, the amygdala, though, sometimes can be oversensitive. And what happens is that that activation can happen even when there really isn't a danger. And what happens in our bodies is if all of those processes are happening, the racing heart, the body cooling, the decreased appetite, that's meant to get us in motion.

But there's nothing to actually fight or flee from. Then our bodies are not meant to be sitting still when it's anxious. Like, no part of us should be sitting still. If the building is on fire, we are supposed to get up and get a fire extinguisher or just our run. But if we're still, then it's almost like our bodies get confused and can create muscle tension and paralysis, dizziness.

We can get clammy and sweaty. We can get nauseous and numb. And all of these feelings that can come along with, like, a panic attack or anxiety. So the brain, though, is wired to see anxiety, even if it seems irrational. So it's almost as if the brain is saying, if there's nothing to worry about, then why am I anxious?

So if somebody is feeling anxious, it's hard to say, don't feel anxious, because the brain is already on a different dialogue. The brain is saying, if there's nothing to be worried, then why am I feeling anxious? Therefore, there must be something to worry about. So I will scan my environment until I find that thing that is worth being anxious about. And it's not that anybody wants to be anxious, but if they're feeling that, the brain doesn't want to just dismiss it quickly because that could be okay, well, then we're dead if there is a saber toothed tiger in the bushes.

But it would rather really scan the environment. So I always want to frame that to the kids and teens that I work with to know, like, it's your body kind of working for you, except it's almost like an oversensitive alarm or radar. Basically, personality traits that we see with anxiety tend to be individuals who are perfectionistic, have difficulties with transition, difficulty with uncertainty, have a high need for control, people pleasers, shyness, which kids who are very, very shy or have separation anxiety. That's a strong predictor of later development of an anxiety disorder. So, so important to really work with that when kids are very young in doing, you know, anxiety related, exposure related work.

Being very empathic can lead itself to lend itself to anxiety. Being sensitive and emotionally intuitive and having a very vivid imagination. I have a very vivid imagination, which lent me to have horrific night terrors and nightmares when I was a kid. That seemed so real, because that part of my thinking is very real to me now. I wouldn't want to give that up for anything.

I love my very vivid imagination, but there's a slippery slope that can come along with that. Anxiety can come in the form of tantrums, separation anxiety, having trouble, maybe sleeping over friends houses, somatic complaints, school refusal, frequent trips to the school nurse, and rejection sensitivity. Negative body image is sometimes more related to an overall feeling of anxiety. It's just sort of manifesting in terms of negative body image, fear of the future, anxiety over making your mark or having a purpose. And I would say that this is something that I see generationally more with teens in general, this real fear around.

They have to this need of making their mark in the world. And I think we always felt that way throughout generations of wanting to contribute. But I do think that social media has really accelerated this to a whole different level of I want to both fit in and belong, and I have to stand out in a very big, big way. And there's a lot of anxiety around that. Sleep issues can give rise to anxiety, depression, self harm.

So a lot of this is why even the symptoms of depression, anxiety can be very fluid, certainly addictive behaviors, why we see it with ADHD. As I mentioned, poor executive functioning people with ADHD generally have a sensitive nervous system and not just in terms of with emotions, but just even with physical stimuli that we know from a sensory level that we might be more affected by hot and cold and noise. Studies show that people with ADHD are more likely to have allergies, ear infections, first ten years of my life, autoimmune issues. So there's something about that that can lend itself to anxiety. And what I always say to people, too, is that I think of a lot of these things, like a coin.

On the flip side of anxiety might be that empathy and that sensitivity, which we don't want to get rid of, but understanding that what can come along with that is where our portal, so to speak, is way open, where too much stuff could be coming in. Genetics play a factor we know with both ADHD and anxiety. Poor sleep. Now, having anxiety can impact ADHD symptoms as well as having depression. It basically exacerbates all ADHD symptoms, attention and concentration.

The ability to even use ADHD strategies can be impacted by ADHD and. And depression. It interferes with executive functioning. But people with anxiety, interestingly, will say that they don't want to feel anxious. But when people with ADHD who have anxiety will say, but it's stimulating, and they're speaking truth, because an ADHD brain would rather feel stimulated than feel nothing.

And everything that's pleasurable is stimulating, but not everything that's stimulating is pleasurable. So danger, conflict, anxiety are all very stimulating. And I could definitely speak to that because having my mom, who is no longer with us, but she definitely had ADHD, and she would always be worried about something, and I would be like, mom, relax. Like, I feel like you're almost looking for things. Well, now I'm my age now with, you know, children, and I totally.

I'm her. You know, I can totally understand that. That if it's my mind, if I'm not thinking about something, it's so easy to just. It's almost like it pulls me into that direction. So I always have to be careful of that.

Studies show, interestingly, that that comorbidity of ADHD and anxiety can mitigate some hyperactive, impulsive symptoms. So it's almost. One could see it as a slight benefit that kids and youth with ADHD and anxiety are less likely to fall into some dangerous, impulsive behaviors, like substance abuse or other dangerous situations in general. So, how do we distinguish between anxiety and ADHD? So, anxiety is really when people are anxious, they avoid things that make them feel anxious.

Anything that has a threat value, overstimulation or hypersensitivity, ADHD avoidance is different. It's more the fear of boredom and feeling understimulated, feeling like you're not going to get enough sort of input and negative conditioning due to ADHD symptoms. So school might be an ADHD avoidance situation because one feels just bored or not getting the input that they need. Sometimes it could be just a sensory hypersensitivity, but not with a threat value. It's just like, oh, that noise is so loud versus I'm scared of this thing that's more anxiety related.

ADHD, we know we can get to hyper focus mode, which can feel great. Sometimes. You know, you're in that mode for 12 hours, you're locked in and you're fluidly moving through something that's different than an anxiety over focus, which is where you're almost stuck on the same thing for a prolonged period of time. As you might see in like, obsessive compulsive disorder, the genesis of the attention deficit is important too, that even with young, like kids as young as eight that I work with, with ADHD and anxiety, or ADHD and OCD, I'll say, if they say, oh, yeah, I was, I was getting distracted in school and I'll say, was it the ADHD who was the driver of the bus then? And most people, I would say, are very good at being able to determine that because an ADHD distractibility is I'm just bored and I'm disconnected from this situation.

And so now I'm searching for something that's just more stimulating versus an anxiety. Attention deficit issue is somebody who can be connected to that. And it's almost, it feels intrusive, the anxiety, something sort of jolts them and like, rips them from that. That is just, again, pulling on that fight or flight response. So sometimes the anxiety also could just be a result of the ADHD.

And all of the executive functioning deficits cause a lot of stress. But the most important thing, the real collateral damage and the insidious impact that depression and anxiety have, which is why it's so important that we pay attention to this, is with both of these conditions, people become more oriented towards avoiding anxiety and moving away from things versus moving toward things that make them happy. So depression, your world becomes very, very small. You start to disconnect from friends, you start to disconnect from things you enjoy. And it just comes smaller and smaller with anxiety.

It's, I don't want to do this thing because this thing might happen, so I'm just going to play it safe. And that makes someone's world really small. So the idea of even orienting somebody to seeing the world as expansive is almost too threatening. When it comes to anxiety and depression, there's a learned helplessness, low self esteem, feelings of ineffectiveness, and the feeling of being done to this idea that the world is a very harsh place. And certainly the world is not always pleasant, 100%, but it's almost like being totally shadowed by that feeling, very isolated.

And when one feels that way, it's not unimaginable to understand how some people feel, that it's not worth living life. So the more optimistic part is that there is treatment and support. And so what do we do in helping individuals who have these conditions? So, first, before we talk about even traditional treatment, it's just pure health hygiene. When I'm working with patients, I want to know, how are they sleeping?

How many hours a night are they sleeping? When are they sleeping? Because if those hours are from 03:00 a.m. To 10:00 a.m. That's not the same quality of sleep as 10:00 p.m.

To 07:00 a.m. How much exercise are they getting? We know that exercise is obviously good for us, but specifically, it creates something called a brain derived neurotrophic factor, or BDNF, which, in a nutshell, kind of produces more insulation over our neurons in our brain that make for faster processing. So exercise is good for ADHD, it's good for depression, and it's good for anxiety, and it's just good for our health overall. So that's like, to me, you know, bam, like, let's.

If we can incorporate. And by exercise, it's not 2 hours a day, seven days a week, even if somebody is moving 1520 minutes a day, how are they eating? And knowing, again, that depression and anxiety and ADHD impact to all of those. So I'm not. I don't want to oversimplify it as like, oh, let them eat well, and all these issues will go away.

It's understandable that their eating is going to be impacted by all these things, but you always want to make sure you're working on all of those things as well, because the benefit of when those things are working well, it can really help the treatment of all of these conditions and then play in humor. Humor is a very therapeutic role. I am a big believer in humor. It's certainly gotten me through a lot. I'm a big lover of stand up comedy and the art of comedy, and that really goes a long way.

How do people sort of connect to, even if it's dark. I mean, I have a very twisted sense of humor. It doesn't have to be sort of traditional, but something that can, what humor does is it gives us just a different perspective, that we have some distance sometimes. In fact, some of my favorite stand up comedians are people that talk about very dark and painful stuff but are making you laugh at the same time. And that doesn't minimize their issue.

In fact, it does the opposite engages you with it, but in a less threatening way. So what can parents do is sort of tips. You know, I always say a lot of times when you have your kid coming home from school, you might say, how was your day? And most of you are probably going to get good. You want to be more specific sometimes saying, you know, tell me two good things about your day and one not so good thing about your day.

And one is that actually helps kids that even if they've had a bad day, it might force them to think about, well, what were two maybe okay things about the day. So it's giving the sense that we don't have all good days or all bad days. Most of our days are somewhere in between that have moments of both. And so asking that question kind of helps them frame that and it'll give you more data as a parent, comment on observed behavior rather than you seem sad. It could be, you know, I noticed that every Saturday you would look forward to hanging out with your friend and you haven't been doing that lately, and instead you've been staying home.

I noticed that you'd always be singing when you're in the shower and you haven't been singing for a couple of weeks now. So it's harder for a kid to resist that when you're making it very operational and very concrete. Discuss the time when you felt down. I mean, a lot of times we expect kids and teens and especially kids with ADHD to always have the vocabulary and sort of the space to even know how to articulate it. Talk about it.

Talk about times where you felt down, where you're anxious, and it doesn't even have to be preachy. It could be like you're driving in the car and you're like, oh, I had a day today and blah, blah, blah. And you're sort of just putting it out there in the ether. You know, it's sort of putting that in the air. So they a have a vocabulary, but two also know, oh, even like adults.

Like, I'm not expected to be, like, perfect and never feel bad. I can feel bad at times and know that I can get through that. How do we find physical, creative ways of engaging and discharging emotions and encourage that? It's not about stuffing the emotion. It's like, you know, if you're angry, maybe let's listen to some loud, heavy metal music and bang, you know, get some drumsticks and bang on some textbooks.

Maybe when you're feeling that way, petting the dog and listening to soft music might do the trick. Like, what's going to work for you? Never brush it off as a phase or drama or something, that they'll just feel better with time, because I know I didn't feel that way when I was younger. Like, those emotions can really come over us. You want your kid to know that you're a collaborator with them.

Let's work together to make you feel happier. And of course, as parents, we just want to take it all away, but we can't do that. We also want to teach our kids resilience. But trust me, I know. Like, there are many times I'm like, I just want to just snap my fingers and make this go away.

But in the long term, that's not so sustainable. Validate that. It can even be hard to articulate what you're feeling. And it's courageous to ask for help for kids or teens. Buy books that are webinars, podcasts, celebrities that they're interested in who might talk about some of these issues.

Teaching relaxation techniques and deep breathing, how to monitor. Even on a scale of one to ten. Again, we want to move away from the black and white. It's all good, all bad. Maybe at a level six.

With my anxiety right now, my mood is kind of at a three. And that way you can also quantify it in some ways when you know you've improved to say, oh, now, at the end of the day, I'm at a level seven. My mood is at a seven. Huh? I was at a three earlier.

What change? Oh, wait a minute. I went out for a bike ride. Maybe physical activity helps. And so having that quant way of quantifying it, challenging, negative thinking, we don't want to accommodate unhealthy avoidance.

And this is really tricky. I can get into a lot more. But basically, yes, we don't want our kids to feel uncomfortable, but we always have to think what's sustainable. And sometimes the best thing we have to do is to have them feel uncomfortable and get through it so that they learn that they can be resilient to it. Assessing your own behavior and always feel okay to ask your child if they ever have thoughts of hurting themselves.

The number one thing in terms of suicide prevention, and everyone thinks that if you ask them, if you ask somebody, have you ever had a thought of hurting yourself or suicide, is that that will implant the thought in their head. Studies and experience from suicide survivors will say that never. That's not the case. In fact, many people who have attempted suicide and who have survived will say they wish that somebody had asked them that. Sometimes even asking that destigmatizes it too, where a lot of times people don't share those thoughts because they seem so unacceptable and so taboo.

They fear that somebody can't handle that thought. So when we say it to them, we're basically saying, I can handle it. I'm giving you the space to talk about that. Seek professional help sooner rather than later. Then I want to leave.

Ten minutes for Q and A. So basically all different treatment models. Education, mindfulness skills, cognitive behavioral therapy, dialectical behavior therapy, which look at assessing negative thought patterns, distorted thought patterns. DBT focuses on mindfulness, emotional regulation skills, interpersonal effectiveness skills. Everyone really could benefit from DBT, interpersonal therapy, certainly executive functioning skills, because we always, always have to treat and manage the ADHD.

Otherwise we're not treating, fully treating the comorbid anxiety or depression and medications I'm going to skip through briefly. But with CBT it's basically a combination, again, of assessing negative thought patterns, relaxation techniques. You don't want people avoiding things. So that could include exposure therapy. If you have a child, let's say that doesn't want to sleep over a friend's house.

It could be start off with, well, why don't you. They call them like a sleep under. You'll stay over their house till eleven and then I pick you up, you know, and then another time, you know, maybe we could try sleeping over a grandma's house or something and having like a hierarchy. And that can work. You could do that kind of work with a therapist and most importantly, feel your feelings, that we must feel our feelings in order to develop coping skills around them.

In fact, when we suppress a feeling, that results in an uncontrollable expression of that feeling. So for example, rage is not an emotion. Rage occurs when we've suppressed anger or suppressed sadness. Panic is not an emotion. A panic attack, in fact, is somebody who's suppressing their anxiety, someone who's getting anxious about getting anxious.

Depression is not an emotion. It's the absence of emotion. It's often when people have been suppressing a lot of different feelings so we always want to encourage, feel those feelings, but let's feel them safely. Let's find a good outlet for those feelings. And as a parent, as an educator, as a clinician, we can handle what your feelings are.

If you are speaking to. I feel like I want to hurt myself. I'm angry, I'm pissed off at you, I'm sad. It's not that it won't affect us. Like I always told my kids, like, I'm your dad, of course I'm going to feel something, but at the same time, I know you're your own person and you're in this world.

Of course you're going to have, if you didn't have feelings, it means you weren't connected enough. So we always want to do that, not being this sense of numbing sort of emotion, because if we numb an emotion, we're numbing all those emotions. Assertiveness skills is also really, really important. And I always end, and, you know, this doesn't have any religious connotation. It's typically known as a serenity prayer.

But I say serenity statement. But the idea that for those of you might be familiar, this is my, with this statement, this is a mantra of mine, of grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. And I feel like with anxiety and depression, anxiety is almost like when we think we can control something that in fact we can't. And sometimes it means we just got to surrender and just recognize the limitations of our control. With depression, it's people who don't think they can affect change or have agency for change when they can.

And so I think for me, you know, this, this statement sort of characterizes all, which is why I begin and end each day saying this. So we have, I went over, as I always do, but hopefully we'll have about ten minutes for questions and answers. Thank you so much, Doctor Lavardia. We do have quite a few questions. I will quickly thank our sponsor.

Annie Rogers
Play attention one more for once more for making today's webinar possible. And then I will turn quickly to the results from the survey that we asked at the outset here today, as it will help guide some of these questions. We asked you to tell us if your child had diagnosed or suspected depression or anxiety, what symptoms were most prevalent or worrisome to you. The number one answer was emotional dysregulation. I felt like it was just such an important point you made.

I wanted to underscore it that emotional dysregulation is an executive function? Yes. I feel like from the comments we receive today and larger, more broadly at attitude, that a lot of caregivers and a lot of clinicians don't understand that that is part of ADHD. Do you feel that perhaps this misunderstanding of emotional dysregulation could be leading to anxiety diagnoses before an ADHD diagnosis? Absolutely.

Roberto Olivardia
Definitely. And to be fair, I mean, emotional regulation, even in the world of ADHD, is recent, I would say fairly recently been conceptualized in executive function. And so I understand why it needs time to almost, like, catch up, you know, where sort of. We understand that on the larger context. But, yeah, I mean, absolutely, it is an executive function because our ability to, if you think about what emotional regulation is, we first have to be aware that we're feeling an emotion that requires what we call intraoceptive awareness, that mindfulness of what's happening in the body.

People with ADHD have a hard time with that. Then we have to pause to even assess, oh, I'm feeling x, y, and z about something where we're more impulsive. And then we have to make a decision around what to do with that emotion. So we have to weigh, okay, my teacher just said something that upset me. How do I respond to it?

And now we might say, I want to tell them, you know, to go jump in a lake, but I'm going to inhibit that because that could lead to a bad consequence that requires that GABA, neurochemistry, and a lot of other stuff going on in the brain. That pause that, and that can be harder for kids with ADHD. Studies will show that kids with ADHD have a harder time soothing themselves, grounding themselves. I often say we get distracted so easily of a lot of things, and unfortunately, we don't get distracted very easily when we're feeling bad. And so we can get real steeped in our misery, like, very, very quickly.

Now, the difference, though, with ADHD versus something like a depression is that sometimes it can be felt very strongly, and then people sometimes can get through it if they have something else to attach to, whereas with depression, it isn't that way. You can have the warm puppy or the shiny nickel right there in front of them, and it just. It won't take.

Annie Rogers
It's just absolutely fascinating. As you said, the understanding that ADHD and executive function go hand in hand is relatively new. And then to understand how that impacts, we didn't talk a lot here today about the difference between the hyperactive, impulsive presentation and inattentive but it kind of stands to reason that someone with inattentive ADHD who is not, for example, disrupting a classroom, but is showing some of these emotional dysregulation symptoms, it might be quite a long road for them to get the proper diagnosis of ADHD. Absolutely. And we know this particularly for inattentive types.

Roberto Olivardia
We know generally for girls with ADHD tend to be more, have more internalizing symptoms of anxiety and depression. So it might not be as external in that way. And so absolutely assessing. And that's why for anybody, I mean, if you're as clinicians, if you're treating someone with ADHD, always, always be looking for signs of any of these comorbid disorders. And I always say for anyone treating depression, addiction, binge eating disorder, I mean, these kinds of issues that we would traditionally see with ADHD, it's always useful to be inquiring or looking for.

Is ADHD also in the mix? We have a number of people here who said exactly that, that in a few cases here, their daughter has been diagnosed and is being treated for anxiety, but they feel there's something more. Are there any red flags or signs that perhaps there is more, especially if they're receiving treatment for anxiety but continuing to experience some symptoms? Yeah, I usually look at how much are they potentially compensating or overcompensating for? Because a lot of times anxiety is just almost like an exhaustion.

It's like just a taxing of the system. And we know, particularly for people with ADHD and people with ADHD who really, you know, are putting in the work, that just because, let's say somebody's a straight a student and looks like they kind of have it all together, we don't know. I want to know behind the scenes, like, how late are you up until? How long is it taking you to do that? I've met with so many people over the years who they will tell you that they know they're spending three times longer on getting their homework done than their peers because they keep getting distracted and have to reread it and reread it, but they care very much and they have the energy enough, they say, to sort of do it, but nobody is really inquiring about that.

And so there's always this sense of, like, imposter syndrome that even if they got the a, they're like, they feel like it'd be taken away at a moment's notice because they don't feel it's, like, solid. So I would look at how much is this person really stretching themselves too thin, asking them their experience in these various domains of academics and social and all of that. Because just because somebody has a lot of friends doesn't mean that they don't have social anxiety. For example, I treat many people who are very personable, who have good friends, but in their minds, they're constantly obsessing around, you know, am I good enough? Is this person, if they get to really know me, maybe they'll reject me.

And with ADHD, we'll often see that rejection sensitivity and all of that. That's so taxing on the mind that a lot of times what looks like even kind of generalized anxiety could be social anxiety, could be aspects of executive functioning. Stress could be things that are related to just a difficulty with emotional regulation.

Annie Rogers
It reminds me of a recent sentiment that I heard within the ADHD community that traditionally we have. We. I'm not a clinician, but clinicians have diagnosed ADHD based on impairment. But a better model might be actually stress. Yeah, seems like that's kind of.

Roberto Olivardia
Yeah, I. I'm a big believer, and this is why, you know, it's. And I still. It still kind of boggles my mind. But I'll hear sometimes from therapists who don't.

Are not well versed on ADHD when I'm, let's say, doing a consultation, and they'll say, oh, I never even thought that this patient could have ADHD. I mean, they do well in school. And I'm thinking, well, I have a PhD. I mean, and I have ADHD. But if you ask me, the behind, it's always, what's the story behind the scenes?

And so impairment is not always in your face. Impairment is compensating factors and all of that. I mean, yeah, I did well in college. My transcript was really, really good, but I wrote every paper overnight, and it was not fun to do that. I was up sometimes two days straight without the aid of caffeine, just on pure adrenaline, like, getting things done.

And so, yeah, I did it and I pulled it up, but it came at a price in that way. So I think the DSM, it's helpful. We need the kind of those symptoms, but in terms of actual assessment, we always want to kind of get the story behind it. And that's where, particularly for young people who might not have. They feel maybe the safety to share those thoughts or they don't have the vocabulary or fear they're going to be stigmatized in some ways or found out is to really get the story.

Like, what is it like? How is doing homework? You know how is when you're with your friends, are you having a good time? Are you in the present moment? Or are you worrying about the fact that you could be ousted from that group at any given second?

And we never want to assume everything is always what it appears to be.

Annie Rogers
So important. I am going to squeeze in one last question, if I can. Sure. Because I know that you're an expert on this topic, and we've received quite a few questions from parents who said that they know where they suspect that their child is using cannabis to address some of the symptoms, whether they be anxiety, ADHD or depression, and the symptoms, the sleep issues that go with them. This could be and has been its own webinar.

But if you could just give us a quick summary of signs of concern if you suspect or know that your child is using cannabis. So first, I would absolutely direct people, because one of the, honestly, the most important, I mean, all the webinars I do, I really feel a lot of importance to. But the one I did with attitude, it was, we did a two part actually on cannabis, was one that really educated me in preparing that, and the one I get probably the most feedback from. Cannabis is not a treatment, it is not medicinal. It is neurologically harmful to a developing brain.

Roberto Olivardia
Now, I'm not advocating for use after the age of 30. The truth is, we don't have much data on people who start using cannabis after the age of 30. So I can't say speak to that. What I can speak to is the scientific evidence, of which there is a lot that show significant harm to the brain. For a developing brain, cannabis is not the same cannabis that people were using in the sixties and the seventies.

The THC is much higher, the levels of THC, the frequency is more higher than we've ever seen. We're seeing kids using it at a younger age than we've ever seen it. So all of those factors together is the difference between someone giving you a little nudge like this in the arm and hitting you in the arm with a hammer. In terms of what it does to the chemistry of the brain, it exacerbates all ADHD symptoms, it helps ADHD symptoms. And I put that in quotes.

In the short term, yes. It's not that these young people are crazy when they say, it helps me sleep, it helps me focus, it calms me down, it is doing those things. And that's why we don't want to moralize people who are using these substances or make them feel bad or stupid or irrational or crazy. It is absolutely designed to do that. And what we know on the long term is it's eroding their ability to have all of those executive functions.

So here you have a group of ADHD individuals who are vulnerable as it is with executive functions, taking a substance that in the long term is eroding their executive functions, which is only going to have them dependent on it more. And you can be addicted to cannabis. It is a myth that you cannot be. Absolutely. And in fact, we're seeing dependence rates skyrocket, even in the last ten years.

There's going to be data. And I know I sound like an alarmist, but I have to let you all know I'm a very strong ally in the recovery community. And when I did this presentation for attitude, I honestly was coming from a place of like, I don't know, let me really do a deep dive in. The research is like, how harmful is it? I really was not coming at it from, I mean, I certainly, again, wasn't advocating for its use, but it's really, and I just, from my clinical experience, I see a lot of young patients who have a lot of problems with, with cannabis, and it can really cause harm.

Annie Rogers
Well, we will absolutely provide the links to doctor Olivardia's two part webinar series that he referenced, because it is chock full of, as he said, research and information that I feel like every parent of an adolescent should see, but especially this audience. And I will also mention we do have an upcoming event that is titled how cannabis use affects ADHD symptoms and sleep in adolescents with Marielle Hernandez. Wonderful. So that's on May 7, so please bookmark that for now. We have actually gone over time.

We could have gone for a whole nother hour. But Doctor Olivardia, thank you so much for joining us today and for contributing your expertise and your voice. As always, you make such a, such a positive impact on our ADHD community. Oh, thank you for having me. Absolutely.

And thank you to everyone who joined us and made podcast episode number 500 possible. The slides and recording of this webinar will be posted in just a few hours after the live event. And if you're listening in replay mode, you can just click on the episode description to get all of that background information. You should also know that our full library of attitude webinars, including those two past webinars on cannabis use, are available in our podcast, which is called the ADHD Experts podcast on all streaming platforms. Make sure you don't miss any future webinars or articles by signing up for our newsletters@attitudemag.com.

Newsletters Doctor olivardia thank you again and I hope everyone has a wonderful day.

For more attitude podcasts and information on living well with attention deficit, visit attitudemag.com. That's additudemag.com.

500- Identifying Depression and Anxiety in Teens with ADHD

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1. Introduction and Background

2. Understanding Depression in ADHD

3. Managing Anxiety in ADHD

4. Treatment Strategies

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