Dr. David Rabiner

* THE EMOTIONAL EXPERIENCE OF CHILDREN WITH ADHD

Because the behavioral symptoms of ADHD are generally so problematic, it can be easy to overlook the emotional experience of children who have ADHD. How do the emotional lives of children with ADHD compare to those of children without ADHD and how can attending to this information be useful in both evaluation and treatment planning?

This important set of questions was the subject of a study that recently appeared in the Journal of Attention Disorders (Kitchens, S.A., Rosen, L.A., & Braaten, E.B. (1999). Differences in anger, aggression, depression, and anxiety between ADHD and non-ADHD children. Journal of Attention Disorders, 3, 77-84). Participants in this study were 29 children who met diagnostic criteria for ADHD, Combined Type and 30 children without ADHD between the ages of 6 and 12. Approximately 3/4's of the children were males and the vast majority were white. The diagnosis of ADHD was made on the basis of behavior rating scales completed by children's parents and teachers. None of the children who participated were currently receiving treatment with medication.

To evaluate the emotional experience of children with ADHD, the researchers had children, parents, and teachers complete a number of different rating scales. Children completed the Child Depression Inventory (CDI) a self-report measure of depressive symptoms in children that has been shown to be both reliable and valid. They also completed the Pediatric Anger Scale (PANG) to evaluate their typical level of angry feelings and the Pediatric Anxiety Scale (PANX), a self-report measure of anxious personality traits. Parents and teachers completed standardized rating scales to evaluate the level of depressive and anxiety symptoms that they observed the child to display.

Based on the self-report data, children with ADHD reported themselves to be significantly more angry than non-ADHD children and to also be significantly more depressed. Differences between children with and without ADHD on these measures were not extremely large, but clearly indicate that, on average, children with ADHD experience greater levels of anger and depressive feelings. No significant differences were found in the amount of anxiety that children in each group reported.

Parents and teachers also reported that children with ADHD appeared more depressed than other children. Teachers, but not parents, also observed the children with ADHD to display more symptoms of anxiety.

IMPLICATIONS

It is important to put these results in the appropriate context. The fact that children with ADHD report more anger and depressive symptoms than other children certainly does not mean that they are all extremely angry and depressed. Like virtually all studies that compare individuals with and without ADHD, there was substantial amounts of variation between individuals. Thus, a number of the children in the ADHD group reported very few problems in these areas while some children without ADHD indicated that they struggled with high level of anger and depression.

The appropriate conclusion to draw from these results is that children with ADHD are more likely than others to be troubled by feelings of anger and depression. This has several important implications for the evaluation and treatment of children for ADHD.

First, ADHD evaluations should routinely incorporate an assessment of children's emotional experience. Regardless of the reasons why children with ADHD are likely to be angrier and less happy than other children, it is important not to overlook this aspect of children's lives in the evaluation process. Too often, in my opinion, ADHD evaluations are restricted to simply answering the question of whether or not a child has ADHD and other important aspects of a child's experience are overlooked. This can result in an overly narrow view of the issues that may need to be addressed in a child's treatment. If this occurs, the unfortunate result is that a child's treatment is incomplete and does not address all the important issues that it needs to.

The implications for treatment follow directly from the above. For many children with ADHD, treatment may need to address issues of anger management and depressive symptoms, in addition to managing the primary ADHD symptoms of inattention and hyperactivity/impulsivity. It is important to be aware that improvement in the core ADHD symptoms will not necessarily translate into comparable improvements in these other areas. Should this be the case, these aspects of a child's difficulties will need to be addressed directly, and specific treatments to deal with anger and depression in children have been developed. Although some would certainly disagree, my reading of the research literature is that specific psychological treatment approaches have so far proven to be more helpful to children with difficulties in these areas than has medication treatment. This, is different from what studies comparing medication and behavioral treatment for ADHD have suggested.

In summary, I think this is an important study in that it reminds parents and health care providers about the importance of attending to the emotional experience of children with ADHD. These data suggest that this is another important area where a child with ADHD may be struggling, and where careful consideration of how to best help the child is needed.

Source: David Rabiner, PhD
Licensed Psychologist