With a patient, psychologist Rick Ostrander.

Twenty years ago, when Rick Ostrander set out to study ADHD and depression in children, he was like one of the first whiskers on a teenager’s chin, standing out, mostly on his own. The boundaries of ADHD were still being plumbed. And at the time, even the idea of children having genuine depression was questioned. “The old psychoanalytic view was that kids couldn’t be clinically depressed,” Ostrander says, “because they lacked a well-developed superego.”

In the intervening years, Ostrander, who directs Hopkins’ pediatric medical psychology, helped show that some children with attention deficit hyperactivity disorder do indeed suffer from depression or its milder dysthymic cousin. Now his work is aimed at discovering why. And the answers are beginning to shape ways to lessen the likelihood of mood disorders.

On a broad scale, Ostrander’s research aims to see ADHD in a truer light, not just as a freestanding illness but as one nestled in potential “comorbidities.” Children with ADHD are also prone to behavior that’s antisocial, to academic failure and to having accidents. “But there’s very little research to tell us the best way to treat these coexisting problems, not much for clinicians to rely on,” says Ostrander. “And having that is key to helping these children.”

As for depression: Research says the link between it and ADHD is strong. One large U.S. study suggests 14 percent of kids with the attention disorder also suffer depression, though Ostrander believes that’s conservative. Is the combination gene-based? There is overlap in potential genes for both disorders. But Ostrander’s work clearly points to a causal relationship: Having ADHD can lead to depression.

Recently, he and his team conducted several community-based studies, surveying parents, children and teachers in inner-city Baltimore and in a middle-class suburb of Minnesota. Some studies were cross-sectional, a single-time snapshot of a population; others followed the children longitudinally.

What stood out from interviews and surveys, Ostrander says, was the role of specific psychosocial elements—inconsistent parenting, social difficulties and academic problems—in the unfolding depression in kids with ADHD. “The idea, if you have ADHD,” he explains, “is that it can lead to parents not responding to you predictably, to other kids not liking you very much, to teachers saying you’re unreliable or careless and marking you as ‘difficult.’ This filters back to a child early on as overwhelmingly negative feedback.” And the unhappy fruit of this acid rain is a negative mood.

As children get older and more cognitively aware—what’s called formal operational thinking—the feedback gets taken personally, says Ostrander. There’s a special kicker in having the realization I can’t prevent what happens to me if you’re biologically unable to regulate your behavior or emotions. All this cements what’s now a negative mindset that, along with a lack of control, paves the way for depression.

“Fortunately, these things are malleable! We’re finding you can do something about parenting, for example,” says Ostrander, who has a soft spot for ADHD parents. “They have to be exceptionally disciplined. But the more hyperactive and impulsive the child, the more difficult that becomes,” he shrugs. Studies show, however, that girding parents with behavioral modification techniques can help. If a child’s acting out lessens, for example, that can trip a cascade that turns up the perception of control and turns down depression.

“And if we can treat the younger kids whose brains are more plastic and social exchanges more fluid, there’s probably some element of preventing long-term unhappiness.”

For more information, call 410-614-6339 or contact the division of Child and Adolescent Psychiatry

This article first appeared in the Spring 2011 issue of Hopkins BrainWise