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Bringing Self-Esteem and Success into Focus:�

Date: November 21, 2024

Presenters: Darren M. Janzen, Psy.D. (he/him) Kat Selah, M.S. (they/them)

Licensed Psychologist LEND Psychology Intern

OHSU Department of Pediatrics OHSU Division of Psychology

Supporting Adolescents with ADHD, Anxiety, and Depression

Integrated Behavioral Health for Pediatric Populations ECHO

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Disclosures

Speakers:

Neither Dr. Janzen nor Kat Selah

have any conflicts to disclose.

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Today’s Learning Objectives

Review the current understandings of ADHD and the mechanisms of vulnerability for emotional challenges.

Recognize the prevalence of anxiety and depression for patients with ADHD, as well as the impact this has on teen development.

Discuss the best approaches towards building self-esteem and experiences of competence for teens with ADHD.

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ADHD is Often Accompanied by Additional Difficulties…

Disruptive Behavior Problems: Oppositional/Defiant, Aggressive, Tantrums, Irritable, Conduct Problems, Antisocial.

Emotional Problems: Anxiety, Depression

Neurodevelopmental Disorders: Autism Spectrum Disorder, Learning Disorder, Intellectual Disability, Developmental Coordination Disorder

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The Mechanism for Vulnerability in Youth with ADHD

Key Points:

1) Anger and emotional dysregulation is related to ADHD.

2) Emotion dysregulation as a trait was related to polygenic risk for ADHD [more than polygenic risk for depression].

ADHD

Irritability-Anger

Exuberant,

extraverted

Sad, fearful, anxiety

ADHD Genetic liability

Depression Genetic liability

Bipolar Genetic liability

Emotion dysregulation

Nigg et al (2020). J Child Psychol Psychiatry, 61,205. DOI: 10.1111/jcpp.13132.

Slide graphics © Joel T Nigg, Ph.D.

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How Traits Overlap…

Irritability-anger

ADHD symptoms

Extraverted, exuberant, energetic

25%

Slide graphics © Joel T Nigg, Ph.D.

Nigg et al 2020, J Child Psychol Psychiatry, 61,205. DOI: 10.1111/jcpp.13132.

Irritability and Anger have the biggest trait overlap with ADHD, versus other traits.

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Neural Circuits are Implicated in Emotional Dysregulation

Emotional dysregulation is prevalent in ADHD throughout the lifespan and is a major contributor to impairment.

Emotion dysregulation in ADHD may arise from deficits in orienting towards, recognizing, and/or allocating attention to emotional stimuli.

Current treatments for ADHD often also help with emotion dysregulation.

Fig. Deficits that implicate dysfunction within a striato-amygdalo-medial prefrontal cortical network

Shaw et al. Am J Psychiatry. 2014 Mar;171(3):276–293. doi: 10.1176/appi.ajp.2013.13070966

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Prevalence Rates for Comorbid Diagnoses in the U.S.

Within the United States, 12-17 years olds with ADHD also experience:

https://www.cdc.gov/adhd/data/index.html

https://www.nimh.nih.gov/health/statistics

Prevalence rates in the United States for 12- to 17-year-olds, in general:

Anxiety = 31.9%

Depression = 20.4%

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The Acute Impacts for Teenagers in Ukraine

The European Psychiatric Association Congress 2024 presented

a study examining 785 teenagers displaced from regions of Ukraine.

There was a significant increase in the prevalence of various mental health conditions over a period of 6- to 12-months following displacement:

o Attention-Deficit/Hyperactivity Disorder: 10.2% to 12.6%

o Depressive disorders: 22.3% to 33.3%

o Anxiety disorders: 30.8% to 11.5%

**PTSD increased from 9.8% to 21.9%.**

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Symptoms of ADHD and Trauma often Overlap

Studies have shown that children with ADHD were likely to experience every type of Adverse Childhood Experience (ACE), and more likely to have experienced more of them than those without ADHD.

This overlap with traumatic experiences may explain the significant increase of diagnosis following displacement in the previous slide.

ADHD and Trauma often have a similar symptom profile (difficulties with concentration, irritability, poor sleep) and should be screened carefully to confirm the correct diagnosis.

Boswell et al. (2024). Journal of Attention Disorders, 10870547241290673. https://doi.org/10.1177/10870547241290673

Brown et al. (2017). Academic Pediatrics, 17(4), 349–355. https://doi.org/10.1016/j.acap.2016.08.013

Ref: The National Child Traumatic Stress Network, 2016

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ADHD Increases the Likelihood for Social Problems

Those with ADHD are more likely to be involved in bullying – both as victims and perpetrators.

Challenges with impulsivity, emotional regulation, and social skills can lead to peer relationship problems.

As a teen, the awareness of being disliked can negatively affect self-esteem and increase loneliness.

(Schoeler et al. 2019; Hu et al. 2016; Murray-Close et al. 2010; Oldehinkel et al. 2007)

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Self-Esteem for Teens can be Impacted in Many Ways…

Low self-esteem can cause problems with peers, affect decision-making, and contribute to (or be caused by) anxiety and depression.

Key causes of low self-esteem:

Adverse Childhood Experiences (trauma, divorces, moving houses, etc.)
Chronic criticism (By age 12, children with ADHD receive an estimated 20,000 more negative messages from adults than peers without ADHD.)
Inability to meet society-based developmental expectations
Poor academic performance – regardless of intelligence
Unsupportive (or exhausted) parents or carers

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Building Self-Esteem in Teenagers with ADHD

Positive Reinforcement

Offer thoughtful praise for behaviors that are desired and operationalized.
Parental praise has been shown to both improve affective mood and increase activity in brain regions supporting social cognition.
Criticism has been shown to negatively impact child behavior, mood, and self-concept.

Encourage Effort

…not just outcome or ability.
Many tasks that appear simple actually require many steps to operationalize.
Focus on encouraging effort towards desired tasks, rather than either only desired outcome (which may be challenging for teens with ADHD) or ability (such as, “you’re so smart”).

Highlight Existing Competence

As mentioned, children with ADHD receive much higher rates of criticism than those who don’t have ADHD.
Help them see where they are successful and help them learn to notice those successes for themselves.
Cognitive Behavioral Therapy can also be helpful for shifting cognitions around self-efficacy.

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Fostering Competence and Patterns of Success

Setting Teens with ADHD up for Success:

Whenever possible, cultivate quiet and clutter-free places for teens to work.

Use reminder systems: timers, alarms, calendars, planners – different tools work for different teens

Focus on manageable and time bound tasks – SMART goals (Specific, Measurable, Achievable, Relevant, and Time-Bound)

Celebrate the wins!

Encourage a healthy lifestyle: Sleep, Nutrition, Exercise, and Limited Screen Usage

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Resources:

Lifestyle recommendations to minimize negative impacts of ADHD:

“Your Lifestyle will Determine your Future” https://d393uh8gb46l22.cloudfront.net/wp-content/uploads/2021/01/ATTN_02_2021_YourLifestyle.pdf

Additional resources for parents of teens with ADHD:

The Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) foundation website (www.chadd.org). Resources for parents and teens with ADHD: https://chadd.org/for-parents/adhd-information-for-teens/
Understood's website: www.understood.org, including their primer on Executive Function: www.understood.org/articles/en/what-is-executive-function
For families considering medication to treat ADHD symptoms, the following resource from the American Academy for Child & Adolescent Psychiatry may be helpful: https://www.aacap.org/App_Themes/AACAP/docs/resource_centers/resources/med_guides/ADHD_Medication_Guide-web.pdf

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Thank you! Questions?

Darren Janzen Kat Selah

janzend@ohsu.edu selah@ohsu.edu