Teen girl struggling with depression and anxiety: What else might be going on? | Medical Mystery

A 17-year-old girl came in for her regular check-up. She has a history of depression, anxiety, and an eating disorder. She has tried several antidepressants, but they haven’t helped much. She’s currently taking Prozac and Wellbutrin, and she also takes a multivitamin.

During her visit, she seemed quiet and withdrawn. She mentioned being tired and a little stressed because she got a B+ in history — her first non-A grade. Still, she quickly said she was “fine” and didn’t want to talk more about how she was feeling. Her weight had dropped by 7 pounds since her last visit three months ago.

Of course, depression and eating issues are big concerns with her medical history. But, when a teenage girl has ongoing mood problems that don’t seem to improve with treatment, it’s important to consider other diagnoses.

To her parents’ surprise, her pediatrician’s thoughts went to a condition that many might not associate with her symptoms: ADHD (Attention-deficit/hyperactivity disorder.)

“Female ADHD” is a term popping up in the medical field and on social media, as women physicians and patients are pushing for improved representation in ADHD diagnostics and research. Historically, girls and women with ADHD often have been overlooked, especially when they’re young. Research has shown that ADHD is more likely to be diagnosed in boys — not necessarily because it’s more common in boys, but because it’s easier to spot and diagnose in boys based on our current understanding of the disorder.

Most ADHD screening tools were created by studying boys, so they don’t always pick up on the way ADHD looks in girls. Also, diagnostic processes usually rely on teachers and parents noticing symptoms — but studies show that adults are less likely to refer girls for ADHD evaluations, even if they show the same behaviors as boys.

But why did the pediatrician suspect that a young woman with ‘classic’ signs of depression — and nothing even approaching hyperactivity — might really be dealing with ADHD?

Many girls with ADHD don’t act out or bounce off the walls. Instead, they might just seem distracted, quiet, or like daydreamers. This is called the inattentive type of ADHD. Because it doesn’t cause major classroom disruptions, teachers might not think anything is wrong.

Additionally, many girls with ADHD work extra hard to “mask” their symptoms. They might create detailed to-do lists, try to stay super organized, copy others’ behavior, or push themselves to fit in. These strategies might help them keep up in school or with friends, but over time they can lead to burnout, anxiety, perfectionism, low self-esteem, and depression.

Girls with ADHD are more likely to also have mental health struggles. Over the years, they may face problems at school, in jobs, or in relationships. Some may even struggle with thoughts of self-harm, depression, or eating disorders.

Unfortunately, diagnosing ADHD isn’t as simple as doing a blood test or brain scan. It takes time and a careful look at how a person has developed over time. That includes talking about their challenges, doing a full physical check-up, and possibly using special rating scales or testing.

This is a lot to fit into a regular 15-minute doctor’s visit. So, if there’s concern that ADHD might be part of what’s going on, the doctor might suggest a referral to a specialist, like a neuropsychologist, developmental pediatrician, or neurologist, for more in-depth evaluation.

If a teen is dealing with long-lasting depression, anxiety, or eating problems, especially if they’re high-achieving but quietly struggling, it’s worth asking: could ADHD be part of the picture? For girls especially, ADHD can hide in plain sight.

For our 17-year-old patient, she ultimately received a diagnosis of ADHD from a developmental doctor after a referral from her astute pediatrician. With proper treatment and therapies, many of her underlying mood symptoms were able to improve and she is looking forward to heading off to college next year.

Casey Toback is a third-year pediatric resident and Hayley Goldner is a pediatrician in the adolescent medicine department at Nemours Children’s Hospital, Delaware.