A fourteen-year-old bi-racial girl, adopted more than a decade earlier, presents with behavioral problems, i.e. bullying, poor grades, difficulty with social interaction with peers and teachers, etc. in middle school. Physicians initially diagnosed, and treated, the child with stimulants for ADHD. We suggest a differential diagnosis (D/Dx) of depression from the unacknowledged trauma of adoption.

Deeper interviewing into the psycho-dynamics of an adopted child, as well as observation, and interview of peers, is required to discern depression from ADHD. The child makes remarks, set as jokes, but which reveal psychic pain. “You don't like me because I'm black,” is a statement she has made to a close friend, on several instances, only to immediately amend the remark by saying, “I'm joking.” We believe this repeated behavior demonstrates self-loathing.

The patient clearly meets the diagnostic criteria for depression – presents with “anger or irritability” as well as “reckless behavior” and “helplessness/hopelessness” and “loss of interest in daily activities” and “self-loathing.” (DSM V, 2013). ADHD presents with similar, but fewer symptoms, e.g. “inattention, hyperactivity, impulsivity.” (DSM-V, American Psychiatric Association Publishing).

As the child enters high school this fall, we believe it is time to adjust the diagnosis and treatment strategy and recommend psychotherapy as well as treatment with an anti-depressant shown to be safe with adolescents as a transitional care strategy. ADHD is too much of a surface diagnosis in this case. Reasoning by analogy, the same kinds of symptoms may be seen in other adoption cases.