ADHD in adolescents: Will you know it when you see it?
Attention deficit hyperactivity disorder doesn&t disappear in teens. But it does look different, and failure to recognize and treat it can have a devastating impact.
Cover article
ADHD in adolescents:
Will you know it when you see it?
By Martin Baren, MD
Attention deficit hyperactivity disorder doesn't disappear in teens, as once thought. But it does look different, and failure to recognize and treat it can have a devastating impact during adolescence and far beyond.
Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood.1 The belief that children outgrow the disorder during adolescence has been replaced by the recognition that they continue to display signs and symptoms of ADHD as teenagers. Prospective longitudinal follow-up studies provide compelling evidence for the continuation of ADHD from childhood into adolescence and adulthood.2,3 Its persistence may be masked by subtle changes in presentation that need to be recognized to manage the disorder and to ameliorate its potentially devastating effects.4
Although ADHD begins in childhood, some patients are not given the diagnosis until adolescence. They include girls (probably because they have a lower incidence of disruptive behavior than boys and more often display the inattentive type of the disorder5), gifted children, children with ADHD inattentive subtype, and those with a very supportive family and good social skills.
Recent field trials have called into question the validity of the diagnostic criterion cited in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) that symptoms be present by 7 years of age.6 Patients with good cognitive skills may not be diagnosed until faced with demands for greater attention, inferential thinking, higher order language processing, management, and multitask activities. In other youngsters, the diagnosis may be missed because of lack of familiarity with teenage presentation. Compounding the difficulties, adolescent specialists are often overburdened with new cases; patients referred for diagnosis and treatment endure a long wait, resulting in a gap in services.7
Developmental and behavioral pediatricians, primary care physicians, psychologists, and psychiatrists need to be aware of the core signs and symptoms of ADHD displayed by adolescents and must be able to distinguish these symptoms from normal adolescent behavior. It is important to make the diagnosis early, before increased social, educational, and family problems occur. ADHD can result in a pattern of serious dysfunction, including school or social failure, that compromises the future life of many affected teens.8 This article reviews the prevalence and clinical characteristics of adolescent ADHD, selected diagnostic and treatment considerations, the impact of the disorder on patient and family, and its implications for adult life.
Basic features of ADHD
The essential features of attention deficit hyperactivity disorder are described as "a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than typically observed in individuals of a comparable level of development."9 Traditionally, the definition of ADHD includes disturbances of motor activity, academic performance, behavior, and lack of impulse control. Underperformance in academic work, accompanied by conflicts with family and school authority, is often present. This pattern of serious dysfunction paves a bumpy road for many children and teens.8
According to the DSM-IV, ADHD represents a combination of deficits in cognitive functioninginattentive behavioral functioning and hyperactive-impulsive behavior. The degree of impairment in these functions determines the patient's subtype of ADHD.10 At present, the DSM-IV categorizes the three ADHD subtypes as follows:9
- Attention deficit hyperactivity disorder, combined type
- Attention deficit hyperactivity disorder, predominantly inattentive type
- Attention deficit hyperactivity disorder, predominantly hyperactive-impulsive type.
Two further categories are included in the DSM-IV:
- ADHD not otherwise specified (less than the full syndrome with some impairment)
- ADHD in partial remission.
The literature documents the educational impact of ADHD, describing how it impairs academic performance and productivity. Deficits in quality of work, social interactions, organizing, listening, and following directions contribute to educational impairment.11,12
How common is ADHD in teens?
The DSM-IV estimates the prevalence of ADHD in school-age children to be 3% to 5%, although recorded prevalence rates vary substantially.9 The American Academy of Pediatrics clinical practice guideline for ADHD suggests 4% to 12% in community samples and 9.2% of males and 2.9% of females in the general population. Prevalence rates vary significantly depending on the sample population, however, (school, 6.9%; community, 10.3%).1 The true prevalence is probably around 5% to 8%.
Long-term studies have documented the persistence of ADHD symptoms into adolescence and adulthood. As many as 80% of children with ADHD continue to exhibit symptoms during adolescence, and 60% display symptoms during adulthood.3,4
Estimates of persistence vary with the definition of ADHD used. Syndromatic remission in adolescent and adult patients is defined as failure to meet full diagnostic criteria (fewer than six symptoms of either inattention or hyperactivity/ impulsivity according to DSM-IV criteria); symptomatic remission refers to the presence of fewer than three or four symptoms with continued impairment. Functional remission is defined as full recovery with no impairment. Recent studies suggest that, although only 40% to 50% of adolescents continue to show the full syndrome, the rate of functional impairment is much highercloser to 85% to 90%. In this group, symptoms of hyperactivity/impulsivity disappear more quickly than inattention.13
From child to teen: The changing clinical picture
As children with ADHD progress to adolescence, the clinical characteristics of the condition typically change. Clinical features of ADHD in childhood include pronounced impulsivity, restlessness, excessive motor activity, inattention, and distractibility. Children with ADHD may be reckless, and accident-prone, often displaying antisocial behavior such as disobedience, temper tantrums, and aggression.9 During adolescence, some symptoms become less conspicuous. Hyperactivity levels may decline and attention span and impulse control may improve. Consequently, many adolescents originally diagnosed with the combined type of ADHD no longer meet the criteria for that type. Impulsivity remains a major problem for many teens, however, creating associated difficulties in school, work, family, and social relationships.2,3
Impairment of academic performance becomes more apparent in secondary school as academic demands increase. Emotional lability and behavioral outbursts, common during adolescence, can be more pronounced when ADHD is present. As many as 25% to 45% of teens with ADHD develop oppositional or antisocial behavior or conduct disorder.10
As independence and responsibility increase, so may encounters with the law, driving accidents, low self-esteem, and drug and alcohol abuse.10 Issues associated with identity, peer-group acceptance, and physical development can be a source of extra stress and seriously affect social functioning.2 Adolescents often deny symptoms and refuse to take medication at school because they don't want to be "different."
The gateway from adolescence to adulthood has been investigated by various researchers and their findings have been consistent. Core symptoms of hyperactivity/impulsivity tend to decrease over time, although inattention persists. In later life, additional difficulties linked to low self-esteem, poor academic performance, and poor interpersonal skills may surface.4,14 [Editor's note: For more on this topic, see "Helping children with learning disabilities toward a brighter adulthood" in the November 2000 issue.]
It should be noted that adolescents with ADHD are not an especially homogeneous group. In my experience in clinical practice, there are at least two subgroups: 13- to 15-year-olds and 16- to 18-year-olds, roughly corresponding to middle school and high school age groups. The 13- to 15-year-olds are more likely to be resistant to diagnosis and treatment while the 16- to 18-year-olds may be more willing to cooperate in their treatment program. Some of the more difficult behavioral and educational issues may therefore be easier to address during later adolescence.
Disorders that accompany ADHD
ADHD often appears simultaneously with a range of psychiatric disorders and learning disabilities. Studies reveal a high rate of such comorbidities among teens with ADHD in both clinical samples and the community (Table 1). It is important that those who assess and treat adolescents with ADHD recognize that such comorbidities may be present.2,10,15,16 Symptoms of psychiatric comorbidities, like those of ADHD, often change as individuals mature. Response to therapy also varies with changes in, or the severity of, comorbidity.17
TABLE 1
Comorbidities often seen with ADHD
Psychiatric disorders commonly seen in association with ADHD include bipolar disorder, depression, anxiety disorders, conduct disorder, and oppositional defiant disorder. In addition, substance abuse, obsessive compulsive disorder, pervasive disorders, stress adjustment disorders, and Tourette's syndrome are often present.16
Learning disabilities and school performance problems are also a feature of ADHD, affecting 20% to 60% of patients.10 As many as 50% of teenagers with ADHD have problems with written language.
When psychiatric comorbidities accompany ADHD, they further affect adolescent behavior. Delinquent behavior and antisocial personality disorders, for example, are seen in 25% to 40% of adolescent and adult ADHD patients who have comorbid conduct disorder.14 Many adolescents display more than one comorbid psychiatric or learning disorder.
Comorbidities may have prognostic value. Severity of childhood ADHD predicts severity of academic difficulty during adolescence, for example. The more comorbidities, the worse the prognosis in most cases. In the majority of cases, outcome may depend on treating comorbid conditions as well as the ADHD.
Although adolescents with ADHD have certain characteristics in common, they each have unique characteristics that need to be addressed as part of their clinical management.17 Comorbidities increase the need for individualized management.
Is it ADHD or normal adolescence?
Many adolescents find their rapid physical maturation, cognitive development, and emotional changes unsettling, often resulting in a weakened self-image. They may reject established parental and adult societal values, preferring to experiment with alternate values and ideas as they strive to establish their own identity. While it is reasonable to expect teenagers to comply with house rules, a certain amount of resistance is unavoidable.
Parents often incorrectly interpret restlessness and thoughtless behavior by teens as malicious, fueling negative reactions and increasing conflict. In the case of adolescents with ADHD, parent interaction and response is affected by ADHD symptoms. Parents should be guided toward reasonable expectations and accurate interpretation of their teens' behavior.18
Motor activity in adolescents may vary from sluggish, careful behavior to constant motion (motoric) with little regard for the effect of the behavior on other people. High-energy activity and an impulsive cognitive style usually diminish gradually as the child enters the adolescent years. It is therefore necessary to distinguish normal variations in hyperactive and impulsive behavior from excesses that could become maladaptive for the adolescent.
Inattention also varies significantly from early childhood, where it is the norm, through middle childhood to adolescence. The developmental stage as well as the surroundings and demands on the youngster's attention must be taken into account before labeling this behavior pathologic.
The Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version (DSM-PC) has formulated a behavioral description that differentiates normal developmental variations from behavioral problems and true disorders (ADHD).19 Table 2 in the print issue (Table 2, Adapted from American Academy of Pediatrics: Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. Elk Grove Village, IL, 1998)summarizes these differences in adolescence.
How ADHD affects teens
Adolescents with ADHD have a substantially higher risk of poor outcomes in psychiatric, social, legal, academic, and family functioning than normal teens do. The areas most affected are:
Family impairment. ADHD magnifies the difficulties typically encountered by adolescents and their families. Parentteenager relationships are often characterized by increased conflict, negative communication, and misunderstandings. The whole family suffers as a result of parental frustration. Parents may be less involved with the teen than they might otherwise be, and problems appear to be intensified, especially when a parent also has ADHD.
Teenagers with ADHD typically have self-esteem problems and interpersonal behavior problems. They are less able to exercise planning and forethought and engage in future-oriented behavior than normal teens are. They are more likely to be impulsive, self-centered, and insensitive to the needs of others. Impulsivity is manifested as increased moodiness, hypersensitivity to criticism, overreactivity, and poor judgment. Adolescents with ADHD who are not treated early may develop antisocial personality problems.
A highly impulsive adolescent presents a major parenting dilemma, often leading the parents to become more controlling and creating an impasse between parents and teenager. The stress this places on the family can result in sibling resentment, marital discord, separation, and divorce.7
Social impairment. Many children with ADHD experience problems with peer interaction, and adolescence can increase these difficulties. Social disconnection may lead to poor self-esteem, social isolation, and attention-seeking or acting-out behaviors. Youths with such problems often drift toward other disenfranchised adolescents, including delinquents, drug abusers, members of cults, and those who espouse antisocial religious or racial views.20
Substance use is often a problem. The combination of poor self-esteem, school difficulties, social isolation, the wrong peer group, and family difficulties often leads to experimentation and, later, abuse. Cigarette smoking is probably the most prevalent substance used, with marijuana and alcohol close behind. Other drugs often follow if intervention is not begun.21,22
Milberger and colleagues23 proposed a link between cigarette smoking and ADHD and investigated this association in children and adolescents. Their results led them to conclude that ADHD, particularly when accompanied by other disorders, is a significant risk factor for early initiation of cigarette smoking in children and adolescents. They emphasize the importance of smoking prevention and cessation programs for these youths.
Several lines of evidence now suggest that functioning of the nicotinic system is relevant in ADHD. Nicotine promotes dopamine release and has been shown to improve attention in adults with ADHD. Researchers are currently exploring the relationship between nicotinic receptor polymorphism and susceptibility to ADHD.24
Major problems with driving are well documented among adolescents with ADHD. They often display a combination of poor attention and impulsivity that leads to a procession of speeding tickets and accidents. It is estimated that teens with ADHD are four times as likely to be involved in a serious accident or collect speeding tickets as teens in the general population.25
Other social difficulties affecting adolescents with ADHD include gambling and eating disorders. An additional major problem I have seen among patients in my practice is total addiction to the computer, especially "chat rooms," pornographic Web sites, and hacking into industrial, commercial, and educational sites. The last has led to incarceration for several patients as well as major family conflicts and financial ruin.
Impulsive and depressed teens are more likely to become involved in risky sexual activity, leading to sexually transmitted disease and unwanted pregnancy. Many adolescents destroy their educational career or health as a result of this type of behavior. Unwanted pregnancy may exacerbate family dysfunction, adding to the family a child who may have ADHD (considering the genetic aspect of the disorder) and does not have a stable, mature parent.
Social impairment also may lead to legal problems, accidental death, or suicide. Comorbidities such as depression, bipolar disorder, anxiety, and learning difficulties typically magnify the impairment.
Academic impairment is one of the least appreciated areas of difficulty for teens with ADHD. Many have already experienced problems in elementary school, especially if they also have a specific learning disabilityin reading or math, for example. In elementary school, they likely had at least some academic accommodations available to them and were exposed to only one or two teachers at a time. Accommodations are not always as available in secondary school, and the change in format to multiple classes, each with a different teacher, can render the transition to middle school and then high school devastating for these students.
The greater demands of secondary schoolfor attention, organizational skills, problem solving, and higher order language exposureoften surpass the abilities of the student with ADHD, and productivity eventually breaks down. ADHD also causes problems with executive functions, such as time management, following directions, planning, and attention to detail. As a result, affected teens have trouble meeting deadlines and typically engage in a cycle of procrastination, followed by studying all night before exams.
Poor working memory in students with ADHD affects listening to lectures and directions, completing book reports, note-taking, writing assignments, and complex math and science projects. These students often have major problems with test taking and need extended time.
Perhaps the most frustrating problem for the student with ADHD is the task of writing, whether it be note-taking, reports, examinations, or other exercises. Inattention and impulsivity are two of the main neurodevelopmental problems here, but these students also have difficulties in other areas, including visual memory, working memory, fine motor delays, and language skills. It is estimated that as many as 50% of all students in middle school are at least one standard deviation below the mean in written language; many of them have ADHD.26,27
As academic problems converge on the adolescent with ADHD, he or she often becomes uncommunicative and moody and may be dismissed as lazy or unmotivated. These labels are especially likely to be applied to girls, who are less disruptive than boys with similar problems. Although behavioral and social changes arising from academic problems may lead to discovery of previously undiagnosed ADHD, often the signs and symptoms remain unrecognized and the underperforming teen is not thoroughly evaluated for a neurodevelopmental disorder.
Problems do not end with high school. Many undergraduate and graduate students with previously undiagnosed ADHD feel incapable of performing at the college level. Lack of organizational skills often prevents them from signing up for the correct classes, and coupled with poor time-management, leads to chronic lateness or skipping classes. Memory problems further interfere with organization and academic function. Diagnosis and treatment must, therefore, follow students throughout their educational careers. School-based problems ultimately may lead to grade retention, less schooling, and impaired career development.
Diagnosis and treatment: A brief overview
This review does not provide a comprehensive guide to the diagnostic process. Many excellent guidelines are available for that purpose.1,14,28 The diagnostic approach in adolescents is much the same as in younger children. Some notable differences exist, however:
Diagnostic criteria as outlined in the DSM-IV do not always fit this age group well, and fewer criteria may be needed to make the diagnosis.10 Symptoms may change and become less obvious during teen years characteristics that must be recognized as part of the ADHD syndrome.
With few exceptions, information gathering, including rating scales, is much more difficult among adolescents because they typically have a number of teachers, many of whom may not know them well. Evaluating a teenager usually takes more time and is more involved than assessing a younger child.
Self-reporting is notoriously poor in adolescence; denial of symptoms and resistance to treatment are common. To overcome resistance, every effort must be made to encourage the adolescent to participate as a working member of the management team. Treating adolescents as adult patients, with regard to consent to treatment and discussions about medication and side effects, can be helpful.
Rules of confidentiality must be established early in the diagnostic process.
A complete educational history from preschool to the current grade with special emphasis on academic and behavioral impairment must be obtained. The history should include as many sources as possible and stress strengths as well as needs.
Adolescents have a greater need for vocational evaluation than younger patients.
A complete in-depth psychoeducational evaluation with attention to academic needs and issues must be included. It is very helpful, but not always possible, to involve the school team as an integral part of this process.
Comorbidity is very common and must be considered carefully during both diagnosis and treatment. Symptoms of other disorderssuch as mood and bipolar disorders, anxiety, sleep deprivation, substance use, oppositional defiant disorder, conduct disorder, and learning difficultiesoften mask, or are mistaken for, ADHD.
Poor driving practices and risky behaviors, including high-risk sexual practices, need to be evaluated.
As with younger children, procedures such as the Continuous Performance Tests, single-photon emission computed tomography, and positron emission tomography, are not considered useful in diagnosing ADHD in adolescents. The disorder is diagnosed primarily by a thorough history and DSM-IV criteria.1,14
Detailed discussion of treatment of ADHD in teenagers is beyond the scope of this article. [Editor's note: An upcoming article will address adolescent ADHD treatment issues in detail.] A number of excellent reviews of the clinical management of ADHD exist.14,2931 Key elements that distinguish treatment of adolescents from treatment of children is outlined in "Treating the teenager with ADHD".
What is the prognosis?
The long-term outcome of ADHD varies according to certain risk factors. Three groups of variables have been identified as possible predictors of the prognosis for teens with ADHD.
Individual characteristics such as cognitive skills and comorbidityespecially oppositional and aggressive behavioremotional state, and peer relationships are known to influence adaptive functioning and outcome.
Family environment and socioeconomic status seem to have an effect on overall adjustment. An unstable family situation can aggravate ADHD symptoms and lead to greater difficulties over the long term.
Interventions such as stimulant medication to improve behavioral symptoms, and psychosocial and educational interventions, can be very helpful. An association has been identified between children with positive family situations who receive help in all three of these areas and a better prognosis during adolescence and adulthood.14 Stimulant medications are often discontinued prematurely, however.
Addressing deficits, building on strengths
In view of the serious consequences of ADHD in adolescence and adulthood, there is an urgent need for increased awareness of the prevalence of this disorder in teenagers. Certain groups, such as adolescent girls, often are not identified until school underachievement has become chronic. To prevent this from happening, earlier diagnosis and management are essential. Primary care physicians, pediatricians, and psychiatrists all must be able to recognize the symptoms of ADHD.
It is a common misconception that ADHD is solely a childhood disorder that disappears by 13 or 14 years of age. Rather, evidence has firmly established that ADHD symptoms and impairments persist through adolescence and into adulthood in 60% to 80% of childhood patients. The diagnosis should be considered in any teenager who exhibits the symptoms outlined here.
I hope that the information presented here enables physicians who care for adolescents to uncover ADHD that has been missed and help patients who are strugglingat school, at home, or in social relationshipsto get the assistance they need to succeed. Greater recognition of ADHD in adolescents may also help prevent some common difficultieswith peers, substance abuse, and driving, for examplein teens who have signs and symptoms of the disorder but are not yet showing significant impairment. In my experience, many adolescents with ADHD can be helped significantly and can succeed at what is asked of them (see "Another treatment goal: Expose the silver lining").
REFERENCES
1. American Academy of Pediatrics: Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105:1158
2. Biederman J, Faraone S, Milberger S, et al: A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry 1996;53:437
3. Barkley RA, Fischer M, Edelbrock CS, et al: The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1990;29:546
4. Ingram S: Outcome issues in ADHD: Adolescent and adult long-term outcome. Mental Retardation and Developmental Disabilities Research Reviews 1999; 5:243
5. Biederman J, Faraone SV, Mick E, et al: Clinical correlates of ADHD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. J Am Acad Child Adolesc Psychiatry 1999; 38(8):966
6. Applegate B, Lahey BB, Hart EL, et al: Validity of the age-of-onset criterion for ADHD: A report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 1997;36:1211
7. Weiss H, Jain U: Clinical perspectives on the assessment of ADHD in adolescence. ADHD Report 2000;8(6):4
8. Mannuzza S: Long-term prognosis in attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin North Am 2000;9(3):711
9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 (DSM-IV). Washington, DC, American Psychiatric Association, 1994
10. Barkley RA: Attention-Deficit/Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, The Guilford Press, 1998
11. Swanson J: School-based Assessments and Interventions for ADHD Students. Irvine, CA, KC Publishing, 1992
12. Fowler M: Attention Deficit Disorders: An In-depth Look at Attention Disorders from an Educational Perspective. Fairfax, VA, CHADD (Children and Adults with Attention-Deficit Disorders) Educator's Manual, 1992
13. Biederman J, Mick E, Faraone SV, et al: Age-dependent decline of symptoms of attention deficit hyperactivity disorder: Impact of remission definition and symptom type. Am J Psychiatry 2000;157:816
14. American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1997;36(suppl 10):85S
15. Biederman J, Faraone SV, Taylor A, et al: Diagnostic continuity between child and adolescent ADHD: Findings from a longitudinal clinical sample. J Am Acad Child Adolesc Psychiatry 1998;37(3):305
16. Plizka SR: Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 2000;9:525
17. Brown TE: Attention Deficit Disorders and Comorbidities in Children, Adolescents and Adults. Washington, DC, American Psychiatric Press Inc, 2000
18. Robin AL: Attention-deficit/hyperactivity disorder in adolescents: Common pediatric concerns. Pediatr Clin North Am 1999;46(5):1027
19. American Academy of Pediatrics: Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version. Elk Grove Village, IL, 1998
20. Greene RW, Biederman J, Faraone SV, et al: Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: Results from a 4-year longitudinal follow-up study. J Consult Clin Psychol 97;65:758
21. Wilens T, Spencer TJ, Biederman J, et al: Are attention-deficit hyperactivity disorder and the psychoactive substance use disorders really related? Harv Rev Psychiatry 1995;3:160
22. Biederman J, Wilens T, Mick E, et al: Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 1997;36:21
23. Milberger S, Biederman J, Faraone SV, et al: ADHD is associated with early initiation of cigarette smoking in children and adolescents. J Am Acad Child Adolesc Psychiatry 1997; 36:37
24. Kent L, Middle F, Hawi Z, et al: Nicotinic acetylcholine receptor a4 subunit gene polymorphism and attention deficit hyperactivity disorder. Psychiatr Genet 2001;11:37
25. Barkley RA, Murphy KR, Kwasnik D, et al: Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics 1996;98:1089
26. Mayes SD: Learning disabilities and ADHD: Overlapping spectrum disorders. J Learn Disabil 2000;33(5): 417
27. Kavale KA, Forness SR: What definitions of learning disabilities say and don't say: A critical analysis. J Learn Disabil 2000;33(3):239
28. Morgan AM: Diagnosis of attention-deficit/hyperactivity disorder in the office. Pediatr Clin N Am 1999;46:871
29. Baren M: Managing ADHD. Contemporary Pediatrics 1994;11(12):29
30. Goldman LS, Genel M, Bezman RJ, et al: Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA 1998;279:1100
31. Zametkin AJ, Ernst M: Problems in the management of attention-deficithyperactivity disorder. N Engl J Med 1999;340:40
THE AUTHOR is a consultant in behavioral and developmental pediatrics in Orange, Calif., and clinical professor of pediatrics at the University of California at Irvine School of Medicine.
Treating the teenager with ADHD
When treating an adolescent with ADHD, keep in mind the following, which distinguish management of teenagers from that of children:
The adolescent must have as much say as possible in the treatment process.
Recognizing and addressing comorbidity is extremely important. Sometimes the other psychiatric and neurodevelopmental conditions must be treated before ADHD.
Stimulant medication has been shown to be effective in this age group.1 It may improve competence in activities such as driving, in which teens with ADHD are at increased risk of a bad outcome, such as automobile crashes and traffic violations.2 Remember that teenagers usually need to be on medication for more hours a day than younger children because their activities often last well into the evening.
Be alert, and warn parents to be alert, to the possibility of substance abuse and drug diversion because abuse of stimulants can lead to marked tolerance and dependence (see "Diversion of stimulants: How big a problem?").
Consider using long-acting stimulant medications. They may reduce the difficulties of in-school and after-school administration and decrease the risk of diversion because medication can be taken at home under adult supervision.
Use stimulant medication cautiously in patients with a history of drug dependence or alcoholism.
Emerging literature suggests that appropriate stimulant use may protect against substance abuse disorder.3
Self-reporting on the results of treatment is particularly difficult for many adolescents and must be carefully evaluated.
Psychosocial interventionfamily therapy and behavior modification, for examplemust fit into well-accepted norms for this age group.
Explore alternate forms of family, psychosocial, and vocational intervention when standard interventions do not seem to be working.
Accommodations in school for the teenager with ADHD are important. Be aware of legislation in this area and know how to use the laws effectively on the patient's behalf.
Communication with the school must be timely, legally correct, and medically sound.
REFERENCES
1. Spencer T, Biederman J, Wilens T, et al: Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 1996;35(4):409
2. Barkley RA, Murphy KR, Kwasnik D, et al: Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics 1996;98:1089
3. Biederman J, Wilens T, Mick E, et al: Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104(2):e20
Diversion of stimulants: How big a problem?
The issue of possible diversion of stimulant medications from ADHD patients to their peers, particularly in secondary schools, has received much attention in the news media. The problem also has been reported to extend to teachers, principals, and other school personnel, who, it is said, sometimes appropriate stimulants for their own use. Based on discussions with a large number of adolescents, I have concluded that diversion of stimulants is not nearly as big a problem as has been reported.
For one thing, oral use of the usual stimulant medications given to patients with ADHD does not lend itself to abuse. It is well known among researchers in this fieldand chronic drug abusersthat the "high" these drugs are supposed to give depends on a quick entrance into and buildup in the bloodstream. Stimulants taken orally do not cause this type of pharmacologic effect and therefore would not be attractive to abusers. Although it is true that these drugs can be crushed and injected or taken intranasally to produce an immediate high, this is not a common situation. Moreover, many adolescents are now being treated with long-acting medications, which come in forms (capsules or beads) that do not lend themselves to crushing and intranasal or intravenous use.
Finally, according to the National Institutes of Health (NIH) and the Drug Abuse Warning Network (DAWN), there is little evidence that abuse of the drugs has increased as production has increased. The NIH and DAWN do recommend vigilance and monitoring, however.1,2
REFERENCES
1. National Institutes of Health Consensus Development Conference Statement: Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). J Amer Acad Child Adolesc Psychiatry 2000;39:182
2. The ADHD Report 2001;9(6):11
Another treatment goal: Expose the silver lining
Physicians who treat teens with ADHD should recognize that, although these youths may have a long history of difficulties, they usually have strengths that can be used in the overall treatment plan. It is important to identify and reinforce these strengths, rather than focusing only on deficits and needs, so that these young people can experience success and gain confidence.
I have noted a significant number of such successes in my practice. Many adolescents with ADHD can, for example, skillfully participate in such activities as tutoring, playing in school music groups, composing music, and taking part in art, drama, and athletic activitiesall of which provide them with a positive experience. Even though these teens may not be doing as well academically as we would like them to, encouraging them to develop other skills can help them play a satisfying part at school.
I have found that it is not difficult to identify areas of competence for adolescents with ADHD, and I believe that, with proper diagnosis and treatment, these teens can look forward to a positive future. We must help these young people to not only deal with their deficits but also maximize their strengths so that they can achieve the best possible outcome.1
REFERENCES
1. Brooks RB: Nurturing islands of competence: Is there really room for a strength-based model in the treatment of ADHD? The ADHD Report 2001;9(2):1
Martin Baren. ADHD in adolescents: Will you know it when you see it?. Contemporary Pediatrics 2002;4:124.
