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The manifestations of attention deficit hyperactivity disorder in adolescence can be subtle. Pediatricians need to know how to identify teens with the disorder and provide treatment that meets their developmental needs.
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By John R. Knight, MD, and Leonard Rappaport, MD
The manifestations of attention deficit hyperactivity disorderin adolescence can be subtle. Pediatricians need to know how to identifyteens with the disorder and provide treatment that meets their developmentalneeds.
Attention deficit hyperactivity disorder (ADHD) has a long and colorfulhistory. The first description is generally credited to German physicianHeinrich Hoffman, who included poems about "Fidgety Phil" and"Johnny Head-In-Air" in a book he wrote for his children.1The poems can be interpreted as descriptions of boys with hyperactive andinattentive behavior disorders, respectively. More formal descriptions appearedin the mainstream medical literature in 1902, when George Still describeda group of children that, along with other symptoms, demonstrated inattention,impulsivity, and hyperactivity.2 During the early 20th century,the disorder was attributed to a "post-encephalitic" state andoften lumped together with dyslexia and other specific learning disabilitiesunder the heading of "minimal brain dysfunction."3
The use of medication to treat ADHD dates back to the early 1930s, whenCharles Bradley, MD, administered psychostimulant medication to a groupof children hospitalized for major behavioral problems. Dr. Bradley didthis in an attempt to stimulate the production of cerebrospinal fluid followinglumbar puncture (part of a complete neurologic work-up), and thereby lessenthe incidence and severity of spinal headaches.4 The stimulanthad little effect on the headaches, but teachers reported dramatic improvementsin the children's learning and behavior until the stimulant was withdrawn.
In a subsequent landmark study, Bradley found that approximately halfof a group of 30 children, 5 to 13 years of age, had dramatically improvedschool performance when given a daily dose of Benzedrine. In a hypothesisthat is surprisingly close to present-day thinking, Dr. Bradley explainedthe apparently paradoxical effect this way: "It should be borne inmind that portions of the higher levels of the central nervous system haveinhibition as their function, and that stimulation of these portions mightindeed produce the clinical picture of reduced activity through increasedvoluntary control."5
Over the years, our understanding of both the disorder and its treatmenthas grown. We now know that the symptoms of ADHD are not confined to youngchildren but persist in many cases into adolescence and adulthood. In addition,ADHD still is not always recognized in the early school years; it may notbe apparent until the teen years that the source of some patients' schoolproblems is ADHD. Pediatricians should be aware of this diagnostic possibilitywhen their adolescent patients get into difficulties and be ready to adaptdiagnostic and management strategies to accommodate the dramatic physiologic,psychosocial, and educational changes associated with adolescence.
According to the Diagnostic and Statistical Manual of Mental Disorders,FourthEdition, (DSM-IV), the essential features of ADHD include:
Three ADHD subtypes are recognized: predominantly inattentive, predominantlyhyperactive-impulsive, and a combined type. Specific symptoms are listedin Table 1. To make the diagnosis, six or more symptoms of either inattentionor hyperactivity-impulsivity should be present or, for the combined type,six or more symptoms of both.
While the DSM-IV helps define the nature of mental disorders, pediatricianshave long recognized that all such problems exist on a spectrum of severity.This view is a theoretical foundation of the new Diagnostic and StatisticalManual of Mental Disorders in Primary Care (DSM-PC), Child and AdolescentVersion.7 According to this model, attention deficits may bedevelopmental variations, attention problems, or true disorders. This isan important concept for pediatricians, who must remember that not everypatient who is inattentive has ADHD. Careful consideration must be givento both qualitative and quantitative aspects of the diagnosis, and treatmentdecisions regarding the use of stimulant medication made accordingly.
Available data suggest that the prevalence of ADHD among elementary schoolchildren is somewhere between 3% and 10%, with a male:female ratio estimatedto be from 3:1 to 6:1.8 Because the natural history of ADHD isunclear, however, there is some uncertainty regarding the extent to whichthe disorder persists into adolescence and adulthood.
Longitudinal studies have estimated that the rate at which an ADHD diagnosisis retained over time varies from 8% to 72%, but indicate a 50% overalldecline in the diagnosis every five years.9 According to thisestimate, the prevalence of ADHD among 20-year-olds would be less than 1%.This seems quite low, and the actual prevalence is unknown. There may bea subgroup of high-severity hyperactive and impulsive patients in whichthe retention rate is much higher.10
During the teenage years, youngsters undergo dramatic changes in bodysize, shape, and appearance. They also experience changes in cognitive skills,family and social relationships, and the expectations imposed on them byschools. The physiologic changes that occur during this time are referredto as puberty, while the accompanying psychosocial changes are defined bythe term adolescence.
Puberty is somewhat easier for parents and physicians to understand.Parents must be prepared to buy new clothes and razors. Pediatricians needto tailor their anticipatory guidance and adjust dosages of medication.Adolescence is more confusing for everyone. Popular misconceptions abound,and the traditional reaction of adults ranges from tolerance to outrightdread.
A review of the literature, however, reveals that adolescence has gottena "bad rap." There is evidence to suggest that teenagers may notbe more moody, antisocial, or suicidal than other age groups. In fact, adolescenceis an exciting developmental period when new cognitive abilities emergeand social relationships are transformed. The emerging capacity for abstractthought allows adolescents to grasp concepts like "future" anduse propositional logic or "what if" thinking. Neurodevelopmentalchanges in language processing enhance the comprehension of inference andother subtleties in reading and writing.11 Families must renegotiateparent-child relationships, as adolescents make the transition from dependenceto autonomy and mutual problem solving. Parents must empathize with theneed to be "one of the crowd" while simultaneously encouragingsafe group activities.
Expectations at school also change. As children move into the upper grades,they must be able to analyze what they read and write down their thoughts.They have to have the organizational skill to deal with multiple teachers,classes, and assignments. Teachers assign more homework and expect the workto reflect independent thinking. Teachers are less accessible, especiallyif they believe a student isn't really trying, which is how the disorganizedbehavior of adolescents with ADHD may be misinterpreted.
Pediatricians are often consulted when parents or teachers suspect thatan adolescent may have ADHD. A careful and complete assessment should alwaysbe performed. Primary care pediatricians may choose to consult with a pediatricneurologist, a developmental specialist, or a child and adolescent psychiatristor to refer these teens to a tertiary-care medical center for diagnosticevaluation. Appropriate assessment, however, may be performed by any pediatricianwith sufficient time and interest in the problem, working in conjunctionwith local school-based professionals.
Signs and symptoms. In adolescents, the signs of ADHD may be subtle ormasked, and adolescents with ADHD may have fewer positive findings thanyounger children with the disorder.10 Adolescents are more likelythan children to have the subtle signs associated with the inattentive subtypeof ADHD: they don't finish tasks or listen to instructions; they lose theirschoolbooks and forget to bring in homework. When teens have the hyperactive-impulsivesubtype, the symptoms are more muted: hyperactivity shows up as fidgetiness;impulsivity manifests as a tendency to begin tasks before instructions havebeen completed or an appropriate strategy has been planned. Table 2contraststypical ADHD symptoms in children and adolescents.
The cardinal symptom of ADHD in adolescents, however, is distractibility.Individuals who have ADHD are not really inattentive. Rather, they pay attentionto too many things at once or to the wrong things. Instead of listeningto the teacher, they may be paying attention to a siren in the distanceor the sound of the heating system. Instead of looking at the math formulaon the blackboard, they may be fixated on a piece of lint on a classmate'ssweater. Other signs of adolescent ADHD include difficulty beginning orfinishing work, a frenetic work tempo, poor attention to detail, mentalfatigue, and deterioration in performance over time.11
Differential diagnosis. Inattention and school failure can be causedby a myriad of conditions--not only ADHD but medical illnesses, sleep disorders,central nervous system dysfunction, substance abuse, other mental disorders,characterologic problems, psychosocial stress, and specific learning disabilities.Further, the existence of one diagnosis does not exclude the possibilityof another. The initial diagnostic assessment must therefore be comprehensive,and periodic re-assessments should be conducted whenever difficulties escalateor a new problem behavior emerges.
A specific learning disability should always be considered in adolescentspresenting for an ADHD evaluation, as it can cause secondary inattention.No one pays attention for very long to things he cannot understand or accomplish.Other problems that may accompany ADHD include oppositional defiant disorder,conduct disorder, depression, and anxiety. Pediatricians evaluating adolescentsfor ADHD must be familiar with the DSM-IV diagnostic criteria for thesedisorders or routinely refer their patients for psychologicical screening.
History. Given the rather subjective diagnostic criteria of ADHD, nothingis more important than the clinical history. When working with adolescents,the rules of confidentiality should be first explained to the whole family;then patient and parents should be interviewed separately. Parent historyshould include prenatal exposure to tobacco, alcohol, or other drugs andcomplications during the delivery or immediate postnatal period. Historyof early developmental milestones, particularly language and temperament,may reveal important clues. Recurrent bouts of otitis media during the preschoolyears may suggest hearing impairment, and history of any disease that isknown to affect the central nervous system (meningitis, encephalitis, lupus,plumbism, head injury)is important.7
Pediatricians should also ask about parents' physical and mental health,level of education, occupation and employment, and view of the adolescent.Parents who have difficulty identifying strengths may have a negative viewof their adolescent that contributes to the teenager's poor motivation andacting out. Pediatricians should also inquire about siblings and try toidentify potential stressors (recent or impending divorce, financial difficulties,dangerous neighborhood) that may be affecting the adolescent's ability toconcentrate on schoolwork. Parents can also provide information about peerrelationships.
Educational history can be taken from parents, but review of old reportcards is also helpful when teachers comment on classroom behavior and motivation.If the results of school-administered standardized tests are available,these should be carefully reviewed. A significant discrepancy between languageskills and mathematics ability, for example, might suggest a specific learningdisability. Family medical history may provide important clues to conditionssuch as Tourette's disorder.
Current performance in school must be carefully assessed. What are theadolescent's particular academic strengths and weaknesses? Are there ongoingbehavioral problems? How much time is spent on homework? Is it usually complete?Is it always turned in? The adolescent should be asked about home life,school, out-of-school interests and activities, goals and aspirations, andpossible health-risk and problem behaviors.
Physical examination. A careful and complete physical examination shouldbe performed, primarily to rule out other medically based causes of inattention.Examination of the face, hands, and general appearance can reveal dysmorphismassociated with chromosomal syndromes known to affect learning or cognition.The skin should be inspected for café-au-lait spots or other manifestationsof a neurocutaneous disorder. Vision and hearing should be assessed, andformally tested unless that was recently done. Examination of the eyes,ears, and nose can help exclude hearing loss and use of psychoactive substances.12The thyroid gland should be palpated.
A complete neurologic examination should be performed. Asymmetry in cranialnerves, muscle strength, or other "hard" neurologic signs mayindicate degenerative CNS disease or a space-occupying lesion, althoughthese are unusual causes of inattention. On the other hand, soft neurologicsigns such as synkinesias or poor coordination may suggest ADHD or a learningdisability.
Structured observations. Rating scales are a useful adjunct in diagnosticassessment for ADHD and critical in assessing pre/post performance duringtrials of medication. The Conners,Brown, and Achenbach scales are well knownand can be completed by parents and teachers.1315 The VanderbiltADHD Rating Scales also come with both parent and teacher forms.16Adolescents should also complete a self-administered scale. The ADD/H AdolescentSelf-Report has been shown to be a reliable and valid self-observation instrument.17The pediatrician should give forms to parents for completion and distributionto teachers. At our institution, we usually recommend that all teachersand other school staff who have substantial contact with the adolescentcomplete a form on Friday, describing the preceding week. The forms canbe collected by the parents and returned to the pediatrician for scoringand interpretation.
Testing. Cognitive and achievement testing can often be administeredthrough the school system at no charge to the family. These tests are mosthelpful in excluding specific learning disability as an underlying or concurrentcause of inattention. In our evaluation program, each adolescent is alsogiven a structured neurodevelopmental examination that includes four attentioncheckpoints, the PEERAMID II.11This examination can establishthe existence of uneven neuro-maturation associated with learning disabilities,and the four ratings of attention often suggest a diagnosis of ADHD.
Blood and urine tests, chromosome analysis, neuro-imaging studies, andelectroencephalograms should be ordered only when suggested by specificclinical indicators in the history or physical examination. If a trial ofmedication is being considered for a sexually active adolescent female,the pediatrician should first obtain a pregnancy test and offer contraceptivecounseling. The safety of stimulants during pregnancy has not been adequatelytested, and they should be used with caution in young women.
The treatment of ADHD should be multimodal, including medication, educationalinterventions, and counseling. In addition, treatment must be simultaneouslyinstituted for any co-morbid condition that has been identified. Parentsand school officials often focus on medication alone, while adolescentsmay see medication as the least desirable option. For this reason, we usuallydefer the mention of medication to the end of the session in which treatmentis discussed. All involved should be told that treatment recommendationsare a "package deal," not a set of options to choose among.
We sometimes use the analogy of a three-legged stool to illustrate theimportance of medical, educational, and psychological treatments. One canmaintain balance for a short time on a one-legged or two-legged stool, buta fall is almost inevitable. With all three "legs" in place, long-termstability is more likely.
Few psychoactive medications can rival stimulants for their proven recordof safety and efficacy over time.18 They are the hallmark ofmedical management of ADHD, and all appropriate varieties should be triedbefore going to second or third line choices. The psychostimulant medicationsmost commonly used to treat ADHD are dextroamphetamine and methylphenidate.Before beginning a trial of either of these, however, the diagnosis of ADHDshould be securely established. Basing a diagnosis on a positive responseto medication is a fairly common mistake, as individuals without the disordermay show improved learning, at least temporarily, when placed on stimulants.
Before we write a prescription for medication, we explain the relativebenefits and risks of stimulants and then ask the family to go home andtalk it over before reaching a decision. This avoids the risk of adolescentsfeeling pressured into taking medication and increases the likelihood ofcompliance when a trial is begun.
The potential benefits of medication include improvement in symptomsof inattention, distractibility, impulsivity, and hyperactivity. Potentialrisks are for the most part immediately apparent and readily reversible.They include headache, dysphoria, upset stomach, loss of appetite, and sleeplessness.19Teens should take the initial dose of medication on a day when they don'thave to go to school, to minimize the impact of side effects if they appear.
Stimulants are unlikely to suppress growth during adolescence. Tics,however, are a more significant potential side effect. While they occurin a small percentage of patients and are usually transient, they can becomechronic.20 There have been rare reports of abuse of stimulantmedication in the medical literature.21
To minimize loss of appetite, stimulants should be taken with meals orsoon thereafter and avoided just before supper when possible. To preventsleep disturbance, only a short-acting form, in the smallest possible dose,should be taken after supper. When treating adolescents, afternoon and eveningdoses are usually necessary for successful completion of homework.
Dextroamphetamine is available in both tablets (5 and 10 mg) and spansules(5, 10, and 15 mg). Length of action varies from three to four hours forthe tablet form and six to eight hours for the spansule. A new form (Adderall)includes a mixture of amphetamine and dextroamphetamine in strengths of5, 10, 20, and 30 mg. A common starting dose of dextroamphetamine for anadolescent is one 10 mg capsule just before school, and a second capsuleat the end of the school day. For students who spend a significant partof the evening doing homework, a 5 mg tablet after the evening meal maybe helpful.
Methylphenidate (Ritalin) comes in both short-acting (5, 10, and 20 mg)and sustained-release (SR) forms (20 mg). Methylphenidate is the most commonlyprescribed stimulant for treatment of ADHD. A common starting dose for anadolescent is 20 mg SR before and after school. A rough guide to dosingis that 10 mg of dextroamphetamine is equivalent to about 20 mg of methylphenidate.
Pemoline (Cylert) comes in 18.75, 37.5, and 75 mg tablet forms. An adolescentdose would be either 37.5 or 75 mg in the morning, with smaller doses laterin the day. Recent reports of hepatic toxicity have greatly reduced enthusiasmfor this drug, and liver function studies should be obtained at baselineand periodically thereafter whenever it is used.
Modest increases in these doses may be needed after instituting stimulantmedication. Once a therapeutic dose has been found, it is likely to remainstable over time, except at puberty, when rapid acceleration in physicalgrowth may require an adjustment. Otherwise, stimulant drugs tend to havea "threshold" effect at moderate doses.22 Increasesprovide little additional benefit but make side effects more likely. Forthat reason, when pharmacologic treatment seems to be ineffective, the besttactic is to resist the temptation to escalate dosages and carefully reconsiderthe diagnosis. When parents or teachers request increases in medication,they may be targeting symptoms like lying, stealing, or fighting that signala second diagnosis and are unlikely to respond to stimulant medications.
Drug holidays. Questions often arise about the necessity of taking medicationon weekends and during school vacations. As a rule, adolescents who areprimarily inattentive may need to take medication only when in school ordoing homework. They should be counseled, however, that medication takenbefore sports participation may improve their performance and that dailymedication is essential if they drive a car. Teens with ADHD who are impulsiveor hyperactive should also take medication daily to avoid difficulties withsocial interactions.
As part of their pursuit of autonomy, adolescents with ADHD should beencouraged to take responsibility for remembering to take their medication.Pediatricians can suggest helpful strategies, such as placing a remindernote on the bathroom mirror. If the adolescent controls the medicine bottle,which should be permitted only during the latter part of adolescence, parentsmust provide careful monitoring.
Pre-arranged drug holidays may enhance compliance.They should take placeduring the final month or two of school, several weeks before final examinations.The adolescent should be told to discontinue medication for one week andschedule an appointment just after that. If symptoms reappear during the"holiday," the importance of taking medication is reinforced.If there is little change, and school performance has been good, discontinuationof the medication may be considered.
Second-line medications. In addition to stimulants, other medicationsare sometimes used in the treatment of ADHD. Pediatricians should considerpsychopharmacologic consultation, if available, before using these otheroptions. Clonidine is indicated for marked symptoms of impulsivity.19It often "lengthens the fuse" in individuals who act out inappropriately.Vital signs should be monitored closely during the initiation of therapy,as hypotension is a possible side effect. Clonidine should be used verycautiously in any adolescent who is noncompliant or depressed. Tricyclicantidepressants may also be considered in young people who cannot toleratestimulants.23 Evidence for use of newer antidepressant drugs,such as fluoxetine and bupropion, comes largely from nonblinded trials andcase reports.
Students with ADHD may need both classroom accommodations and remedialservices. Pediatricians should work closely with teachers and other schoolofficials to develop an appropriate plan. Common strategies include preferentialseating toward the front of the class and check-ins with the teacher afterclassto be sure homework assignments have been accurately recorded. Someadolescents with ADHD also need extra time to complete tests. Most adolescentsdo not wish to be singled out from their peers by taking tests in a separateresource room and should be allowed to return at the end of the school dayto finish tests. Students who are significantly behind grade level in aspecific academic area like reading or mathematics will also need remedialassistance to catch up. This usually requires a certain amount of time ina specialized remedial program. Resource rooms or learning centers, withsmall class size and enhanced structure, may also be best for students whoare excessively impulsive or hyperactive.
Organizational coaching. All adolescents with ADHD should receive coachingin how to organize their school work. The best coach is usually a teacherthe student likes who is available for five minutes each day after schooland for 15 to 20 minutes once each week. The five-minute check-ins are fora daily review of homework assignments. Are they all recorded in an assignmentbook? Does the student have a realistic and logical plan for getting thework done? The once-a-week check is for a review of long-term assignments,which are increasingly common in the upper grades. What steps need to betaken to get this project done on schedule? Which steps were completed duringthe past week? Which are planned for the next week?
Electronic tools. Because they are so easily distracted, adolescentswith ADHD have difficulty remembering information.24 Hand-heldelectronic organizers are inherently more interesting than traditional notebooksand therefore more likely to be used. The use of computers should be encouragedat home and school. Word processing programs allow for repeated correctionsof written text, easy reorganization of the document, and automatic spell-checking.The neatness of a final product free of multiple erasures and cross-outsimpresses teachers. Judicious use of electronic calculators should alsobe considered. They are particularly appropriate for students who have alreadylearned basic math facts but make careless errors when performing calculations.
Tutors. If a teacher cannot be found to act as an organizational coach,parents should be advised to consider using tutors at home. Special educatorsare relatively expensive and not always available to come to the home, butthey are well qualified to teach the organizational strategies an adolescentneeds for educational success. A student or peer tutor, on the other hand,can be located by talking with the high school guidance counselor or facultyadvisor to the National Honor Society, Future Teacher's Club, or a similarorganization. When the adolescent is shy about working with someone fromhis or her own school, parents should try to recruit from a nearby townor local college.
Whatever approach they decide to take, parents must resist the temptationto take on this role themselves. This is a common mistake and a source ofintense parent/ adolescent conflict that only worsens the teenager's problems.Pediatricians can help by reminding parents of the adolescent's need forautonomy, and explaining that parents are too important to teenagers towaste their time and influence on being the "homework police."They should save their strength for more important tasks, like helping theirson or daughter navigate the complexities of adolescent social and sexualdevelopment and supporting the young person's self-esteem when school becomesstressful.
The pediatrician should provide initial psychoeducational counselingor "demystification" to adolescents with ADHD and their parents.The family needs to be told what ADHD is and is not and directed to othereducational resources such as books and support organizations. Individualcounseling for the adolescent may also be helpful. When a referral seemsnecessary, seek out a mental health professional who offers both emotionalsupport and a cognitive-behavioral approach to self-management. In someareas, group therapy may be available for adolescents with ADHD, learningdisabilities, and problems with social skills, self-esteem, and other relevantissues.
Help for families. Family counseling is an essential component of treatment.The best therapist for this purpose is one who can educate parents aboutADHD and teach them new strategies for managing adolescent behavior. Siblingsshould be encouraged to participate in family therapy sessions. Some parentswill need treatment for their own psychological problems.
Anticipatory guidance about driving. As pedestrians or bicycle riders,teenagers with ADHD are more likely than age-mates without ADHD to be injuredin traffic accidents.25 When teens with ADHD are in the driver'sseat, they are more likely than other teens to be cited for speeding, tohave their licenses suspended, to be involved in crashes, and to have crashesinvolving bodily injury.23 Pediatricians should share this informationwith adolescent patients before they obtain a driver's license and consideradvising against driving when the adolescent is not compliant with treatmentor has a poorly controlled co-morbid impulse-control disorder. In all cases,adolescents with ADHD should be given guidance on the importance of takingtheir medication and minimizing distractions while driving. They shouldbe told not to use cell phones, eat or drink, adjust the car radio, or engagein conversation while operating a motor vehicle.
The degree to which ADHD symptoms will persist into adult life is unknownfor an individual patient, but there is little question that children andteens who have been diagnosed with ADHD are at increased risk for socialand behavioral problems as adults. Hyperactive boys, for example, are atsignificantly higher risk for antisocial personality and substance-abusedisorders as teenagers and adults.26 It is particularly importantto convey to parents and teachers that it is ADHD itself--and not the stimulantmedication used to treat ADHD--that puts teens at risk for addiction. Thereis no evidence to support the notion that stimulant medication causes addiction.24Treatment may, in fact, lessen the risk by improving school performanceand helping preserve self-esteem.
Adolescents with ADHD should be advised that they will probably needsome type of treatment throughout their formal education (including collegeand graduate school) and possibly further into adult life. They should beclosely monitored for other psychiatric disorders, so that prompt treatmentcan be provided. Pediatricians should offer either to continue care of thesepatients or to arrange for transition to an adult medical clinician knowledgeableabout ADHD when the patient reaches an agreed-upon age.
DR. KNIGHT is Director, Young Adult Team Program, Department of Pediatrics,Harvard Medical School and the Division of General Pediatrics, Children'sHospital, Boston.
DR. RAPPAPORT is Director, Developmental and Learning Programs, Departmentof Pediatrics, Harvard Medical School and Children's Hospital, Boston.
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