With the diagnosis of ADHD on the rise in American teenagers, there is a risk of mislabeling teens with ADHD when the cause of their inattentiveness and falling grades may be related to something else entirely—like anxiety, family issues, or their media-infused lifestyle. This misdiagnosing was especially striking to me with a sixteen-year-old girl named Joy, whose family came to consult me a few months ago.
Up until last year, Joy was a straight A student. All of her high school classes were either honors level or Advanced Placement (AP). But in the fall of her junior year, Joy seemed to lose her motivation to do well in school. Her grades began to slip to C’s then to D’s until finally she was close to failing two classes. She also showed signs of depression—low energy, insomnia, and lack of motivation. Joy’s parents suggested that she consult a psychiatrist and she agreed. Their family doctor referred them to a prominent psychiatrist.
The psychiatrist prescribed first Zoloft then Wellbutrin for Joy, hoping to find a drug that would help her depression. He also prescribed Adderall for what he believed was the ADHD that was keeping Joy from focusing at school. After four months, nothing was helping. Joy could scarcely get out of bed in the mornings and get herself to school. Fortunately, she was on the school tennis team and this motivated her to get herself to school most days. But even with the exercise, Joy complained of low energy and sadness. Finally, her psychiatrist prescribed Clozapine—an antipsychotic drug typically prescribed for treatment of bipolar disorder and schizophrenia.
After five months, there was still no improvement in Joy’s symptoms. Her grades were so low that she was in danger of failing two classes. Her parents, previously worried about Joy getting into the best Ivy League college, were now concerned that she wouldn’t graduate high school. A friend of Joy’s mother suggested that they try family therapy. Both parents were scientists and they were skeptical about the benefits of a type of therapy they did not understand. But they couldn’t bear to watch their daughter suffer and finally called me for an appointment.
My first question to the family was to ask when Joy’s depression began. Without blinking an eye, Joy told me that it began "about six months ago" when her parents “were quarreling almost every day.” How extraordinary, I reflected. If only every teenager would give me the key to their problem in the first few minutes of therapy. Joy’s parents told me that on the advice of Joy’s psychiatrist and the school counselor, Joy had dropped her AP and honors classes. The parents had stopped pressuring her about doing her homework or getting into an elite college. As the story unfolded, Joy wept silently.
As with most teenagers, the therapy had to be conducted on two levels. I had to solve the family system problem by meeting with the parents privately and getting them to stop quarreling, and I had to resolve Joy’s depression, anxiety and insomnia. Fortunately, the parents were scientists and were able to understand how systems worked—with effects not always resembling causes. Although they resisted at first, they eventually accepted that their arguing was affecting their daughter. They admitted that they had occasionally mentioned divorce, but only in the heat of anger. They promised to keep their fights away from the house where Joy could hear them.
One of their main concerns was that Joy stayed up until two in the morning on the Internet and was therefore too tired to get up in the morning. They were afraid to limit the Internet because, on the advice of the psychiatrist, they didn’t want to put any pressure on Joy.
Strangely enough, when I met with Joy she confessed that she thought she was “addicted” to the Internet. She knew that she needed limits on the amount of time she spent on the Internet at night. In a family session, I was able to negotiate a compromise. Her father would turn off the Internet at 9:30 PM to help her overcome her addiction. In return, her parents would stop bugging her about starting her homework after school.
Once the Internet issue was settled, I worked with Joy alone to help her with her fear of death and other anxieties. After our second meeting, she stopped weeping through the session. Her parents had stopped quarreling, she told me. For her anxiety, I asked her to spend a half hour each day in her room conjuring up her worst fears. After the allotted time, she could stop and go about her day. I also asked her to keep track of her fears in a small notebook, which we would then discuss in therapy. I saw her every two weeks, and her fears gradually dissipated. Since the fears were what had been keeping her awake at night, she was sleeping better now as well. Joy’s grades began to improve. She would have to repeat one class in summer school, but was passing all the rest of her classes.
Joy’s problems were not ADHD or clinical depression, even though her symptoms might have fit the DSM-4 or DSM-5 criteria for both conditions. Her problems were anxiety triggered by family issues and spending too much time on the Internet at night because she was too worried to sleep. A therapist cannot get to these kinds of problems by going through a checklist of criteria for ADHD or depression. The best way to resolve Joy’s problems was not an endless series of medications but eight sessions of carefully targeted family therapy. Joy was not able to focus not because of a biological dysfunction in her brain, but because of a stressful family situation.
With the explosion of ADHD diagnoses among American teenagers, as clinicians we should not be too quick to attribute all of a teen’s school problems to a yet unknown biological cause. Although family therapy takes more time than a quick fix of stimulants, it is a safer, more effective and less expensive solution in the long term.
Copyright Marilyn Wedge, Ph.D.
Marilyn Wedge is the author of Pills Are Not for Preschoolers: A Drug Free Approach for Troubled Kids