Attention-Deficit/Hyperactivity Disorder, Teen

Definition

Attention-Deficit/Hyperactivity Disorder is a neurobehavioral disorder characterized by a combination of inattention, hyperactivity, and impulsive behavior. Symptoms include difficulty sitting still, problems maintaining attention on school or homework, and responding before thinking. Hyperactivity symptoms can include being fidgety, restless, and talking or interrupting others excessively.

ADHD appears early in life. It is estimated that 5 percent of school-age children and 2.5 percent of the adult population are diagnosed with ADHD, according to the DSM-5. Boys are diagnosed twice as often as girls. Teens with ADHD have difficulty sitting still and paying attention in class and may not do well in school, even when they have normal or above average intelligence. More than half of children diagnosed with ADHD continue to have symptoms during adolescence and adulthood. Symptoms of ADHD can be treated effectively with a combination of medication and therapy. When left untreated, however, ADHD can have long-term adverse effects on academic performance, vocational success, relationships, and social-emotional development.

Symptoms

According to the DSM-5, ADHD is diagnosed when a teen experiences six or more of the following symptoms. If they are 17 or older, they need to experience just just five symptoms. The symptoms must persist for six months and be severe enough to negatively impact academic or social functioning. They must also be inconsistent with the teen's developmental level, and not be attributable to other mental disorders such as an anxiety disorder, mood disorder, or personality disorder. The teen should have exhibited several of these symptoms prior to age 12.

Symptoms of inattention include:

  • Making careless mistakes, overlooking details
  • Difficulty remaining focused on tasks or conversations
  • Being easily distractible
  • Difficulty following through on instructions or assignments
  • Difficulty organizing tasks and activities
  • Avoidance or refusal of activities that require sustained attention (reports, forms, papers)
  • Losing things frequently
  • Being forgetful of daily activities (appointments, chores)

Children with the inattentive type of ADHD, characterized by the symptoms above, are less disruptive and are often not diagnosed.

Symptoms of Hyperactivity and Impulsivity include:

  • Frequent fighting, squirming, tapping
  • Often leaving seat when remaining seated is expected
  • Feeling overly restless
  • Difficulty being still for an extended period of time
  • Difficulty engaging in leisure activities 
  • Talking excessively
  • Preemptively blurting out answers to questions
  • Difficulty waiting for a turn
  • Intruding or interrupting others

The combined inattentive/hyperactivity type of ADHD displays equal, predominant symptoms of inattention and hyperactivity. This is the most common type of ADHD among children and adolescents.

The predominantly inattentive type displays symptoms of inattention but fewer than six hyperactivity/impulsivity symptoms.

The predominantly hyperactive-impulsive type displays criteria for hyperactivity/impulsivity symptoms but fewer than six inattentive symptoms.

Every teen suspected of having ADHD deserves a careful evaluation both to distinguish between ADHD and ADHD-like symptoms commonly seen in other psychiatric and medical conditions and to determine if some situational or environmental stressors may be creating symptoms similar to those of ADHD. Psychiatrists, psychologists, pediatricians, neurologists, and clinical social workers most often are trained in providing an evaluation and diagnosis of mental disorders and ruling out other reasons for the teen's behavior.

Possible causes of ADHD-like behavior include a sudden change in the teen's life, the death of a parent or grandparent, parents' divorce, a parent's job loss, undetected seizures (such as petit mal or temporal lobe seizures), a middle-ear infection that causes intermittent hearing problems, medical disorders that may affect brain functioning, underachievement caused by learning disability, anxiety, and depression.

A thorough evaluation should include a clinical assessment of the individual's performance in academic and social settings, emotional functioning, and developmental abilities. Additional tests may include intelligence tests, measures of attention span, and parent and teacher rating scales. A medical exam by a physician is also important. A doctor may look for allergies or nutrition problems like chronic caffeine highs that might make the teen seem overly active. The assessment may also include interviews with the teen's teachers, parents, and other people who know the teen well.

Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most teens with ADHD are able to control their behavior and perform well.

Causes

Health professionals are still unsure what causes ADHD. It may be a genetically determined disorder, as attention disorders often run in families. Studies indicate that 25 percent of close relatives in the families of children with ADHD also have the condition, whereas the rate is about 2.5 percent in the adult population. Many studies of twins now show that a strong genetic influence exists in the disorder.

Recent studies show that ADHD is caused by neurobiological dysfunction. Scientists using neuroimaging and brain scanning tools have demonstrated a link between a person's ability to maintain attention and the level of activity in the brain. For example, scientists have found differences between the frontal lobes of individuals who have ADHD and those who do not.

Current research is exploring the structure of the brain to determine if there are differences that might indicate a physical basis for ADHD.

There is correlating evidence between the use of cigarettes and alcohol during pregnancy and the risk for developing ADHD in the unborn child. These substances may endanger the fetus' developing brain. It is best to refrain from smoking, alcohol, and other drugs during pregnancy, as they may distort developing nerve cells.

Toxins in the environment may also disrupt brain development or brain processes, which may lead to ADHD. Lead is one possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline or paint were once used. It is also present in some older water pipes.

There is little evidence that ADHD stems from the home environment. Researchers report that not all teens from unstable or dysfunctional homes have ADHD, and not all teens with ADHD come from dysfunctional families. Scientists have also found no real evidence that head injury, undetectable damage to the brain, early infection, or complications at birth cause ADHD.

Researchers have found that refined sugar and food additives do not generally make children hyperactive and inattentive. In 1982, the National Institutes of Health concluded that diet restrictions seemed to help about 5 percent of children with ADHD, but these were mostly young children with food allergies.

Treatments

Every family wants to determine which treatment will be most effective for their teen. This question needs to be answered by each family in consultation with a health-care professional. To help families make this important decision, the National Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD and conducted one of the most intensive studies evaluating the treatment of this disorder, the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder.

The results of the study indicated that long-term combination treatments (medication and behavioral therapy) and medication management alone were superior to intensive behavioral treatment and routine community treatment. In some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children and teens could be successfully treated with lower doses of medicine.

No single treatment is the answer for every teen with ADHD. A teen may sometimes have side effects from a medication that would make that particular treatment unacceptable. And if a teen with ADHD also has anxiety or depression, a treatment combining medication and behavioral therapy might be best. Each teen's needs and personal history must be carefully considered.

Medications

For decades, medications have been used to treat the symptoms of ADHD. The medications that seem to be the most effective are a class of drugs known as stimulants. For many people, stimulants dramatically reduce hyperactivity and impulsivity and improve the ability to focus, work, and learn. The medications may also improve physical coordination, such as that needed in handwriting and in sports. Those commonly prescribed include Amphetamine/ Dextroamphetamine (Addreall), Dexmethylphenidate (Focalin), Lisdexamfetamine (Vyvanse), Methylphenidate (Concerta, Ritalin). It is important to work with the prescribing physician to find the right medication and the right dosage.

Stimulant drugs, when used with medical supervision, are considered quite safe. Stimulants do not make the teen feel high, although some children and teens say they feel different or funny. Such changes are usually very minor. Although some parents worry that their teen may become addicted to the medication, there is no convincing evidence that stimulant medications, when used to treat ADHD, cause drug abuse or dependence. A review of all long-term studies on stimulant medication and substance abuse, conducted by researchers at Massachusetts General Hospital and Harvard Medical School, found that teenagers with ADHD who remained on their medication as teens had a lower likelihood of substance use or abuse than did adolescents with ADHD who were not taking medications.

The stimulant drugs come in long- and short-term forms. The newer sustained-release stimulants can be taken before school and are long-lasting. The doctor can discuss the teen's needs with the parents and decide which preparation to use and whether the teen needs to take the medicine during school hours only or in the evening and on weekends too.

If the teen does not show symptom improvement after taking a medication for a week, the doctor may try adjusting the dosage. If there is still no improvement, the teen may be switched to another medication. About one out of 10 children is not helped by a stimulant medication. Other types of medication may be used if stimulants don't work or if the ADHD occurs with another disorder. Antidepressants and other medications can help control accompanying depression or anxiety.

Side Effects of the Medications

Most side effects of the stimulant medications are minor and are usually related to the dosage of the medication being taken. Higher doses produce more side effects. The most common side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. Some report mild stomachaches or headaches.

Appetite seems to fluctuate, usually being low during the middle of the day and more normal by suppertime. Adequate amounts of nutritional food should be available for the teen, especially at peak appetite times.

If the teen has difficulty falling asleep, there are several options to consider, such as a lower dosage of the stimulant, taking the stimulant earlier in the day, discontinuing the afternoon or evening dosage, or giving an adjunct medication, such as a low-dosage antidepressant or clonidine.

A few develop tics during treatment. Changing the medication dosage can often lessen these.

A very few cannot tolerate any stimulant, no matter how low the dosage. In such cases, the teen is often given an antidepressant instead of the stimulant.

When a teen's schoolwork and behavior improve soon after starting medication, the teen, parents, and teachers tend to credit the drug for the sudden changes. Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But medications don't cure ADHD; they only control the symptoms on the day they are taken. Although the medications help the child pay better attention and complete schoolwork, they can't increase knowledge or improve academic skills. The medications help the teen use those skills he or she already possesses.

Behavioral therapy, emotional counseling, and practical support will help ADHD teens cope with everyday problems and feel better about themselves.

Facts to Remember About Medication for ADHD

  • Medications for ADHD help many children and teens focus and be more successful at school, home, and play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.
  • About 80 percent of children who need medication for ADHD still need it as teenagers.
  • Over 50 percent need medication as adults.

Psychosocial Treatments

Medication can help with ADHD in everyday life. Teens may be able to better control some of the behavior problems that have led to trouble with parents and siblings. But it takes time to undo the frustration, blame, and anger that may have gone on for so long. Both parents and children may need special help to develop techniques for managing the patterns of behavior, including the development of new skills, attitudes, and ways of relating to each other. In individual counseling, a therapist helps children and teens with ADHD learn to feel better about themselves, help them to identify and build on their strengths, cope with daily problems, and control their attention and aggression. Sometimes only the teen with ADHD needs counseling support, but because the problem affects the family, in many cases, everyone may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors, promote change, and teach parents techniques for coping with and improving their teen's behavior.

Several intervention approaches are available.

Psychotherapy helps people with ADHD to like and accept themselves. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change.

Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping a teen learn how to think through tasks and organize his or her schoolwork. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way.

Social-skills training can also help a teen learn new behaviors. In this training, the therapist discusses and models appropriate behaviors like waiting for a turn, asking for help, or responding to teasing, then gives the teen a chance to practice. For example, a teen might learn to read other people's facial expression and tone of voice in order to respond more appropriately. Social skills training can help teach how behavior affects others and develop new ways to respond when angry or upset.

Support groups help parents connect with others who have similar problems and concerns with their ADHD children. Members share frustrations, successes, referrals to qualified specialists, and information about what has been effective, as well as their hopes for themselves and their children. There is strength in numbers, and sharing experiences with others who have similar concerns helps people know that they aren't alone.

Structured situations may help teens with ADHD by:

  • Limiting distractions in the teens' environment
  • Providing one-on-one instruction with the teacher
  • Ensuring the teen gets enough sleep
  • Ensuring the teen gets a healthy, varied diet, with plenty of fiber and basic nutrients
  • Helping the teen divide a large task into small steps if the teen has trouble completing tasks, and then praising the teen as each step is completed

It is beneficial for parents to use stress management methods, such as meditation, relaxation techniques, and exercise to increase their own tolerance for frustration so that they can respond more calmly to their teen's behavior.

The American Academy of Pediatrics has provided guidelines for treating children and teens with ADHD.

  • Set specific target goals to guide therapy
  • Medication and/or behavior therapy should be started
  • When treatment plan has not met target goal, re-evaluate the original diagnosis, the possibility of other conditions, and how well the treatment plan has been implemented
  • Systematically follow up; regularly reassess target goals, results, and any side effects of medications. Information should be gathered from parents, teachers, and the child/teen.

Your ADHD Teen and Education

You are your teen's best advocate. To be a good advocate for your teen, learn as much as you can about ADHD and how it affects your teen at home, in school, and in social situations.

Teens with ADHD have a variety of needs. In order to assess these needs, the special-education teacher, along with the parents, the school psychologist, school administrators, and the classroom teacher, must assess the teen's strengths and weaknesses and design an Individualized Educational Program (IEP). The IEP outlines the specific skills the teen needs to develop as well as appropriate learning activities that build on the teen's strengths. Parents play an important role in the process. They must be included in meetings and given an opportunity to review and approve their teen's IEP. Some children may be placed in a special education class for all or part of the day. However, most children are able to stay in the regular classroom and learn along with their peers. Special accommodations may be used in order to assist the teen with ADHD to function in a regular classroom.

In general, children with ADHD are fully capable of learning, but their hyperactivity and inattention make learning difficult. As a result, some students with ADHD repeat a grade or drop out of school. Fortunately, with the right combination of appropriate educational practices, medication, and counseling, these outcomes can be avoided.

ADHD Teens: Right to a Free Public Education

Individuals with ADHD or other disabilities are entitled to a free and appropriate public education (FAPE), including special education services that are guaranteed by two federal laws: The Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). IDEA requires that a student must first qualify for special education, according to the following criteria:

  1. The student must be diagnosed with ADHD by either the school district or a qualified professional
  2. The severity of ADHD must increase the student's sensitivity to his or her surroundings and impair alertness to academic tasks
  3. The effects of ADHD must have a significant impact and/or be a long-standing condition
  4. ADHD must impair educational achievement in a manner that requires special educational services

The National Rehabilitation Act, Section 504, defines disabilities more broadly. Often called "504 Eligibility," it qualifies children that have a diagnosed physical or mental impairment that substantially limits learning and requires special education or related services. Children who need assistance in certain areas may qualify even if they do not need special education.

The Americans with Disabilities Act (ADA), Title II, requires that state and local governments give people with disabilities an equal opportunity to benefit from all of their programs, services, and activities (e.g., public education, employment, transportation, recreation, health care, social services, courts, voting, and town meetings). Title III has the same requirements for private, independent, and nonreligious schools. This act prohibits discrimination against otherwise qualified students who are limited by a disability such ADHD, and it requires that educational institutions that receive federal funds to provide academic and other adjustments so that students can avail themselves of courses, examinations, and other activities.

Private schools are required to facilitate participation in educational and other activities. However, they are not required to provide remedial services to improve skills in an area of disability.

Navigating the Teen Years with ADHD

Your child with ADHD has successfully navigated the early school years and is beginning his or her journey through middle school and high school. Although your child has been periodically evaluated through the years, this is a good time to have a complete re-evaluation of your child's health.

The teen years are challenging for most children; for the child with ADHD these years are especially hard. All the typical adolescent problems—peer pressure, the fear of academic and social failure, low self-esteem—are harder for the ADHD child to handle. The desire to be independent and try new things can lead to unforeseen consequences. The rules that once were for the most part followed are often now flaunted. Parents may not agree with each other on how the teenager's behavior should be handled.

Now more than ever, rules should be straightforward and easy to understand. Communication between the adolescent and parents can help the teenager know the reasons for each rule. When a rule is set, it should be clear why the rule is set. Sometimes it helps to have a chart, usually posted in the kitchen, that lists all household rules and all rules for outside the home (social and school). Another chart could list household chores with space to check off a chore once it is done.

When rules are broken—and they will be—respond to inappropriate behavior as calmly and matter-of-factly as possible. Use punishment sparingly. Even with teens, a time-out can work. Impulsivity and a hot temper often accompany ADHD, so a short time alone can help calm the situation.

As the teenager spends more time away from home, there will be demands for a later curfew and the use of the car. Listen to your child's request, give reasons for your opinion, listen to his or her opinion, and negotiate. Communication, negotiation, and compromise will prove helpful.

Your Teenager and the Car

Teenagers, especially boys, begin talking about driving by the time they are 15. In some states, a learner's permit is available at 15 and a driver's license at 16. Statistics show that 16-year-old drivers have more accidents per driving mile than any other age. In the year 2000, 18 percent of those who died in speed-related crashes were age 15 to 19. Sixty-six percent of these youths were not wearing safety belts. Youth with ADHD, in their first two to five years of driving, have nearly four times as many automobile accidents, are more likely to cause bodily injury in accidents, and have three times as many citations for speeding as young drivers without ADHD.

After looking at the statistics for automobile accidents involving teenage drivers, most states have begun to use a graduated driver licensing system (GDL). This system, developed by the National Highway Traffic Safety Administration and the American Association of Motor Vehicle Administrators eases young drivers onto the roads by a slow progression of exposure to more difficult driving experiences. The program consists of three stages: learner's permit, intermediate (provisional) license, and full license. Drivers must demonstrate responsible driving behavior at each stage before advancing to the next level. During the learner's permit stage, a licensed adult must be in the car at all times. This period of time will give the learner a chance to practice. The sense of accomplishment the teenager with ADHD will feel when the coveted license is finally in his or her hands will make all the time and effort worthwhile.

References

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Last reviewed 02/07/2019