Attention-Deficit/Hyperactivity Disorder, Teen
Attention-deficit/hyperactivity disorder is a neurobehavioral disorder characterized by a combination of inattention, hyperactivity, and impulsive behavior. In teenagers, symptoms related to inattention can include problems maintaining attention on school or homework, frequently losing important possessions, and struggling to organize or complete multi-step tasks. Hyperactivity symptoms can include being fidgety, restless, and talking or interrupting others excessively; teens may also struggle to manage impulsive or reckless behavior. Teens with ADHD may not do well in school, even when they have normal or above-average intelligence, or may struggle to navigate the more complex peer relationships that are a hallmark of adolescence.
ADHD typically appears early in life; per the DSM-5 definition, teens should show symptoms before age 12 in order to qualify for a diagnosis. According to the CDC, more than 9 percent of school-age children were diagnosed with ADHD in 2016; the prevalence in adults is estimated to be between 2 and 6 percent. In youth populations, boys are diagnosed twice as often as girls. More than half of children diagnosed with ADHD continue to have symptoms during adolescence and adulthood, though many find that their symptoms lessen in severity as they age.
Symptoms of ADHD can usually be treated effectively with medication, therapy, or a combination of the two. When left untreated, however, ADHD can have long-term adverse effects on academic performance, vocational success, relationships, and social-emotional development. Teens with ADHD may also engage in risky behaviors that have the potential to cause serious harm, such as driving dangerously or having unprotected sex. Thus, it's important to proactively manage problematic symptoms and encourage a teen to take ownership over their ADHD treatment.
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 five symptoms.)
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)
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 symptoms must persist for six months and be severe enough to negatively impact academic, occupational, or social functioning. They must also be inconsistent with the teen's developmental level, and not be attributable to other mental health or developmental disorders such as an anxiety disorder, mood disorder, or personality disorder. The teen should have exhibited several of these symptoms prior to age 12.
The combined 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 few or no hyperactivity/impulsivity symptoms. The predominantly hyperactive-impulsive type displays criteria for hyperactivity/impulsivity symptoms with few or no 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. 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 should also include interviews with the teen's teachers, parents, and other people who know the teen well.
Some families do find that ADHD symptoms appear to increase in severity during the teen years. This is likely due to a mix of hormonal changes, growing academic and extracurricular demands, and an increasing focus on peer relationships and social life, which can further distract a teen with ADHD from schoolwork and other demanding tasks. While these changes are usually temporary, if a teen’s symptoms worsen significantly and begin to interfere with their quality of life, treatment may need to be adjusted to compensate.
Because ADHD can manifest as impulsivity, recklessness, or distractibility, evidence does suggest that teens with untreated ADHD are more likely than their peers to speed, drive without a seat belt, and be involved in car accidents. One study, for example, found that new drivers with ADHD were 62 percent more likely to be in a car accident in their first month of driving than peers without ADHD. On the other hand, research conducted on adults suggests that adequate treatment greatly reduces the risk of ADHD-related car accidents.
Evidence does suggest that teens with ADHD are more likely than their peers to abuse alcohol or other drugs. For example, one twin study found that teens with ADHD started drinking alcohol and using marijuana significantly earlier than their peers, on average, and were also more likely to escalate to heavy use. The link between ADHD and substance abuse is theorized to be due to impulsivity, poor judgment, genetic vulnerability, and/or because substances may serve as a coping mechanism for problems in school or difficulties getting along with peers. Just because a teen has ADHD, however, does not mean he is destined to misuse substances. Open communication with parents, healthy alternative activities, and appropriate ADHD treatment can all reduce the risk of problematic drug and alcohol use during adolescence and young adulthood.
ADHD is thought in large part to be a genetically determined disorder, as studies indicate that 25 percent of close relatives in the families of children with ADHD also have the condition (compared to 2-6 percent in the adult population overall). Many studies of twins now show that a strong genetic influence exists in the disorder.
Environmental factors likely play a key role as well. There is correlating evidence, for example, 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.
Toxins in the environment may also disrupt brain development or brain processes, which may lead to ADHD. Lead is one possible toxin under investigation for its ties to ADHD. 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—though experts caution that dysfunctional parenting may exacerbate symptoms in ADHD, it does not appear to cause it. Despite popular claims that sugar causes 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.
Scientists have found differences between the frontal lobes of individuals who have ADHD and those who do not. What’s more, 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.
Puberty cannot cause ADHD. But it may intensify its symptoms, largely due to dramatic hormonal shifts that teens experience. Increases in testosterone, for example, may push teen boys to take more risks or partake in dangerous behavior. Changes in progesterone and estrogen lead to heightened moodiness in many teen girls; in girls with ADHD, these mood swings may be even more intense or may worsen problems of inattention or distractibility. Some girls also report that their symptoms wax and wane with their menstrual cycles, which can be confusing and frustrating. Many parents find that their teen’s medication seems to lose efficacy during the teen years, likely due to changing body compositions and hormonal makeup. Teens may also resist or refuse medication during this time, often out of concerns of seeming “different” from their peers. Inconsistent medication use could further worsen symptoms.
Per the DSM-5 criteria, teens must have demonstrated symptoms before the age of 12 to qualify for an ADHD diagnosis. If a teen older than 12 suddenly starts displaying ADHD-like symptoms, it may be that symptoms were missed during childhood or flew under the radar because they did not interfere significantly with a child’s functioning. It’s also possible that another cause, such as a stressful life event or another psychiatric disorder, underlies the teen’s sudden inattention or hyperactivity. A teen who starts displaying ADHD symptoms should be evaluated by a medical professional to determine the underlying cause.
Possible causes of ADHD-like behavior—such as sudden recklessness or difficulty paying attention in school—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.
It does appear to be possible for a teen to seemingly “outgrow” their ADHD. Approximately 60 percent of children with ADHD will continue to display diagnosable symptoms in adolescence or adulthood; the rest, however, may see symptoms decrease in severity or even disappear altogether. Regularly reevaluating symptom severity and treatment outcomes can help parents track how their teen’s ADHD changes with age.
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 healthcare 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 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 medication.
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. 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 when deciding on a treatment plan.
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 (sold under the brand names Adderall and Mydayis), dexmethylphenidate (Focalin), lisdexamfetamine (Vyvanse), and methylphenidate (sold as Ritalin, Quillivant, Daytrana, QuilliChew, Concerta, and others).
Stimulant drugs, when used with medical supervision, are typically considered very safe. Stimulants should not make the teen feel “high,” although some children and teens say they feel different or funny. Such changes are usually minor, or they may signal that the dose is too high. 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.
Stimulants come in long- and short-term forms. The newer sustained-release stimulants can be taken before a teen begins their school day 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 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 ADHD occurs with another disorder. Nonstimulant medications, which include atomoxetine (sold under the brand names Strattera), guanfacine (Intuniv), and clonidine (Kapvay) may be used if stimulants are ineffective or contraindicated for a particular patient. Antidepressants and other medications can also be used, and may help control accompanying depression or anxiety in addition to ADHD. Regardless of the class of drug, it is important to work with the prescribing physician to find the right medication and the right dosage.
Side Effects of Medications
Most side effects of the stimulant medications are minor and are usually related to the dosage of the medication being taken. Higher doses tend to produce more side effects; the goal of medication management should be to find a drug and dose that best controls symptoms and that doesn't come with intolerable side effects. The most common side effects of stimulant medications are decreased appetite, insomnia, increased anxiety, and/or irritability. Some report mild stomach aches or headaches.
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. In some cases, taking an additional dose at bedtime may actually help, as some teens find that their racing minds are calmed by their stimulant.
A few teens develop tics during treatment. Changing the medication type or dosage can often lessen these. Some teens cannot tolerate any stimulant, no matter how low the dosage. In such cases, the teen is often given a nonstimulant or an antidepressant instead of the stimulant; they may also decide to pursue non-medical treatment options such as behavior therapy.
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 help 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. Rather, 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.
Medication can help with ADHD in everyday life. Teens may be able to better control some of the behavior that has led to trouble with parents and siblings.
But it takes time to undo the frustration, blame, and anger that can often come with untreated ADHD and that may have damaged a teen's self-esteem. 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, helps 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, for example, helps people with ADHD learn 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 expressions and tone of voice to respond more appropriately. Social skills training can help teach how behavior affects others and develop new ways to respond when angry or upset.
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.
When it comes to navigating ADHD-related academic challenges, arents are often their teens’ best advocates. Parents who wish to advocate effectively for their teen are advised to learn about ADHD and how it might affect their teen at home, in school, and in social situations.
Teens with ADHD can have a variety of academic needs. To assess these needs, the special-education teacher, along with the parents, the school psychologist, school administrators, and the classroom teacher may work together to assess the teen's strengths and weaknesses; once they've done so, they may recommend a 504 plan, an Individualized Educational Program (IEP), or less formalized assistance.
A 504 plan or IEP will typically outline 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 are often included in meetings and given an opportunity to review and approve their teen's special education plan. Depending on the nature of their challenges, some children with ADHD may be placed in a special education class for all or part of the day. However, many children with ADHD are able to stay in the regular classroom and learn along with their peers. Special accommodations may be used 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 can 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.
In addition to medication, therapy, and/or in-school accommodations, parents can help teens with ADHD by limiting distractions in the environment; ensuring the teen gets enough sleep; feeding the teen a healthy, varied diet, with plenty of fiber and basic nutrients; and helping the teen divide large tasks into small steps if the teen has trouble completing tasks, and then praising the teen as each step is completed. They can also simply listen to their teen and provide emotional support. Being a teen is hard with or without ADHD, and active, empathetic parents can help teens feel understood, supported, and valued in a world that may not always embrace their idiosyncrasies.
It’s common for teens with ADHD to suddenly refuse to take a medication that they’ve taken for years. In many cases, this is due to a natural adolescent desire to fit in; having ADHD, or taking medication for it, may make a teen feel flawed or different from her peers. Teens may also refuse medication in a bid for independence, or due to legitimate concerns about side effects or other health-related problems. Regardless of their motivation, experts usually recommend that parents not unilaterally force medication on teens. Instead, it’s advised to talk with them openly and without judgment to determine the motives for their refusal. Validating their concerns, and making an effort to adjust treatment as needed, can help teens feel heard, supported, and as if they have some autonomy over their medical care. Some experts also recommend allowing a teen to go off medication for brief periods so she can observe how her symptoms are affected. If she finds that her symptoms are truly manageable without medication, stopping it may indeed be in her best interest; if not, she may realize on her own that the pros of medication outweigh the cons. In some states, teens do have a legal right to refuse medical treatment; most parents, however, find that working with their teen collaboratively and allowing them to take ownership of their ADHD treatment reduces their discomfort with taking medication.
Individuals with ADHD or other disabilities are entitled to what’s known as a free and appropriate public education (referred to by the acronym 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). Disability is very specifically defined in IDEA, and many teens with ADHD alone may not meet criteria; teens with comorbid conditions, however, such as autism or physical disabilities, may qualify under IDEA. Section 504 of the National Rehabilitation Act, on the other hand, 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 for a 504 plan even if they do not need special education under IDEA.
Not every teen with ADHD will qualify for special education under IDEA. To do so, he or she must meet 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; and 4) ADHD must impair educational achievement in a manner that requires special educational services.
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 as ADHD, and it requires that educational institutions that receive federal funds 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.