Pediatric Annals

Attention-Deficit/Hyperactivity Disorder in Adolescents

Arthur L Robin, PhD

Abstract

Approximately 78% of children with attention deficit /hyperactivity disorder (ADHD) continue to display die full clinical syndrome in adolescence.1-2'3 Although physical hyperactivity may diminish, inattention and impulsivity persist, creating greater impairment as school and home environments become more demanding. Teenagers with ADHD are more likely than non-ADHD teens to have failed a grade, been suspended or expelled, scored lower on achievement tests, or dropped out of high school.1 They are more likely to have increased conflict, negative communication and distorted beliefs in their relationships with their parents, particularly when they are also diagnosed with oppositional defiant disorder.4

ADHD in adolescents is also associated with high-risk behavior. Adolescents with ADHD have worse driving habits, more accidents, and have received more tickets than their non-ADHD counterparts.5 They have an earlier age of first sexual intercourse, more sexual partners, less use of birth control, more sexually transmitted diseases, a greater frequency of testing for human immunodeficiency virus (HIV), and more teen pregnancies than non-ADHD individuals.6 In adolescents with ADHD 59% to 65% also have oppositional defiant disorder, 22% to 43% have conduct disorder, 29% manifest major depressive disorder, 11% have bipolar disorder, and 27% manifest multiple anxiety disorders.7

Children presenting with the classic picture of the hyperactive child usually have been diagnosed before they reach adolescence. However, the increased demands of middle school and high school lead a significant minority of youngsters who do not show this classic picture to manifest impairment due to ADHD symptoms for the first time in adolescence. These youngsters may not always be easy to identify.

Therefore, it is important for the pediatrician to have an updated understanding of ADHD in adolescents. This article addresses three issues: common clinical presentations of ADHD in adolescents; diagnostic methods for adolescents with ADHD; and treatment practices for adolescents with ADHD.

COMMON CLINICAL PRESENTATIONS

Sarah, Sarah is an attractive, highly social 14year-old who has many friends, is charming to adults, and gets along well with her parents. Sarah excelled in elementary school, but began to have difficulties completing her assignments in 6th grade. Because of her charm, teachers often overlooked her tardiness with assignments, accepted her creative excuses for incomplete work, and mistook her extroverted verbal style for high intellectual ability. By the middle of 8th grade, the increasing demands for organization and planning inherent in middle school had overwhelmed Sarah's limited abilities to concentrate and to finish tasks. She was failing 3 classes, had 30 missing assignments, often came to class unprepared, missed teachers' directions, and began to be depressed and disinterested in school.

Girls often present for the first time with possible ADHD in adolescence because they are not hyperactive as young children, they try to please teachers, successfully hiding their inattentiveness until the organizational demands of middle or high school overwhelm them, and they do not have behavioral problems at an early age.8 Actually, their hypersociability and talkativeness are the forms that hyperactivity often takes in females, along with minor motor restlessness. The diagnosis of ADHD is often missed in girls during the elementary school years. Sarah exemplified this presentation of ADHD.

Bill. Seventeen-year-old Bill, a junior in high school, presents for depression, sleep difficulties, and heavy marijuana use. Bill is staying up until 2 or 3 am on school nights, getting up late, missing his first-hour class, and smoking marijuana with his friends every weekend. He is depressed, lethargic, and is failing most of his classes. Bill has no history of childhood hyperactivity and was an outstanding student who excelled in gifted and talented programs until high school. His grades have slipped consistently during the 3 years of…

Approximately 78% of children with attention deficit /hyperactivity disorder (ADHD) continue to display die full clinical syndrome in adolescence.1-2'3 Although physical hyperactivity may diminish, inattention and impulsivity persist, creating greater impairment as school and home environments become more demanding. Teenagers with ADHD are more likely than non-ADHD teens to have failed a grade, been suspended or expelled, scored lower on achievement tests, or dropped out of high school.1 They are more likely to have increased conflict, negative communication and distorted beliefs in their relationships with their parents, particularly when they are also diagnosed with oppositional defiant disorder.4

ADHD in adolescents is also associated with high-risk behavior. Adolescents with ADHD have worse driving habits, more accidents, and have received more tickets than their non-ADHD counterparts.5 They have an earlier age of first sexual intercourse, more sexual partners, less use of birth control, more sexually transmitted diseases, a greater frequency of testing for human immunodeficiency virus (HIV), and more teen pregnancies than non-ADHD individuals.6 In adolescents with ADHD 59% to 65% also have oppositional defiant disorder, 22% to 43% have conduct disorder, 29% manifest major depressive disorder, 11% have bipolar disorder, and 27% manifest multiple anxiety disorders.7

Children presenting with the classic picture of the hyperactive child usually have been diagnosed before they reach adolescence. However, the increased demands of middle school and high school lead a significant minority of youngsters who do not show this classic picture to manifest impairment due to ADHD symptoms for the first time in adolescence. These youngsters may not always be easy to identify.

Therefore, it is important for the pediatrician to have an updated understanding of ADHD in adolescents. This article addresses three issues: common clinical presentations of ADHD in adolescents; diagnostic methods for adolescents with ADHD; and treatment practices for adolescents with ADHD.

COMMON CLINICAL PRESENTATIONS

Sarah, Sarah is an attractive, highly social 14year-old who has many friends, is charming to adults, and gets along well with her parents. Sarah excelled in elementary school, but began to have difficulties completing her assignments in 6th grade. Because of her charm, teachers often overlooked her tardiness with assignments, accepted her creative excuses for incomplete work, and mistook her extroverted verbal style for high intellectual ability. By the middle of 8th grade, the increasing demands for organization and planning inherent in middle school had overwhelmed Sarah's limited abilities to concentrate and to finish tasks. She was failing 3 classes, had 30 missing assignments, often came to class unprepared, missed teachers' directions, and began to be depressed and disinterested in school.

Girls often present for the first time with possible ADHD in adolescence because they are not hyperactive as young children, they try to please teachers, successfully hiding their inattentiveness until the organizational demands of middle or high school overwhelm them, and they do not have behavioral problems at an early age.8 Actually, their hypersociability and talkativeness are the forms that hyperactivity often takes in females, along with minor motor restlessness. The diagnosis of ADHD is often missed in girls during the elementary school years. Sarah exemplified this presentation of ADHD.

Bill. Seventeen-year-old Bill, a junior in high school, presents for depression, sleep difficulties, and heavy marijuana use. Bill is staying up until 2 or 3 am on school nights, getting up late, missing his first-hour class, and smoking marijuana with his friends every weekend. He is depressed, lethargic, and is failing most of his classes. Bill has no history of childhood hyperactivity and was an outstanding student who excelled in gifted and talented programs until high school. His grades have slipped consistently during the 3 years of high school. Missing and incomplete assignments are the main reason for his low grades; he receives As and Bs on most exams without studying. He is disorganized and leaves major projects until the last night to complete. As he has failed at school, he has turned more and more to an alternative peer group that is involved with drugs and has become increasingly depressed, falling into very poor sleep habits.

Bill exemplifies the bright adolescent whose high IQ masks his ADHD until high school. Frustrated and bored academically, such students may become depressed and turn to drugs and deviant peer groups. By the time they present to health care professionals, the overt issues are depression, drugs, and perhaps sleep difficulties. Only by conducting a thorough evaluation could the health care professional discover that ADHD really lies at the root of Bill's other problems.

These two cases illustrate how ADHD has many different faces in adolescents and may not at first be readily apparent in the youngster's initial presentation to the pediatrician. The astute pediatrician needs to cast a wide net when considering the possibility of ADHD in a teenager presenting for school difficulties.

DIAGNOSTIC PRACTICES

An adequate diagnostic evaluation of an adolescent for possible ADHD includes: thorough interviewing of the adolescent and the parents; completion of standardized rating scales by the adolescent, the parents, and each of the adolescent's teachers; and administration of intellectual ability and achievement testing designed to rule out the possibility of associated learning disabilities.7 The use of continuous performance tests may be helpful but is not essential. Such an evaluation usually takes 4 to 5 hours to complete; the interviewing takes 1 to 2 hours, and the testing takes 3 hours.

It is most efficient to begin the evaluation by mailing out the rating scales and arranging to have them returned before the visit. At least one psychometrically sound parent, teacher, and adolescent self-report rating scale should be used. Brief teacher rating scales are preferred because of the importance of obtaining input from each of the adolescent's teachers.

Although it is recognized that there are many other choices, this author uses the following ratings scales: For parents, The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ADHD behavior checklist9 and the Conners' Parent Rating Scale, Revised Long Form;10 for Adolescents, the DSM-IV ADHD behavior checklist9 and the Brown attention deficit disorder scales;11 and for teachers, the child attention profile9 and the Conners' Teacher Rating Scale, Revised Short Form.10

The interviewing is divided into four phases. First, the 18 symptoms of ADHD in OSM-IV12 are reviewed with the parents so mat the interviewer can make judgements about how many of these symptoms currently apply to the adolescent and how many have applied since early childhood. Second, the symptoms of other disorders that may be coexisting conditions or differential diagnoses (oppositional defiant disorder, conduct disorder, mood disorders, anxiety disorders) are reviewed with the parents. Third, medical, developmental, and school histories are taken from the parents, along with a review of report cards and any other pertinent school records. Fourth, the adolescent is interviewed regarding the core ADHD symptoms, school experiences, peer and family relationships, mood and anxiety disorders, and possible substance use.

The testing will typically include the Wechsler intelligence scale for children, third edition (16 or younger),13 or the Wechsler adult intelligence scale, third edition (16 and older),14 and an achievement test such as the Wechsler individual achievement test-II.15 When time permits, a continuous performance test such as the Conners' continuous performance test16 may be administered, as long as the practitioner realizes that such measures have a relatively high rate of false negatives (ie, normal scores in teens proven to have ADHD as measured by other criteria).

Many pediatricians have been trained to conduct some interviewing and to administer, score, and interpret some rating scales. Psychologists and educational specialists are trained to administer the testing, as well as to conduct interviews and administer rating scales. Pediatricians must decide on their role in the evaluation. In a busy medical office practice, pediatricians may not be able to take the time to conduct the thorough diagnostic interviewing necessary to evaluate adolescents accurately for possible ADHD. In such circumstances, pediatricians may define their role as conducting a brief screening for possible ADHD, then refer the family to a psychologist or educational specialist for the remainder of the evaluation. Such a screening might consist of the rating scales discussed earlier and a brief review of the teen's school history along with several of the DSMIV12ADHD items.

TREATMENT OF ADOLESCENT ATTENTIONDEFICIT/HYPERACTIVITY DISORDER

A key principle for effectively treating adolescents with ADHD is to "respect adolescent development." Developmentally, adolescents are becoming independent from their parents, maturing cognitively, forming deeper peer relationships, exploring sexuality, and making career choices and plans. The adolescent's ideas and opinions should treated seriously, and the adolescent should be involved in all decisions regarding the management of ADHD. The pediatrician needs to relate to the adolescent in an informal, non-authoritarian manner, discuss issues rather than lecture, talk with the adolescent rather than preach to him/her, and display a good sense of humor.

The multimodal treatment of adolescent ADHD involves the following steps7: (1) educate the adolescent about ADHD; (2) prescribe, titrate, and monitor medication; (3) intervene to enhance school success; (4) intervene to improve behavioral problems at home; and (5) deal with any comorbidities or remaining problems. The pediatrician typically carries out the first two steps and may provide some anticipatory guidance regarding the other steps. Mental health professionals and educators typically carry out steps 3 through 5. The entire intervention works best when the pediatrician and the mental health professional coordinate their efforts.

Educating Adolescents About ADHD

Before undertaking any formal interventions, it is important to educate adolescents about ADHD, correcting common myths and misconceptions. The pediatrician should start by asking the adolescent patient to explain what the term ADHD means to him/her.

As the teen responds, the pediatrician should be on the lookout for and correct the following common misconceptions which many adolescents believe about ADHD: Myth: I am crazy or sick because of ADHD. This is a life sentence. Rebuttal: ADHD is not a disease. It's an invisible disability that represents the extremes of traits such as inattention, impulsivity, and restlessness, which all people exhibit to a more or less degree. ADHD is not all bad. You can accomplish a lot and be very creative despite it.

Myth: If I have ADHD, I am dumb, stupid, lazy, or a bad person. Rebuttal: ADHD has nothing to do with IQ. People with ADHD are sometimes very smart. You are not lazy or a bad person, and ADHD is not your fault. Differences in your brain chemistry and genetics make it more difficult for you than other people to get things done efficiently. Some of the world's greatest figures - Einstein and Churchill - are thought to have had ADHD.

Myth: Because I have bad genes and brain chemistry, I should be excused from doing my homework or chores. Rebuttal: ADHD is a challenge, not an excuse. You are responsible for your own actions, even though you have a legitimate problem. You need to meet the challenge of coping with ADHD.

Myth: I will never have any more fun. My parents will drag me to doctors, therapists, and tutors all the time. This ADHD thing is just one more way for them to control me. Rebuttal: The issue is you controlling yourself, not your parents controlling you. People with ADHD are not exercising enough self-control. And no one is going to drag you anywhere. You need to understand your choices for coping with ADHD and choose to do the things that might help you.

Adolescents might also benefit from talking to other teens with ADHD, viewing specially developed videotapes,17 or reading books about ADHD.18 The pediatrician should develop a list of other patients with ADHD who are coping effectively and would be willing to mentor the newly diagnosed ADHD teenager.

Piascilblng Medication

Most adolescents with ADHD need the biological correction provided by medication to cope with school and home. The technical details of prescribing stimulant medication to individuals with ADHD can be found elsewhere.19' 20 Three issues will be discussed here: acceptance of medication; developmentally sensitive selection of stimulants; and monitoring medication effects.

Medication should never be forced on an adolescent. Teenagers are often reticent to take medication because they perceive it as a form of adultimposed external control over their bodies and minds at a time when they are striving for autonomy from all sources of external control. The pediatrician should give the adolescent veto power over all medication decision- making to enhance the teen's perception of control and increase cooperation. Medication should be discussed privately with the teenager without the parents in the room, and the pediatrician should later explain to the parents the importance of getting the adolescent to buy into the idea of taking medication. Reassurance should be given that the goal of medication is not to change the adolescent's personality or drug him/her into compliance with adults' demands, but to give the adolescent a biological edge for coping effectively with ADHD. Giving an example of how medication might enhance performance in sports or driving, areas of intrinsic interest to teens, may help make concrete the salience of having a biological edge.

Taking a problem-solving approach, the pediatrician might ask the adolescent to list the advantages and disadvantages of taking stimulant medication, and then review the list to determine whether the advantages outweigh the disadvantages. If the adolescent concludes that the disadvantages clearly outweigh the advantages, the pediatrician should accept that decision. However, a contract should be proposed whereby the adolescent agrees to make specific behavioral and academic changes during the next few months without medication. If die adolescent fulfills this contract, the issue of medication will be dropped; if the adolescent does not fulfill the contract, then die issue of medication will be revisited

Medication needs to be selected and dosed in a developmentally sensitive manner. The pediatrician should start a long-acting stimulant such as OROS-methylphenidate, extended release mixed salts of amphetamine, or dextroamphetamine spansule to avoid the need for a noon dose in school. The dose may be titrated upwards during several weeks so that the adolescent does not wait too long for a positive effect to occur. For example, the adolescent could be told to take 18 mg of OROS-methylphenidate once daily for the first week, 36 mg of OROS-methylphenidate once daily for the second week, and 54 mg of OROSmethylphenidate once daily for the third week, and then report the results to the physician during the fourth week.

The pediatrician should prepare the adolescent and the parents to evaluate the effectiveness of the medication by guiding him/her to select two or three target behaviors that the adolescent will perform regularly on each dose of medicine. The target behaviors should be activities that the adolescent acknowledges are difficult to remain focused on for a long period of time.

Enhancing School Success

The practitioner needs to establish which of the following factors are the causes of the adolescent's poor school performance: (1) failure to complete or turn in homework; (2) poor test preparation and testing skills; (3) poor organizational skills; (4) missing important material during class due to inattention and /or poor note-taking; (5) inadequate understanding of material; (6) failure to ask for help; (7) disruptive classroom behavior; and /or (8) truancy. Working with the adolescent and the parents, specific behavioral interventions involving structuring the environment, remediating the skill deficits, creating incentives for performing the needed academic behaviors, and arranging for accommodations from the teachers are undertaken for each of these problems.7 The pediatrician's role is to provide anticipatory guidance and then make sure that the family follows through with a referral to a mental health professional for in depth intervention.

In the case of failure to complete or turn in homework, the pediatrician might review the following tips with the adolescent and his/her parents:

1. An assignment sheet or student planner should be used to record all homework. Parents should review the planner daily and check its accuracy through direct contacts with the teachers.

2. There should be a regular time and a quiet, non-distracting place to do homework and a plan for attacking multiple homework assignments. No television, video games, or Internet access should be permitted during homework time, although listening to relaxing music may sometimes be helpful. A parent should be in the house during homework time to walk by casually and monitor whether the adolescent is actually doing the homework.

3. Completed assignments should be put in a folder, binder, or section of a notebook delineated for work to be turned in.

4. Parents should coach the adolescent to divide long-term projects and papers into a series of small steps and write these steps on a calendar at the times when they will be completed, and should prompt the adolescent to complete each step at the designated time.

5. The parent should arrange to obtain weekly progress reports regarding the status of the assignments, and may request, as seems applicable, a second set of textbooks at home, a reduction in the amount of homework, or an organizational check to make sure the teen has all of the required materials at the end of the day.

Parents may report that they have tried repeatedly to implement these steps, but have run into resistance and conflict from their adolescent or refusal of the teachers to cooperate. This sets the stage for the pediatrician to reinforce the need to seek help from a mental health professional. The mental health professional analyzes the nature of the conflicts, designs interventions to overcome them, and works with the family and the school until success is achieved.

The pediatrician needs to have a basic understanding of the legal rights of the adolescent with ADHD to receive extra help in school under two federal laws.7 The Individuals with Disabilities Act (IDEA) specifies that when ADHD contributes to significant impairment in learning, an adolescent may be eligible for special education services on the basis of an other health impairment, even if the adolescent does not qualify for help because of a learning disability or emotional impairment. A letter from a physician is mandatory when a parent requests special education services on the basis of an Other Health Impairment. Section 504 of the Rehabilitation Act of 1973 also specifies that when ADHD interferes with learning, an adolescent may be eligible for accommodations in regular education. Parents should make a signed, dated, written request to the school to activate the process of obtaining assistance for their adolescent under either of these laws.

Problems at Home

Conflict between adolescents with ADHD and their parents concerning rules, regulations, chores, freedoms, and responsibilities is common. As with school issues, the pediatrician should provide brief, informational counseling to the family, then refer them to a mental health professional for family therapy and to organizations such as Children and Adults with Attention Deficit Disorder (CHADD) for support. The pediatrician should steer parents away from the extremes of either an authoritarian or a permissive child-rearing approach and toward an authoritative/ democratic approach. The adolescent gradually should be given freedoms in exchange for demonstrating responsible behavior.

Parenting principles should be reviewed:7

1. Actively encourage and shape responsible independence-related behavior.

2. Divide the world of issues with your teenager into those that can be negotiated and those that cannot. Non-negotiable issues are basic rules for civilized family life - no violence, drugs, or alcohol, tell parents where you are going. Everything else is negotiable.

3. Develop incentives and punishments for following or not following the non-negotiable rules and enforce them consistently.

4. Problem solve with your adolescent to identify mutually acceptable solutions for the negotiable rules.

5. Strive to maintain good communication, listening when your teen needs to talk, and targeting specific negative communication habits for change.

6. Actively monitor your adolescent's whereabouts.

7. Be your adolescent's cheerleading squad and encourage your adolescent to build upon his/her strengths.

Using a judicious combination of family and individual therapy, the mental health professional puts mese principles into operation in a series of specific interventions that target the conflict, oppositional behavior, and negative interactions that occur in families with ADHD teens.

Comorbtdltles and Other Problems

As noted, some adolescents with ADHD also have mood, anxiety, or other psychiatric disorders. The mental health professional uses a combination of behavioral, cognitive, dynamic, and supportive interventions to address these issues. The pediatrician may be asked to prescribe medication for depression or anxiety disorders. General pediatricians who have sought out advanced training in psychoactive medication may be comfortable treating depression and anxiety. Others may refer the patient to a developmental-behavioral pediatrician or a child psychiatrist.

COKCLUSlON

Research has supported the use of stimulant medication and behavioral interventions for helping the adolescent cope with ADHD.7 In this article the clinician is given practical guidelines for recognizing, diagnosing, and treating ADHD in adolescents. By following these suggestions and coordinating efforts with the mental health professional, the pediatrician can make a positive impact on the lives of these adolescents.

REFERENCES

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2. Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gm Psychiatry. 1996;53:437-446.

3. Hart EL, Lahey BB, Loeber R, Applegate B, Frick PJ. Developmental changes in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study. / Abnorm Child Psychol 1995;23:729-749.

4. Barkley RA, Anastopoulos AD, Guevremont D, Fletcher KE. Adolescents with attention deficit hyperactivity disorder: mother-adolescent interactions, family beliefs and conflicts, and maternal psychopathology. / Abnorm Child Psychol. 1992;20:263-288.

5. Barkley RA, Murphy, KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics. 1996;98:1089.

6. Barkley RA. Young adult outcome of hyperactive children. Paper presented at: 10th Annual CHADD International Conference; Ocotber, 1998; New York, NY.

7. Robin AL. ADHD in Adolescents: Diagnosis and Treatment. New York, NY: Guilford; 1998.

8. Nadeau KG, Littman EB, Quinn PO. Understanding Girls With ADHD. Silver Springs, MD: Advantage; 1999.

9. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. New York, NY: Guilford; 1991.

10. Conners CK. Conners ' Rating Scales-Revised Technical Manual. North Tonowanda, NY: Multi-Health Systems; 1997.

11. Brown T. Brown Attention Deficit Disorder Scales. San Antonio, TX: The Psychological Corporation; 1996.

12. Diagnostic and Statistical Manual of the Mental Disorders. 4lh ed. Rev ed. Washington, DC: American Psychiatric Press; 2000.

13. Wechsler D. Wechsler Intelligence Scale for Children-Ill (WISC-IU). San Antonio, TX: Psychological Corporation; 1991.

14. Wechsler D. Wechsler Adult Intelligence Scale-Ill (WAIS-UI). San Antonio, TX: Psychological Corporation; 1997.

15. Wechsler D. Wechsler Individual Achievement Test II (WIAT-U). San Antonio, TX: Psychological Corporation; 2001.

16. Conners CK. Conners Continuous Performance Test II (CPT-II). North Tonowando, NY: MHS Systems; 2001.

17. Schubiner H. .ADHD in Adolescence: Our Point of View [Videotape]. Detroit, MI: Children's Hospital of Michigan, Department of Educational Services; 19%.

18. Quinn PO. Adolescents and ADD. New York, NY: Magination Press; 1995.

19. Adesman A. New medications for attentiondeficit/hyperactivity disorder. Fed Annals. 2002;31:514-522.

20. Wender E. Managing stimulants medication for Attention-Deficit /Hyperactivity Disorder. Fed Rev. 2001;22:183.

10.3928/0090-4481-20020801-08

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