Your Adolescent - Attention Deficit/Hyperactivity Disorder (ADHD)

Excerpts from Your Adolescent on ADHD

Once called hyperkinesis or minimal brain dysfunction, attention‑deficit/hyperactivity disorder (ADHD) affects between 3 to 5 percent of all children, perhaps as many as two million American youngsters. Two to three times more boys than girls are affected, though the disorder is being identified increasingly in girls. On the average at least one or two teens in every classroom in the United States need help for the disorder. While it appears that some of the symptoms of ADHD disappear by adolescence, some teenagers continue to have difficulties in their social relationships and school performance. In some teens, attention deficit‑hyperactivity disorder may coexist along with antisocial or delinquent behaviors.

Teens with ADHD are inattentive, overactive, impulsive, and disorganized. These behaviors may resemble normal teen behavior. They are, however, persistent, extreme, and truly outside the control of the teen with ADHD. Adolescents with attention deficit/hyperactivity disorder have a harder time keeping their minds focused on individual tasks for even short periods of time without becoming bored or distracted. And even more impulsive than their non‑ADHD peers, these teens seem incapable of curbing their automatic reactions of thinking before they act. During stressful situations, these already exaggerated behaviors become more extreme. Because of these troublesome symptoms, the adolescent may have trouble developing a sense of mastery and positive self esteem.

In most youngsters with ADHD, the signs have been noted and the condition diagnosed long before the teens reached adolescence. Therefore, many have received treatment and symptoms have been controlled. Moreover, research suggests that by adolescence almost 50 percent of all children diagnosed with ADHD no longer have symptoms.

Identifying the Signs
Although signs of this disorder are often evident during toddlerhood or even earlier, most children would have been seen by their pediatricians or mental health clinicians in elementary school. Occasionally, the disorder is first diagnosed in the teenager. Like other behavioral disorders, ADHD is most often identified by people other than the youngster. Adults have varying tolerances for excessive activity, so the same behavior may be accepted as exuberant by one teacher but considered more serious by another. Some parents do not know what level of activity, concentration, and compliance to expect from their children, especially during the teen years

Sometimes problems may be present at school but not in the home, or at home but not at school. Some youngsters are bored, discouraged, restless, and unable to follow instructions at school not because they have ADHD but because they don't find the type of structure or challenge they need. Other teenagers may have undiagnosed learning disabilities and may express their frustration through behavior. They may have difficulty concentrating and, ultimately, become disruptive in the classroom. In addition, because anxiety, depression, and other emotional problems can produce symptoms that resemble ADHD, the need for accurate diagnosis is important.

ADHD is a chronic disorder most often diagnosed in the elementary‑school years with symptoms varying from mild to severe. Some teenagers with ADHD have more problems in large groups but do better one on one. A teen with severe symptoms of ADHD will have problems in all settings: at home, at school, and at play. If ADHD goes unrecognized and untreated, a teenager can develop low self-esteem, frustration, academic underachievement, even failure, and social isolation, which can follow her into adulthood.

While most teenagers are impulsive at times, those with ADHD are impulsive to a degree that can be not only distracting but occasionally dangerous. Teenagers with ADHD may talk inappropriately in class or may blurt out answers before questions are completed or while classmates are attempting to answer. Their schoolwork often is messy, showing a lack of thought and focus, or assignments are lost. Homework papers and assignments are frequently incomplete or full of errors. Such teenagers may act recklessly: driving too fast and dangerously or stealing, sometime on a whim without considering the consequences.

Yet, paradoxically, the very same youngsters may be able to concentrate for considerable stretches of time on certain activities that they enjoy or that come easily, such as drawing cartoons or watching television. Such selective attention seems related to motivation and pleasure in the task.

It is still not clear whether hyperactive teenagers have difficulty perceiving and understanding social cues or whether they perceive them correctly but fail to respond appropriately. In normal circumstances, most teens adjust behavior intuitively and through learning so that for they can join a group activity smoothly and without interrupting. Teens with ADHD, however, have problems in monitoring their behavior reflecting upon its impact, and adjusting to specific social situations. They are more likely to barge in and disrupt the process. As a result, teenagers with ADHD have difficulties in social situations and frequently have few friends

In sports activities they might run into others, pushing, hitting, shoving, ignoring the rules and structure of the game. Often they lack the concentration to succeed in learning a sport. While there may ne no particular anger, hostility or malicious intent in the intrusive physical contact, it often results in quarrels and fights. At other times, teenagers with ADHD may be oppositional and argumentative with parents, teachers, and pears.

Causes and Consequences
Despite years of research, the cause of ADHD is still not fully understood. Evidence to date indicates that there are many things underlying ADHD, among them genetic and neurobiological vulnerabilities. A child's environment may contribute to the development of the disorder or worsen the symptoms. Some cases of hyperactive behavior are linked to levels of lead in the blood; fetal alcohol syndrome (in which alcohol consumed during pregnancy has a range of effects on the unborn child); exposure to other drugs in utero; or serious head injury. In the 1970s, speculation centered on ADHD being a result of food additives: later it was concluded that additives were not a significant cause of the syndrome. In the 1980s, public attention turned to sugar in its search for an explanation for ADHD. Many parents still limit dietary sugar, but follow-up research studies have discounted the sugar theory.

Stressful circumstances in the youngster's home, coupled with neurological vulnerabilities, seem to increase the likelihood of problems related to ADHD. The prevalence of teenagers with hyperactivity, impulsiveness, and inattention is greater in disadvantaged, large inner‑city environments. This may be due to such related factors as poverty; malnutrition; lead poisoning: poor prenatal and neonatal health care (which can lead to prematurity or low birth weight); drug or alcohol abuse during pregnancy; and family disturbances, including violence and drug and alcohol abuse. Any one or a combination of these factors can play a significant role in developing and perpetuating ADHD symptoms.

While the exact degree to which a chaotic environment contributes to ADHD symptoms is still unclear, it does appear that parents who are able to provide support, stability, educational stimulation, and hope can help their adolescent partially compensate for her vulnerabilities. The symptoms of ADHD make parenting more challenging. Dealing with ADHD symptoms, and the inevitable frustration that results, may cause many parents to doubt their parenting skills. Parents of teenagers with ADHD report greater stress, social isolation, and self blame and demoralization. These factors can translate into a parenting style that is more intrusive, controlling, and disapproving. As a result, the teen's emotional development, competence, and self esteem can be negatively affected.

From time to time, every teenager appears to live in her own world, and parents complain that the teenager is uncooperative or doesn't listen. Parents of teens with ADHD however, have often experienced years of the frustration and exasperation that comes from trying to establish limits and discipline for children who seem consistently unable or unwilling to listen. Because all adolescents naturally strive toward assuming more responsibility and independence, the frustration of parenting a teen with ADHD may well intensify during this period of development.

A cycle of negative interaction, stress, and failure can also occur in the classroom between teachers and teens with ADHD. Teenagers who are disruptive, fidgety and impulsive can be singled out by the teacher, and labeled as disciplinary problems. Academic settings with multiple periods, large classes, teachers who have differing styles, and complex schedules present additional problems for the teenager with ADHD.

In addition to classroom conduct, your teen's schoolwork will likely show the effects of the disorder. Unable to give close attention to details, your teenager may make careless mistakes. It might appear that she does not follow through on instructions or finish schoolwork. Most hyperactive youngsters avoid, dislike, or refuse to engage in tasks that require sustained attention. As a result, homework and schoolwork often go unfinished or are sloppily executed, especially when the work is boring, repetitive, or difficult. At home, they typically don't finish chores or fail to remember weekly tasks.

While some teenagers with ADHD function well in the classroom, especially if they are bright, others tend to underachieve at school. Some fail to achieve up to their potential because they have trouble paying attention, find it hard to organize their thoughts, or actually have trouble processing and remembering information. The less successful that teens with ADHD are with their schoolwork, the less motivated they may be to succeed in academics. With many youngsters with ADHD, it seems that even their most concentrated efforts bring little success. Not unexpectedly, truancy and dropout rates are high among these youngsters.

It is hardly surprising that adolescents with ADHD tend to have low self esteem. Many find themselves in constant trouble, and many feel socially isolated. Most lack the feelings of mastery and competence that other adolescents gain from social and academic successes. Therefore, many of these youths feel demoralized within a cycle of failure and criticism that is perpetuated both at school and in the family.

There has been considerable debate in recent years about whether children outgrow ADHD and whether it becomes less active a problem in adolescence and adulthood. Many researchers believe that the syndrome itself never really disappears but rather that adolescents learn to control or compensate for it to some degree. For those who receive the diagnosis early, medication in combination with other treatments, may have stabilized the condition.

In one study, most youngsters between the ages of eleven and seventeen experienced less severe symptoms. Nevertheless, these very same teenagers were more easily distracted and had more difficulties than those teens without the disorder. In fact, another study found that after the age of sixteen, nearly half of these teenagers had some problem behaviors. They tend to be more combative and argumentative and are more likely to engage in vandalism or truancy. According to the same study, about one‑third of these youngsters also used and abused drugs.

ADHD commonly exists with other problems, such as specific learning disabilities, depression, or anxiety disorders. Almost half of those diagnosed with ADHD are also diagnosed with oppositional defiant disorder or conduct disorder.

How to Respond

ADHD is a treatable condition, that requires a comprehensive approach. More than 200 studies have shown that medication can produce beneficial results. During adolescence, however, some youngsters may be unwilling to take medicine that they took in childhood because they feel ashamed or controlled by the medication. Other treatment approaches, singly or in combination with medication, include cognitive therapy, behavioral therapy, social skills training, parent education and support, and remedial education.

If attention deficit/hyperactivity disorder is diagnosed in your teen, learn about the condition. Talk to your teenager's doctor, child and adolescent psychiatrist, and teachers, Stay involved in her school to see that she is getting appropriate remedial education or special tutoring whenever necessary. Parents of adolescents with ADHD continue to be their youngster's best advocates. They need to be involved in getting their teens the help they need.

Cognitive‑Behavioral Therapy. Behavioral therapy can help control aggression, modulate social behavior, and regulate attention and physical movements. This approach encourages and rewards teens for proper behaviors. Cognitive therapy ideally teaches those with ADHD greater self‑control, self-guidance, and more thoughtful and efficient problem‑solving strategies.

Social Skills Training. When coupled with cognitive therapy and medication, social skills training helps teenagers understand and smooth out difficult social behaviors. Social skills training uses reinforcement strategies and rewards for appropriate behavior. Through this approach, teens learn to generalize behavior, that is, to apply one set of social rules to other situations.

Social skills training can help adolescents learn to evaluate social situations and adjust their behavior accordingly. This can also be learned through group therapy because youngsters of this age are especially likely to benefit from such group interactions with their peers. Despite such programs, however, youngsters with ADHD may continue to have socialization problems, which can be quite painful for the adolescent who is seeking acceptance from peers.

Parent Training Programs. Some parents are helped through parent training programs. In these sessions, parents learn practical strategies for managing then youngster's behavior. In this type of training, the emphasis is on observing the youngster and communicating clearly. Furthermore, parents are often helped through such training to appreciate and respond appropriately to their teenager's changing developmental needs, Parents are taught new and age appropriate negotiating skills, techniques of positive reinforcement, and other strategies to assist a teen with ADHD to manage her behavior. Parents may also benefit from participating in programs run by local and national support organizations that help advocate for their teenagers. These programs can help lessen parents' feelings of isolation, frustration, and demoralization which can occur when parenting a child or teen with ADHD.

Family Therapy. When teenagers are willing to participate in therapy along with their families, this approach can address the family stress normally generated by living with a youngster who is struggling with the symptoms of ADHD. Sometimes, when ADHD has been diagnosed in childhood, parents understandably become closely involved with their child's disorder and care. As the child matures, it is necessary to continue to shift greater responsibility for monitoring and managing the disorder to the youngster. Family therapy can help parents make the appropriate shifts and adjustments to accommodate then teenager's changing needs and to shift more control to the teen.

Occasionally in the course of family treatment, a parent may be identified with the same disorder, and treatment of that parent may be considered. Family therapy can also help other members ‑ siblings and grandparents, for example ‑ adjust to and accommodate the changing, increasingly independent youngster and her needs.

Medication. Since the 1930s, psychostimulants have been used to treat what we now call ADHD. Stimulant medications include methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert). These medications increase a person’s attention and reduce excess fidgeting and hyperactivity, allowing the youngster to focus more effectively. They increase nervous system alertness by stimulating the brain to produce more dopamine and norepinephrine, two of the many neurotransmitters (chemical messengers). When used judiciously and appropriately, the beneficial results from medication can be dramatic.

Some believe that the diagnosis of ADHD is used to justify medicating children who are perceived as active, expansive, or difficult by adults who lack the patience and willingness to tolerate them. The rapid increase in the use of methylphenidate worldwide has resulted in concern about the overuse of medication.

Using, stimulant medications to treat a teen with ADHD ID is a serious decision. There are a variety of factors to consider, among them the duration of the disorder, the short-term and long term benefits of medication, and the potential side effects. During adolescence, it is also important to review the effectiveness of your teenagers medication and to insure that she has a growing participation in the review. If medication is being recommended for the first time, ask how the decision to prescribe medication was arrived at and the kind of follow up needed to monitor its use. If your teenager has been taking medications since childhood, discuss the advantages and disadvantages of continuing the medication with your teen's physician.

In many cases, medication enables youngsters to concentrate for longer periods, to complete tasks, and to comply with requests. The most common side effects of stimulant medication are reduced appetite and difficulty falling asleep. Some youngsters report stomachaches and headaches, especially during the first few days of treatment. If these side effects continue, they can often be controlled by reducing the dosage.

In rare cases, stimulant medication is thought to have interfered with a child's growth, although some researchers dispute the point. There is, however, general agreement that once medication use is discontinued, normal growth will resume. It is crucial that the treating physician carefully monitor height and weight.

When stimulants fail to effectively modify the symptoms, or cause problematic side effects, other medications might be helpful. The most commonly used are bupropion (Wellbutrin), fluoxetine (Prozac), guanfacine (Tenex), imipramine (Tofranil), nortriptyline (Pamelor), and sertraline (Zoloft).

In general, youngsters with ADHD are at higher risk for academic failure, social isolation, accidents, low self esteem, demoralization, and disruptive behavior (including antisocial behaviors). For some, ADHD can be a lifelong disorder, but for those children diagnosed and treated early, the condition can be effectively managed, and their lives can indeed be productive, successful, and fulfilling.

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