ADHD in Adolescents

Assessing teenagers and adolescents with ADHD is one of the most challenging for any professionals. There is a wide range of difficulties that such adolescents can have and in our experience by the time they get to adolescence with untreated ADHD/ADD, they frequently are really struggling, are demotivated and may have low self esteem, and often oppositional and quite resistant to being helped. Careful assessment of the situation and management at the interview is essential to a satisfactory outcome. The LANC professionals will need to spend time with the teenager alone and with their parents, to develop a good working relationship and to do a careful assessment recognising that there may well be an underlying problem existing from what is currently going on with the teenager, the school and the family.

For example by teenage years many children have become less hyperactive and may just be fidgety and restless. However it is frequently in reality said that because of this the child has outgrown his or her ADHD. This is usually very far from the case as the adolescent usually has great difficulty in focussing on mundane tasks and is usually impulsive particularly verbally impulsive. In addition the struggle of achieving in life, getting the normal task that most of us take for granted done and socialising means that they have become demotivated with low self esteem. Particularly if they have been oppositional from an early age, the oppositionality is likely to become much worse at puberty with ongoing progression. Thus very careful and experienced assessment is necessary. However even by adolescents they can be effectively managed with carefully fine-tuned multi model approaches.

The teenage years are ones of change and development for all children.  They, their parents and teachers need to be able to adapt to these changes.  Adolescents can be described as follows:

In early adolescence (12 – 14 years), teenagers’ bodies change, they are very aware of their physical appearance, and the need to be similar to their peers.

In middle adolescence (15 – 17 years), they become more independent and generally more competent.  They become less attached to their parents and more to their peers, and there are often problems with mood swings, disruptive behaviour and academic difficulties.

By later adolescence (18 – 21 years), there is usually a clearer direction in life, increasing indepdence from home and preparation for adulthood.

One of the many myths surrounding ADHD is that it is outgrown by teenage years.  This is far from the truth: although the symptoms most obvious to the casual observer – hyperactivity -  has often declined by puberty, the other core symptoms remain.  Impulsiveness can still be a very significant difficultly.  While physical impsuliveness has often lessened, adolescents with ADHD are likely to be much more verbally and emotionally impulsive.  They will interrupt conversation, speak out of turn and lose friendsips because of inappropriate remarks.  They explode and have frequent tantrums, and often seem immune to rational and reasoned argument.  Their difficulties with rule governed behaviour mean that they push the limits, argue a lot, have difficulties with behaviour at school, are frequently excluded, and may get traffic fines and have problems with the law.  Inattentiveness also remains, which for about 30% of children with ADHD, especially girls, has always been the major symptom.  Reliance solely on the hyperkinetic criteria completely ignores this group of children who may have equally severe problems and who comprise quite a large percentage of the children seen at ADHD clinics.

Moreover, while core symptoms may have declined or remained the same, ADHD is a progressive condition and, as the years go by, the underlying ADHD is frequently masked and obscured by many of the complicating factors-particularly oppositionality, learning problems, self-esteem problems and poor social skills.  By the time the hormonal changes of puberty occur, life is extremely difficult.  Motivation has usually diminished after years of persistent failure, and is often very low by adolescence.  Lack of persistent and failure to follow rules and instructions also become very prominent features at this stage.

Physical and emotional upheavals are usual in adolescence, but ADHD seems to aggravate such difficulties, and teenagers with ADHD have a higher than average incidence of a number of complications.

Youth Justice
LANC staff have always been very concerned that a percentage of adolescents with ADHD are more vulnerable to ending up in difficulties with the Youth Justice System. The characteristics of these people with ADHD are outlined in the attached article. In summary they are by no means all people with ADHD but they tend to be the group of children with the more hyperactive and impulsive type of ADHD, where there are associated specific learning difficulties, adverse environmental factors, and the early onset of severe impulsiveness and of antisocial behaviour consistent with conduct disorder. This combination appears to make the lack of self-control which is part of the impulsiveness of ADHD, much more likely to cause difficulties for the adolescent. Particularly when in the untreated situation the adolescent has struggled through school with lowering of self-esteem and social skills difficulty can become more and more demotivated, much more likely to be easily led, to be involved in drug and alcohol abuse, and subsequent antisocial behaviour. Even at this late stage the ADHD-related conditions can be treated with a combination of medication and carefully contained environmental strategies.

In recent years the Youth Justice Board has introduced the ASSET screening programme which to some extent helps screen for underlying conditions. We consider this programme needs to be much more further developed in combination with Youth Offending Teams.

There is still the frequently held belief that family and environmental factors only, are the sole cause of youth justice difficulties. There are complex societal interactions between this approach and the need to appropriately punish offenders, and the awareness of ADHD and related conditions where the biological impulsiveness and lack of self-control creates a vulnerability to other problems. This is not an excuse rather an explanation. Data from the US has shown that with effective multimodal management of such adolescents, the re-offending rate can be reduced from over 60% to about 10%. The LANC is therefore keen to work with other providers in this area to establish more effective services. Please see the enclosed articles for more information.

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  • Teenagers with ADD and ADHD, by Chris Dendy