By James J. Crist, Ph.D.
Introduction
Research is continuing to expand the options for treatment of teens with ADHD. As we now know, symptoms of ADHD often continue into the teen years and often into adulthood as well. While hyperactivity tends to decrease, many continue to struggle with attention difficulties, impulsivity in words and actions, and a restlessness that can cause problems in school and doing homework. This article will address some of the latest treatment options available as well as some concerns specific to working with ADHD teens.
Diagnostic Considerations
The importance of early diagnosis and treatment cannot be overemphasized. Research shows that children with ADHD are at greater risk for developing additional psychiatric disorders in adolescence and adulthood. These include depression, substance abuse, and disruptive behavior disorders such as Conduct Disorder and Oppositional Defiant Disorder. One possible reason for this is that children with unrecognized and untreated ADHD are more likely to experience academic and social failures, thereby increasing their frustration and leading to lower self-esteem.
ADHD teens and young adults may not be very accurate in their ability to identify themselves as having ADHD, which suggests that parental involvement, in terms of seeking proper evaluation and treatment, is especially important as adolescents may not recognize the need for treatment once they are older. A study by Barkley, R. A. et. al. (2002) found that based on self-report data, only 5% of young adults diagnosed with ADHD as a child identified themselves as meeting current criteria for ADHD, while when parent reports were used, 58% of these adults met full diagnostic criteria for ADHD.
An area of growing concern is the overlap between symptoms of ADHD and Bipolar Disorder. Often, Bipolar Disorder is not accurately diagnosed until adolescence, with patients often having a long history of psychiatric symptoms that may have been inaccurately diagnosed as ADHD. Symptoms of Bipolar Disorder may include elated mood (feeling overly excited, giddy, or silly), irritable mood (which can include severe tantrums out of proportion to the triggering situation), inflated self-esteem and grandiosity (exaggerated sense of one’s abilities), sleep disturbance, pressure to keep talking, racing thoughts that feel out of control, depression, excessive involvement in pleasurable but risky activity (sexual acting-out or preoccupation), and at times visual or auditory hallucinations.
One major concern in terms of misdiagnosis is that medications typically used to treat ADHD (stimulants) and the depression that can go along with ADHD (antidepressants) can both trigger an increase in mood cycling in bipolar patients. While both ADHD and Bipolar Disorder may be present, it is generally recommended that mood stabilization be attempted first, generally using a mood stabilizer. If ADHD symptoms persist, then the use of a stimulant or bupropion, which may be less likely to trigger mood cycling, can be considered.
Treatment
While research on ADHD treatment for adolescents is sparse, a new study (2002) by psychologists at the University of Pittsburgh showed that methylphenidate, in combination with a behavior modification intervention, led to improved academic performance on a range of academic measures, including taking notes, completing daily assignments, and quiz scores. The researchers emphasized that medication alone is not likely to be as effective.
One of the most helpful developments in medication for treating teens with ADHD is the introduction of effective sustained release formulations of stimulants. Methylphenidate is available as Concerta, which is currently available in 18, 36, or 54 mg. capsules. Adderall is also now available as Adderall XR and is available in 5, 10, 15, 20, 25, or 30 mg. capsules, permitting close titration of dosages. Metadate CD is another long-acting medication, available in 20 mg. capsules. Duration of action can last up to 10-12 hours, thereby eliminating the need for a noontime dose, which was often embarrassing for teens or was simply forgotten.
A new, non-stimulant medication, atomoxetine, is about to be released in the U.S. pending FDA approval. It is a potent, noradrenergic specific reuptake inhibitor that has been well studied, including some studies with adolescents. It appears to be associated with a lower incidence of insomnia, though some appetite suppression and mild elevation in diastolic blood pressure and heart rate may be present. Given that not all patients respond to stimulants or cannot tolerate their side effects (an estimated 30%), the introduction of atomoxetine is a promising development. Another possible bonus is that it does not appear to have a high potential for abuse, which is a concern among teenage patients.
Another concern with regard to medication is the increasing use of multiple medications. Few studies exist that demonstrate the effectiveness and safety parameters of combining medications. It is not unusual to see ADHD teens treated with stimulants for the ADHD and antidepressants for issues with anger, anxiety, or depression that may or may not be secondary to ADHD. One concern about the use of multiple medications is raised by research that suggests that an “amotivational syndrome” can occur in youths treated with SSRI’s, characterized by apathy, indifference, loss of initiative and/or disinhibition, especially at higher doses. Such symptoms may not occur until a month later or more. Hence, it may be difficult to know whether or not such symptoms are caused by depression, frustration caused by inadequately treated ADHD, or the side effects of antidepressant medication. Keeping track of starting dates of medicines as well as dates of dose changes can help track such adverse reactions.
Academic concerns are a common problem among ADHD adolescents. Keeping track of assignments, completing homework in a timely fashion, remembering due dates, and studying for exams present significant challenges for most ADHD students. The recent development of PDA’s such as the Palm Pilot can be quite useful for teens and adults with ADHD. Programs are available for students to track assignments and to provide reminders at preset intervals. Using an electronic gadget to keep organized is often more appealing to teens than trying to write things down.
Additional Concerns in Working with Adolescents with ADHD
It is important for teens to have a clear understanding of what ADHD is, how it affects their lives, and how medication can help. Parents may assume that teens will simply take their medicine as prescribed, but this may be naïve. Many ADHD teens simply forget their medication, particularly after school doses. Some may skip doses to see if they can prove to themselves that they can cope without the medication. Other teens are noncompliant because of side effects such as loss of appetite or decreased spontaneity. Counseling can be very helpful in terms of monitoring the effectiveness of medication and improving compliance. Parents also need to learn when to intervene and when to allow their children to experience the consequences of their actions.
One area of risk for ADHD teens is that of driving a car. Highway accidents are the biggest killer of teens between the ages of 15 and 20. A study by Barkley, Murphy, and Kwanik (1996) showed that greater driving risks are associated with a diagnosis of ADHD. The study, published in Pediatrics, showed that ADHD teens were involved in accidents approximately four times as often, were more likely to receive traffic citations, and were over four times as likely to be at fault in accidents as compared to non-ADHD teens. Parents need to consider whether or not their ADHD teen is ready to assume the responsibility of driving. Observing teen drivers during different periods of the day, when medicine may be more or less effective, can be helpful in determining the need for medicine while driving. Other recommendations include providing ADHD teens with more driver training, including in more dangerous road conditions, insisting on seatbelt use, role-playing how to handle an emergency, and immediate consequences for driving infractions.
Another concern is that of substance abuse. Teens and adults with untreated ADHD are at greater risk for developing substance abuse disorders. The impulsivity that typically accompanies ADHD can contribute to experimentation with drugs. Also, some teens may turn to alcohol and drugs in an attempt to self-medicate their ADHD symptoms. This of course can cause symptoms to worsen instead of improve. Marijuana in particular can interfere with concentration and motivation. Some clinicians have been hesitant to prescribe stimulant medication for teens with substance abuse problems. Parents sometimes fear that stimulants may lead to substance abuse. But research shows that the biggest risk for developing substance abuse problems in ADHD teens is to fail to treat the ADHD. It is wise to conduct drug testing before starting medication. Periodic drug screens may also help teens combat the temptations to use drugs.
Finally, recent research also suggests that ADHD, particularly the combined type (inattentiveness and hyperactivity/impulsivity), when not properly treated, can have negative consequences that last well into adolescence and young adulthood. Such findings further highlight the importance of proper identification and treatment of ADHD.
References
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Pavuluri, M.N., et. al. “Recognition and Treatment of Pediatric Bipolar Disorder.” In Contemporary Psychiatry, Vol. 1, No. 1, April 2002.
Rabiner, D. “How Often Does ADHD Persist into Adulthood?” In Attention Research Update, Vol. 65, July 31, 2002.
Snyder, M. & Hemphill, R. “Parents of Teen Drivers with AD/HD: Proceed With Caution.” In Attention, Spring, 1999, pp. 42-45.
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Seay, B. “Atomoxetine: The First Non-Stimulant Treatment for AD/HD.” Attitude Magazine.com, November, 2001.
“Studies reveal atomoxetine effective treatment for ADHD.” In The Brown University Child and Adolescent Psychopharmacology Update. Vol. 4, No. 1, January 2002.
