Diagnosing ADHD in Adolescence
Some teens with ADHD were not diagnosed in childhood and may begin to struggle more as demands increase in adolescence. You or your teen’s teachers may suspect that ADHD symptoms are contributing to these struggles. For teens not diagnosed in childhood, obtaining a diagnosis of ADHD in adolescence can be complicated for several reasons. First, to qualify for a diagnosis of ADHD, symptoms must be present in some way prior to age 12; however, recalling symptoms that were present in the past is often difficult. Second, many of the symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria are primarily written for younger children (e.g., “runs about or climbs excessively”) and may not be applicable to teens. Third, obtaining reliable reports of teens’ symptoms from external observers, such as parents or teachers, is more difficult. This is because adolescents usually have several different teachers, each of whom sees them for only a small portion of the day. Similarly, you likely have less direct contact with your teen during the teenage years than you did during their younger childhood. Fourth, as mentioned above, some of the striking symptoms of ADHD, such as extreme hyperactivity, may be more subtle in teens than in younger children. Finally, the presence of other disorders may complicate the diagnosis of ADHD.
If you or your teen’s teachers suspect that your teen may have undiagnosed ADHD, it is important to seek a comprehensive evaluation that includes a careful history; clinical assessment of academic, social and emotional functioning; and reports from you, teachers, other involved adults (such as coaches) and your teen. This evaluation should also include a physical examination to rule out other causes of observed symptoms. If you would like to have your teen assessed for ADHD, see a psychologist, psychiatrist or other clinician with expertise in ADHD.
Causes of ADHD
Research has clearly shown that the majority of cases of ADHD have a genetic component. ADHD is a brain-based disorder, and the symptoms shown in ADHD are linked to many specific brain areas. Other causal factors, such as low birth weight, prenatal maternal smoking or other prenatal complications also contribute to some cases of ADHD. Patterns of parenting and family interaction may help reduce the impact of the symptoms of ADHD or may make them worse; however, parenting styles do not cause ADHD.
Co-occurring conditions in the teen years
It is common for other conditions to occur along with ADHD. These conditions may have been present since childhood or may emerge with the additional stress of adolescence. In fact, up to 60% of children and teens with ADHD have been found to have at least one additional disorder. These disorders can make parenting more challenging, and many parents find professional assistance helpful in providing support, resources and additional parenting strategies for their teens.
Some of the most common conditions experienced by teens with ADHD are difficulties with disruptive behavior, including oppositional defiant disorder (ODD) and conduct disorder (CD). ODD is characterized by a pattern of temper outbursts and irritability along with refusal to comply with adults’ requests and rules. CD is a more severe form of noncompliant and defiant behavior that includes tendencies such as harming people or animals, stealing, trespassing and truancy. Research has shown that teenagers with ADHD are 10 times more likely to experience disruptive behavior disorders. Other research has estimated that anywhere between 25%–75% of teens with ADHD have one of these disruptive behavior disorders.
Mood disorders, including depression and dysthymia (a type of negative mood similar to depression but longer in duration), can also be prevalent in teens with ADHD. Teens with depression often feel sad or irritable and may not be interested in activities they once enjoyed. They may also have trouble sleeping, feel hopeless about the future, and think about death or suicide. Research has estimated that between 20%–30% of teens with ADHD have a co-existing mood disorder.
Anxiety disorders may be present in as many as 10%–40% of teens with ADHD. Anxiety disorders are characterized by excessive worry and difficulty controlling worries. Individuals with anxiety may also experience physical symptoms including headaches, upset stomach and rapid heartbeat. They can also experience anxiety attacks and begin to avoid anxiety-provoking activities.
Substance use and abuse is a significant concern of many parents of teens. Indeed, risk for substance use among children with ADHD ranges from 12%–24%. Use of medication to treat ADHD is not associated with increased substance use. In fact, use of medication to treat ADHD may protect adolescents from developing substance abuse disorders later in life. The strongest predictor of substance use among teens with ADHD is an additional diagnosis of conduct disorder. Symptoms of substance use in teens may include smelling of alcohol or smoke, changes in eyes or face (bloodshot eyes or flushed face), mood changes, deceitful or secretive behavior, changes in motivation or decreased academic performance and/or changes in peer group.
Learning and communication problems can be significant, and research has indicated that learning disorders may be present in as many as 1/3 of youth with ADHD. The demands of middle school and high school place additional stress on teens, and parents should remain aware of their teen’s academic performance and carefully monitor any changes or declines in performance. Communication disorders include not only difficulty with speech (such as stuttering), but also difficulty with understanding language and the ability to express oneself clearly. If parents are concerned about their teen’s communication, they should contact the school and/or consult a speech/language pathologist for an evaluation.
Sleep disturbance is also common in teens with ADHD. Changes in sleep cycles are normal for all teens, as youth begin to stay up later at night and want to sleep later in the morning. Teens also require more sleep overall. In teens with ADHD, sleep disturbance may be even more pronounced and is not necessarily a side effect of medications. Given this risk, sleep should be carefully assessed prior to starting medication to determine whether pre-existing sleep disturbance exists.
At this time, it is not possible to predict which teens will experience these additional conditions. It is likely that genetics play a role. The additional stresses experienced by teens with ADHD, such as social criticism or internal frustration, may also make teens more vulnerable to these difficulties. For more information on these co-occurring conditions, please see ADHD and Co-existing Conditions. If you suspect that your teen may have any of these additional conditions, consult a psychologist, psychiatrist, or other clinician with expertise in ADHD to have an assessment.