Moving from Childhood into Adolescent ADHD: What Parents Need to Know

What Symptoms Remain in Adolescence?

  • 80% of adolescents still meet diagnostic criteria for ADHD
  • Symptoms do not magically disappear
  • For most, attention dysregulation (under and over focusing, difficulty switching and prioritizing attention) remains
  • Impulsivity may remain
  • Executive Functioning (EF) skill impairments continue in working memory, organization, time management etc.
  • Cognitive deficits such as slower processing speed, language deficits in reading and writing, dysgraphia and any learning disability impairment continues
  • Emotional dysregulation may have improved but can still be an issue for many, however consequences are now greater

What Changes in Adolescence?

  • Outward hyperactivity decreases or becomes more subtle, but internal restlessness remains
  • Impulsivity with less supervision due to age results in increased risk:
    • More sensation seeking
    • Riskier physical activities
    • Impulsive decisions have greater consequences
    • Impulsive spending now possible
    • More impulsive eating
    • Verbal impulsivity greater consequences
    • Stealing and Fighting
    • Substance use begins
    • Sex begins earlier for many adolescents with ADHD

What Changes at School?

  • The load on attention and executive functioning (EF) skills increase while impairments remain, which causes greater issues at school
  • The Individual Education Plan (IEP) may be removed by the school or accommodations listed may not be followed
  • If EF skills and strategies were not taught and practiced in elementary school, demands on the impairments now become greater and cause impediment to success
  • With the increase in teachers, subjects and assignments, organization and time management skills become essential
  • With the expectation of increased responsibility EF impairments are now more often interpreted as laziness by teachers and parents
  • Increased complaints of boredom especially around certain subjects, teachers and uninteresting assignments
  • A drop in grades is often due to assignments not being completed and handed in rather than content not being understood
  • The adolescent often refuses to use learning strategies and accommodations – they do not want to be seen as different than their peers 

What Changes at Home?  

  • Regular adolescent changes occur – hormones, fight for independence
  • Some adolescents may avoid the move to independence due to uncertainty and fear
  • They are expected to become more responsible
  • Parents may become tired of accommodating them and frustrated when they see other adolescents maturing and taking more responsibility
  • Conflict between siblings may remain and even increase
  • Rules will need to be added, altered and negotiated due to the increased risk of adolescence
  • EF impairments impact chores and responsibilities – impairments are now more often interpreted as laziness
  • Adolescents often refuse to admit that they need help
  • They resist using strategies and accommodations when they could be helpful

Some Useful Parenting Strategies to Help Them Move into Adolescence 

  • Educate your child about ADHD in general and their individual impairments
  • Discover, discuss and encourage their strengths/talents – this may increase their self-esteem and possibly lead to a career path
  • Develop habits in organization – the load on executive functioning (EF) decreases when things become habitual you don’t need to think about it
  • Teach, model and practice EF skills
  • Practice Life Skills
    • Food buying and preparation
    • Clothes purchase and care
    • Finances, budget, credit card,

Healthy Life Style Choices

  • As children move into adolescence it becomes more difficult to monitor and influence their life style choices – diet, exercise, sleep
  • A delayed sleep phase is inherent to ADHD but it can now become exacerbated by excessive screen time and poor sleep habits
  • There is often a lack of sleep during the week, which is made up with excessive sleep during the weekend, resulting in being unable to sleep Sunday night
  • Cardio exercise can be very beneficial for brain functioning so should be encouraged
  • Specialty diets are not beneficial, but a balanced diet high in proteins is good for general brain functioning
  • The more that you can promote healthy lifestyle choices in adolescence and turn them into habits the better chance adolescents will continue those choices when they leave home and become adults

Coexisting Disorders

  • Learning Disabilities (LDS) and Oppositional Defiant Disorder (ODD) have generally been diagnosed by adolescence
  • Tic Disorders and mood and anxiety disorders may now become evident
  • Anxiety and depression increases at this age and may be more common in the primarily inattentive presentation
  • ADHD adolescents experience more suicidal ideation and attempts
  • Eating disorders are 3.6 times more likely in adolescents with ADHD
  • Children with ADHD are not overly insightful about their impairments and can be unaware of their issues – by adolescence they start to become more aware of their differences and failures which can lead to depression and anxiety

 Substance Use and Abuse

  • This is the age where drug use and abuse begins
  • Adolescents with ADHD have much higher rates of use than teens without ADHD – age 15 is when rates begin to increase
  • Adolescents often used substances to self-medicate especially when untreated

Substances commonly used are:

  • High quantities of caffeine – coffee, energy drinks
  • Tobacco (nicotine is a stimulant) used to occupy hands – but can also improve focus
  • Cannabis is used to stop the racing mind, relax, reduce anxiety and sleep
  • Earlier alcohol use and more problem drinking in adolescence, excessive use and binge drinking is more common in adolescents with ADHD 
  • ADHD medication use for treatment neither creates or protects against substance use and abuse

ADHD Medication Misuse and Abuse

  • Misuse is defined as the use of medication for another reason than what it is prescribed for, or in other dose – it does not lead to dysfunction
  • Abuse is defined as the use outside normal accepted standards (to get high or enhance other substances) – it does result in disability or dysfunction
  • Diversion is defined as the sharing or sale of medication
  • Motivation for the use of medication other than ADHD Treatment
    • To improve attention and concentration
    • To stay awake all night and cram
    • To achieve higher grades on tests – has been proven to be incorrect
    • Pressure for higher and higher grades and too much to accomplish in the time allotted  
    • Party drug

Strategies for ADHD Medication Use and Abuse

  • Be aware that your child may be approached or intimidated by others into sharing or selling their medication – medication may also be stolen
  • Adolescents need to be warned that medication is a controlled substance and sharing can be considered dealing even if money is not involved
  • Be proactive and discuss how to deal with this situation before it happens
  • Help them to develop a strategy – practice by role playing
  • Make sure they report this when it happens
  • Discuss risks of misuse and abuse
    • Increased BP and heart rate – Cardiovascular incidents
    • Psychiatric – hallucinations
    • Intoxication and withdrawal
    • Interaction with other substances
  • Long acting medication is much more difficult to abuse – use to get high
  • Become hyper vigilant if prescriptions run out prior to expected date or there is a frequent loss of pills

ADHD Offending and the Justice System

Involvement in the justice system is not a given however,

  • ADHD symptoms of impulsivity and executive functioning impairment result in self-regulation impairment and emotional regulation impairment
  • There may be an additional substance abuse
  • With this profile it is not surprising that individuals with ADHD are at a much higher risk of becoming involved with the criminal justice system
  • ADHD is 10 times more likely in adolescents in the correction system and 5 times more likely in adults when compared to rates in the general population – 26 to 33% incident rates
  • Those with ADHD begin offending earlier
  • Their offences are more impulsive in nature

Parental Strategies around Offending

  • Remain hyper vigilant
  • Catch small things before they escalate
  • Be cognizant that immaturity, impulsivity and low self-esteem sets these kids up to become followers
  • Their need for acceptance may make them more vulnerable – arrange for positive role models
  • Keeping them away from less desirable peer groups is important
  • Open communication is needed about temptations, impulsivity and increase in consequences at this age

 Driving

  • Attention dysregulation, distractibility, impulsiveness and poor risk perception combine to increase driving risks
  • Adolescents with ADHD:
  • Are more likely to have received traffic cautions – most often for speeding
  • Sustain three times as many car crash injuries
  • Are four times more likely to be in an accident
  • Are four times as likely to be at fault
  • Are six to eight times more likely to have their license suspended
  • Are more likely to have driven a vehicle without supervision before they get their license

Parental Strategies for Driving 

  • Only allow them to drive when medical treatment is in effect
  • Openly discuss concerns and dangers – think aloud and discuss issues when you drive
  • Model good driving
  • Always send them to driver training
  • Discuss issues and collaborate on strategies – e.g. place cell phone in glove compartment
  • Implement rules and consequences as soon as driving begins
  • Allow absolutely no alcohol or drugs when driving
  • Use a no passenger policy in the beginning to reduce distractions
  • Be aware that night driving more risky
  • Driving in unknown areas is more risky – have them always pull over to use their GPS
  • Loud music makes it difficult to hear emergency vehicles, horns etc. – compromise on a level

Sexual Activity  

  • Adolescents with ADHD engage in more risky sexual behaviour
  • They engage in sexual activity earlier and with more partners
  • They have more casual sex
  • They are more impulsive and less likely to use protection and contraception
  • Those with ADHD have more teen pregnancies and 54% do not end up with custody
  • They have a higher incidence of sexually transmitted disease, 17 % vs 4%
  • Their less developed social skills can result in unintentional or wanted advances and perceived harassment

Tips for Parents on Sexual Activity 

  • Since adolescents with ADHD are more likely to misinterpret boundaries, rules and nuances, it is necessity to be very frank and clear about these issues
  • You need to have many open discussions about these topics – let them know that you will discuss anything
  • Be prepared for these discussions by educating yourself so you can answer questions
  • Discuss pressure and coercion especially with your daughters – everyone is not doing it!
  • If teens have low self-esteem they are more likely to be promiscuous in order to be liked – work on boosting their self-esteem and frankly discuss feelings of value
  • Discuss safe sex

Resources

Challenges in Transitioning into Adolescence and Adulthood

Growing Up With ADHD: Clinical Care Issues, Thomas E. Brown

January 29 2016 Psychiatric Times, http://www.psychiatrictimes.com  

What We Know About ADHD and Driving Risk: A Literature Review, Meta-Analysis and Critique. Laurence Jerome et al, J Can Acad Child Adolesc Psychiatry. 2006 Aug; 15(3): 105–125

http://behindthewheelwithadhd.com/the-statistics/

How to Help Kids With ADHD Drive Safely. Extra precautions and clear rules pay off for kids at higher risk of accidents, Rae Jacobson, Child Mind Institute, https://childmind.org/article/how-to-help-kids-with-adhd-drive-safely