ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults
ADHD brains develop differently than neurotypical brains. In the adolescent years, this may mean explain increased risk for motor vehicle accidents, medication diversion, substance abuse, academic setbacks, and self-harm. It also means that families need to remain vigilant through the teen’s development and treatment in this critical period. Here is how.
In adolescence, ADHD is associated with a set of distinct and measurable challenges — executive dysfunction, increased risk for substance misuse and automobile accidents, stimulant medication diversion, emotional dysregulation, high-risk behaviors, and more. Robust, long-term studies confirm that, if unaddressed, these teenage challenges can impact quality of life and general functioning well into adulthood.
For best outcomes, clinicians must help patients and families understand how ADHD impacts the adolescent and young adult brain specifically, and how early care and interventions can have positive effects. If the conversations and interventions begin early, and a family’s vigilance remains high, teens with ADHD will grow and launch into remarkable young adults.
ADHD in Adolescents: Developmental Overview
ADHD Persists into Adulthood for Many
While symptoms of attention deficit hyperactivity disorder (ADHD or ADD) tend to decline and shift with time, it is the rule – not the exception – that the majority of teens with ADHD (75 percent) continue to experience ADHD in adulthood1. This fundamental aspect of the condition underscores the importance of creating supports and using strategies in earlier years that are built to last particularly through the critical transition from adolescence into young adulthood.
ADHD Adolescent Years and Brain Development
Significant brain growth, especially in the frontal lobe – the region involved in executive function skills like problem solving, conflict resolution, planning, and impulse control – occurs during the teenage years and continues until about age 25. With ADHD, however, brain development in this region is slightly delayed, meaning these skills may develop slowly.
Delayed frontal lobe development also makes regulating the limbic system – the circuitry associated with emotion, anxiety, reward, and risky behavior – more difficult. This differential brain development may explain some observable dysregulation and instability in adolescents with ADHD, and it builds a case for why families still need to remain involved and vigilant through the teen’s development in this period.
ADHD in Adolescents: Challenges and Impacted Areas
Increased Academic Demands
Teens with ADHD progressing through high school must navigate and tackle increasingly difficult workloads. There are more exams, more homework, a grueling and increasingly competitive college or trades application process, and more to keep track of generally compared to prior school years. Missed assignments and truancy, for example, may have serious consequences.
Extracurricular activities also come with increased demands, especially in college or the trades. In sports, for example, playbooks are becoming thicker and more complex. Increased competition makes for a higher level of play, and self-discipline is required to keep up with practice, training, diet, and other aspects of the game while also maintaining grades high enough to qualify for play.
The risk of dropping out of high school is higher in those with ADHD compared to peers without ADHD2, which has a strong influence over future income levels, hire-ability, and other realms.
Many individuals with ADHD struggle with social skills, and the transition to adulthood can highlight these challenges. Studies demonstrate that teens and young adults with ADHD tend to:
- Be less socially competent than their peers3
- Be involved in fewer social activities4
- Have fewer friends4
- Have delinquent friends5
- Be socially isolated5
Adolescents with ADHD may also be unreliable sources for assessing their social functioning, giving themselves overly optimistic appraisals of their skills3. To improve peer relationships, teens can join in person or on-line groups and activities that align with their interests and hobbies.
Substance Use and Misuse
ADHD is associated with greater risk of cigarette or nicotine vaping, recreational drug use and substance use disorders6, particularly in those untreated for their ADHD. About one-half of young adults with ADHD report recreational drug use compared to just over 30 percent in the neurotypical group2. This also includes cigarette smoking – the transition from adolescence to adulthood is where we see a dramatic increase with about 70 percent of teens with ADHD identifying as smokers compared to less than 40 percent of teens without ADHD2.
Substances are deleterious to the developing adolescent brain. Alcohol alone impacts learning, information recall, memory, and sleep. Marijuana use, especially before the age of 16, creates significant problems with the brain’s connectivity and capacity, and hampers executive functioning. On a positive note, long-term, large-scale studies show that early stimulant treatment lowers the risk of cigarette smoking and substance use disorders in individuals with ADHD7.
While highly effective, stimulant medication misuse and diversion is also a problem for teens and young adults with ADHD. Research suggests that up to 20 percent of youth have used stimulants non-medically, with the majority – up to 85 percent – diverting them from teens with ADHD and a stimulant prescription. Misperceptions around stimulants – that they’re harmless, that sharing is not illegal, and without ethical considerations – contribute to relatively high rates of misuse of stimulants. Immediate-release formulations are more likely to be misused than are extended-release formulas8, making a strong case for clinicians to prescribe extended-release medications when appropriate for adolescent patients with ADHD. Parents are encouraged to supervise and monitor their adolescent’s medications carefully; and in college or boarding schools, safe storage of stimulants-not in medicine cabinets-is highly recommended.
Other Comorbid Conditions
The risk for other comorbid conditions with ADHD is high, especially during the transition from adolescence into young adulthood. Depression and anxiety problems are perhaps the most common and pressing comorbid conditions among teens with ADHD. Treatment of young people with ADHD includes a focus not only on the ADHD, but also the comorbid conditions.
Research shows that treatment has a protective effect against the development of multiple comorbid disorders in individuals with ADHD9. But apart from stimulant misuse, teens with ADHD may face barriers to medical adherence for a number of reasons, including stigma, cost, side effects and insurance problems, plus simple lack of consistency.
The frequency of automobile accidents and violations is greater among teens with ADHD compared to their neurotypical peers. According to the National Highway Traffic Safety Administration, teens with ADHD are:
- Two to four times more likely to be in an automobile accident
- Four times more likely to be at fault for accidents
- Up to six times more likely to get speeding tickets
- Six to eight times more likely to have suspended licenses
All young people with ADHD should be aware of the increased risks for accidents-and to minimize distractions such as cell phones during driving. It is critical to note that the higher rates of motor vehicle accidents improve dramatically when young people with ADHD are receiving effective ADHD treatment9.
ADHD in Adolescents: Core Treatments
An effective treatment plan for youth with ADHD centers on ongoing education about possible challenges and interventions, and also has the following components:
- Awareness of the individual’s unique strengths and weaknesses
- Supports and interventions for areas of most need
- Collaborative monitoring by parent and teen of ADHD symptoms, activities, and habits
Accommodations and Self-Regulation Skills
If heading to college and the trades, teens and young adults with ADHD must accept that they will need to seek out help. Many accommodations available in the educational setting can be helpful, such as extended time for tests and additional help from writing and math tutoring centers.
The importance of tapping into one’s self-help skills is put to the test in college and early-occupational training. It is best for caregivers to help instill healthy habits — like adequate sleep and nutrition, exercise, and stress management — in early adolescence. They should check in with the young adult regularly by asking questions about how they’re covering these habits. Teens will also need to know how to independently create structure, and if receiving certain medications, how to study during medication coverage periods. Also consider reducing the academic load per semester, especially when transitioning to the tough first semester.
Outside the college route, families can consider vocational assessment and career counseling to explore options for their teen. Many occupational fields offers training with some type of accommodations.
Cognitive behavioral therapy (CBT) for ADHD is an effective treatment that improves ADHD symptoms and self-management overall, and new research shows that it is specifically effective for young people with ADHD. In this therapy, patients learn to compensate for residual symptoms and are taught to see their patterns of thought , emotion, and behavior and their consequences. Group and individual modes are available, and both settings are helpful.
Medicines should not be promoted as cure-alls, but they are helpful for ADHD, . Stimulants are first-line treatments, followed by non-stimulants, antidepressants, and other empirically based medications. The patient and clinician should work with the goal of reducing target symptoms by about 50 percent.
To ensure medical adherence, clinicians and/or parents can suggest a reminder system at home, or offer more information on engagement programs (designed to boost independence and self-advocacy, which may help reduce negative feelings toward medication)
The adolescent to young adult transitional years mark an important period for independence and development. ADHD in not a cosmetic or trivial disorder; it brings with it struggles, suffering, and impairment. Now, can you harness ADHD and use it to your benefit? Absolutely, yes. Knowing yourself existentially will help you do that. With the right care and special attention, teens with ADHD will grow and flourish as they transition to adulthood.
ADHD in Teens: Next Steps
- Read: When ADHD Meets Puberty
- Understand: Warning Signs of Conduct Disorder in an Oppositional Teen with ADHD
- Learn: Abandon Your Pre-Conceived Notions of ‘Success’ (and More Advice for Parents of Teens with ADHD)
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The content for this article was derived from the ADDitude Expert Webinar “Navigating the Life Stages of ADHD: Key Concerns in Diagnosing and Treating Adolescents” by Timothy E. Wilens., M.D. (available as ADDitude ADHD Experts Podcast episode #321), which was broadcast live on August 26, 2020.
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2Biederman, J., Faraone, S. V., Spencer, T. J., Mick, E., Monuteaux, M. C., & Aleardi, M. (2006). Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. The Journal of clinical psychiatry, 67(4), 524–540. https://doi.org/10.4088/jcp.v67n0403
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4Bagwell, C. L., Molina, B. S., Pelham, W. E., Jr, & Hoza, B. (2001). Attention-deficit hyperactivity disorder and problems in peer relations: predictions from childhood to adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40(11), 1285–1292. https://doi.org/10.1097/00004583-200111000-00008
5Greene, RW., Biederman, J., Faraone, SV., Sienna, M., Garcia-Jetton, J.Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: results from a 4-year longitudinal follow-up study. J Consult Clin Psychol. 1997; 65: 758-767
6Wilens, T. E., Martelon, M., Joshi, G., Bateman, C., Fried, R., Petty, C., & Biederman, J. (2011). Does ADHD predict substance-use disorders? A 10-year follow-up study of young adults with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 50(6), 543–553. https://doi.org/10.1016/j.jaac.2011.01.021
7Boland, H., DiSalvo, M., Fried, R., Woodworth, K. Y., Wilens, T., Faraone, S. V., & Biederman, J. (2020). A literature review and meta-analysis on the effects of ADHD medications on functional outcomes. Journal of psychiatric research, 123, 21–30. https://doi.org/10.1016/j.jpsychires.2020.01.006
8 Timothy Wilens, Courtney Zulauf, MaryKate Martelon, Nicholas R. Morrison, Andrew Simon, Nicholas W. Carrellas, Amy Yule, Rayce Anselmo. Nonmedical Stimulant Use in College Students. The Journal of Clinical Psychiatry, 2016; 940 DOI: 10.4088/JCP.14m09559
9Biederman, J., Monuteaux, M. C., Spencer, T., Wilens, T. E., & Faraone, S. V. (2009). Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics, 124(1), 71–78. https://doi.org/10.1542/peds.2008-3347