Boys vs. Girls: How Puberty Affects ADHD Symptoms
Hormonal changes directly impact most adolescents’ ADHD symptoms. But the shift can look different for males and females. Here’s what to watch out for — and how you can help your child navigate the changes of puberty.
When ADHD, adolescence, and puberty collide, the teenage years can take a harrowing turn. The emotional and social changes of adolescence, compounded by the hormonal and physical riptides of puberty, add layers of struggle for tweens and teens with ADHD.
“Adolescence is a critical period for children with ADHD,” says Joel Nigg, Ph.D., clinical psychologist and professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. “First, it’s the period when the most serious risks for negative outcomes occur — for example, substance abuse, engagement in delinquent behavior, problems with regrettable internet use, or serious accidents such as traffic accidents. However, it’s also a period when a subset of youth with ADHD seem to begin to recover and their symptoms improve.”
In one way or another, hormonal changes directly impact most adolescents’ ADHD symptoms. Puberty’s physical influence on ADHD is undoubtedly more intense for girls, but it shouldn’t be minimized for boys.
ADHD and Puberty in Boys
Changing testosterone levels during puberty is associated with greater risk-taking behavior among boys. “Testosterone also interacts in complex ways with dopamine and other hormones that are relevant to ADHD,” Nigg explains. “Thus, we might speculate that boys with ADHD may be more susceptible than other boys to the risk-enhancing elements of pubertal testosterone, and this may be related to greater risk for substance abuse among youth with ADHD.”
These “raging hormones” can cause intense physical and psychological changes, both of which teens often find distressing at a time when they desperately want to fit in. That’s why many kids who cooperatively took medication in elementary school begin to protest and rebel when they hit puberty: They simply want to be more like their peers.
If your adolescent suddenly refuses treatment, try to understand and help. Ask your child why he isn’t taking his medication. Listen, discuss his concerns, and make adjustments that work for both of you. He could merely be forgetting to take his pill(s). On the other hand, he may be attempting to deny his ADHD. If your teen insists on not taking medication, propose a trial period without medication, and then meet to assess how things — including schoolwork, extracurricular activities, and relationships — are going.
ADHD medication changes aren’t automatically required or assumed when a boy enters puberty. Even significant weight increases may not warrant an increased dose. If your son’s current dose still works, don’t change it. If it seems to be losing effectiveness, then talk with his doctor about an adjustment.
All children need to feel accepted by peer groups. If lifelong ADHD symptoms have resulted in poor social skills and limited success with friends, early adolescence may be painful, lonely, and dangerous. Socially rejected boys with ADHD frequently latch on to other “misfits” who don’t do well in school or sports. The combination of a fringe peer group, the need to be accepted, and low self-esteem places teens with ADHD at heightened risk for trying alcohol and drugs. Learn the signs of substance abuse and, if you suspect it, get help.
Lastly, individuals with ADHD face an increased risk for comorbid disorders — two or more conditions that occur at the same time. Depression and anxiety often first show up between the ages of 8 and 12, and again in early adolescence. Watch your son for symptoms and seek help if you think there’s a problem.
Also watch for signs of Conduct Disorder and Oppositional Defiant Disorder, which are marked by antisocial, hostile, and unusually adversarial behavior. These disorders frequently place impulsive boys with ADHD in dangerous or even criminal situations. Intervention is imperative.
ADHD and Puberty in Girls
The hormones that lead to rebellion and risky behavior in teenagers in general can have profound effects on girls with ADHD, who typically start puberty between ages 9 and 11, and get their periods between 11 and 14.
“We found that girls with ADHD in their early teens have more academic problems, more aggressive behavior, earlier signs of substance-related problems, and higher rates of depression than girls who don’t have the condition,” says Stephen Hinshaw, Ph.D., professor and chair of the department of psychology at the University of California, Berkeley, who has been studying girls with ADHD for more than 10 years. “Unlike teenage boys with ADHD, who tend to act out, girls with ADHD often internalize their problems. This makes their struggles easier to overlook.”
Hormonal changes at puberty — especially the higher levels of estrogen and progesterone — can cause the efficacy of ADHD medications to wane. “Studies have shown that estrogen may enhance a woman’s response to amphetamine medications, but this effect may be diminished in the presence of progesterone,” says Patricia Quinn, M.D., co-author of Understanding Girls with ADHD.
The average menstrual cycle is about 28 days, counting from the first day of a woman’s period. During the first two weeks, known as the follicular phase, levels of estrogen rise steadily, while progesterone levels are low. Estrogen promotes the release of the feel-good neurotransmitters serotonin and dopamine in the brain. Not surprisingly, studies suggest that the first two weeks of the cycle go more smoothly for women with ADHD than do the second two weeks, when progesterone levels rise.
During the third and fourth weeks, called the luteal phase, rising progesterone diminishes the beneficial effects of estrogen on the brain, possibly reducing the effectiveness of stimulant medications. That’s a perfect storm resulting in intense ADHD symptoms at certain times of the month, even creating cognitive fog the week before a girl gets her period.
Quinn believes that women with ADHD experience premenstrual syndrome (PMS) more acutely than do women who don’t have the condition. “Feelings of depression and anxiety typically worsen in women with ADHD during this time,” says Quinn. The good news? Treating ADHD can improve PMS symptoms, too.
Discuss different medications — or different dosages of current medications — with your daughter’s doctor. It may take time to figure out what works best, so be patient.
In the meantime, behavioral strategies for time management and improving organizational skills can help. If your daughter notices that her ADHD symptoms worsen at certain times of the month, encourage her to complete schoolwork before they hit. Have her prepare for a big test or finish writing a paper a week before it’s due, if possible.
“Identify your daughter’s strengths and emphasize them during the worst times of her cycle,” says Kathleen Nadeau, Ph.D., director of the Chesapeake ADHD Center of Maryland. “Be patient with your daughter if she becomes argumentative or snippy,” Nadeua says. “Instead of yelling, suggest that she rest for a while. You’ll be teaching her self-management skills.”
What Parents Can Do
Nigg advises a series of risk-reducing steps, the first of which is to maintain excellent parent-child communication. “The communication must be non-judgmental,” Nigg says. “Educate your teen, in a minimally-invasive way, on how to handle herself around major risks — internet use, social media, drugs, friends engaging in delinquent pranks or more serious illegal activities, peer pressure, automotive safety, and firearms safety for youth who are or might be exposed to firearms.”
Second, a healthy lifestyle is critical. A child who is well-rested, well-nourished, getting enough exercise, and managing his or her stress well is much less likely to fall prey to impulsivity-related dangers in a moment of weakness. Keep a close eye on your teen’s stress level and provide support and guidance when you see overload approaching.
Many parents of teens with ADHD worry about diminishing motivation. “Many youth become demoralized during the teen years, after an accumulation of many social and academic setbacks, as well as family conflict,” Nigg advises. Demoralization can contribute to diminishing motivation. Offer your child many opportunities to participate in activities that boost self-esteem. “This can be anything from sports, to a hobby, to a responsibility, like caring for a younger child, which is affirming to their ability, value, and capacity to contribute.” It’s critical to work on turning around damaged family relationships by nurturing more positive interactions, as well.
Additionally, insufficient sleep is an obvious biological explanation for decreasing motivation. And it’s very common since teen bodies crave lots of sleep in the morning hours, yet society dictates that they be at school bright and early each morning. Nigg says teens should get between 9 and 10 hours of sleep a night, but he acknowledges that it’s a very real challenge. He offers further guidance on helping your child get sufficient sleep in his book Getting Ahead of ADHD.
Compassion and working to understand your teen’s current experience go a long way to keeping him or her from getting derailed by puberty and adolescence. Creating a positive parent-child relationship, offering self-esteem-building activities, affirming efforts, extending non-invasive guidance, and supporting a healthy lifestyle will all help your teen make it through puberty on a favorable track.
Larry Silver, M.D., is a member of ADDitude’s ADHD Specialist Panel.