Q: I have a child with Attention Deficit/Hyperactivity Disorder (ADHD). Knowing that adolescence is a difficult stage for some children, I am especially concerned that his ADHD may stress our family even further. A famous movie star recently commented that ADHD might not even be a true diagnosis; it is over treated and children may become drug-addicts because of an overly aggressive approach by some doctors. What am I to do now?
A: Attention Deficit/Hyperactivity Disorder (ADHD) is the most common mental disorder in childhood. It is a very real diagnosis with a strong family history. No single gene for ADHD has yet been found. However, it is more likely that several genes will be found in the future.
According to a superb book on this topic, ADHD: A Complete and Authoritative Guide, written by Michael I. Reiff, MD, FAAP (published by the American Academy of Pediatrics), close relatives of people with ADHD have approximately five times greater than random chance of also having ADHD. As for a sibling, he or she has a 30% chance of having a similar problem.
The majority of medical experts agree that as a child grows, his or her ADHD symptoms are expressed in different ways. As well, the diagnosis of ADHD persists into adolescence in at least 65% of children who were diagnosed at an earlier age.
The clinical picture of an adolescent with ADHD is, like adolescence itself, much different from the rest of the population. Normal adolescents frequently believe they are a unique species, much to the chagrin of those who have to live closely with them. So for many parents of adolescents with ADHD, life is extra challenging!
The features of ADHD during adolescence may be more salient than during childhood. Hyperactivity, so often seen in younger patients, becomes less visible during adolescence. Then as cognitive demands increase and the adolescent is expected to become more independent (while adult supervision shrinks), academic problems jump to the front page. As their social environment changes, adolescents with ADHD also experience additional problems: poor peer relationships, substance abuse, earlier experimentation with smoking, drugs and sex, dangerous driving, anxiety, disorganization, depression, procrastination, a shorter fuse, easier frustration and other mood disorders.
According to a recent review article published in Pediatrics (June 2005), the authors state that anywhere from 25% to 75% of adolescents with ADHD also meet the diagnostic criteria for Oppositional Defiant Disorder (ODD). In short, a child diagnosed with ADHD as well as ODD is that much more difficult to deal with; ODD behaviors create conditions which are extremely stressful to deal with for the child, parents, schools and society as a whole.
Adolescents are difficult to assess when trying to diagnose ADHD. Obtaining a consistent history and accurate information for diagnosis can be difficult for many reasons: adolescents value their independence and privacy; they typically have more than one teacher; parents and teachers often do not agree on the severity and frequency of symptoms; less structured settings (such as cafeterias, hall ways and buses) are not ideal; and symptoms are frequently under-reported on self-reporting scales.
Unfortunately, up until now, the adolescent with ADHD has too often "fallen through the cracks". The reason for this appears to be two-fold: first, more focus is placed on younger, newly diagnosed patients; second, people are influenced by popular books, such as Driven to Distraction by William Hallowell. Hallowell is a well-known physician from Harvard and influential speaker on the topic of adults with ADHD, who himself was diagnosed with ADHD only in adulthood.
When making the diagnosis of ADHD for the first time in adolescence, some clinicians unfortunately forget to factor in the effects of recurrent drug use (especially marijuana) or frequent alcohol misuse with regard to the patients inattentiveness. As a result, ADHD may be over diagnosed during this stormy time of growing up!
Contrary to the inaccurate observations and opinions of one outspoken celebrity, there is no evidence that the medical treatment of children and adolescents with ADHD causes an increase in substance use and abuse. Appropriate treatment of adolescents with ADHD does not increase the risk of drug-addictions.
While it is important to note that young patients with ADHD are at an increased risk for developing substance abuse as they grow older, close to twice that of individuals without ADHD, a recent meta-analysis study (which looks at a combination of many studies) found the use of medication by people with ADHD was in fact protective with respect to substance abuse. Interestingly, this effect was stronger among adolescents when compared with adults.
Treatment of adolescents with ADHD remains a major challenge. Unfortunately, the diagnosis of ADHD still carries a stigma, despite efforts to compare it with less stigmatizing conditions such as asthma or poor eyesight. With the latter, it is clear the patient is not at fault; there is nothing about their condition they caused themselves - they were simply born with it. The same consideration has not yet been applied to those with ADHD.
Adolescents with ADHD need to be reminded that they are not "bad”, "damaged", "stupid", "deranged" or mentally incompetent. Having ADHD should not be seen as a reflection of their intelligence. Despite efforts to destigmatize ADHD and it’s treatment, as many as 68% of adolescents stop taking their medications at some point.
Newer long-acting medications such as Concerta and Strattera (For more information, see www.healthykids.ca and click on “Parent Resources”) have been associated with better patient compliance. Other important factors which contribute to better compliance include: family stability, good self image, a sense of being in control, lack of side effects, and a trustworthy, patient, supportive physician with good verbal and nonverbal skills.
Additional treatment to medication includes psychosocial interventions such as behavioral therapy, academic interventions and family therapy. The National Resource Center on ADHD (www.help4adhd.org/en/education/college) and the Attention Deficit Disorder Association (www.add.org) provide further resources to patients and families who want more information.
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