Parenting and Adolescents With AD/HD: An M.D.'s Advice
Does your teenager have AD/HD? Learn how to keep lines of communication open while promoting his indpendence.
By Shashank V. Joshi, M.D.,FAAP
Many parents wonder what kinds of challenges and changes kids with Attention-Deficit/Hyperactivity Disorder (AD/HD) experience during their teen years. Dr. Shasank Joshi, a pediatrician and child psychiatrist, answers:
Parents are often interested in knowing whether puberty will lead to specific physical and emotional changes in their teens with AD/HD. Contrary to popular belief, teens do not routinely go through a "really hard time" adjusting to puberty and the developmental tasks of adolescence. According to some classic work by Conger (1977), there are at least five such tasks for the average teen:
- To become independent from his parents;
- To establish an identity/find out who he is and what he stands for;
- To learn how to make deep, close interpersonal bonds with members of both sexes;
- To understand and come to terms with his emerging sexuality;
- To complete his education and decide on a career direction.
Robin (1998) expands on this, and comments that a teen is expected to successfully complete these tasks while getting along with his family and doing his schoolwork!4 So, although puberty per se may not predispose teens with AD/HD to different problems than teens without the condition, it may be that adolescence as a period of development is more contentious for a teen with AD/HD. In this article, I'll address questions parents often ask about AD/HD in teenagers.
Do teens struggle with anxiety and acceptance of their AD/HD?
When a child with AD/HD reaches early adolescence (age 11-14) several factors may affect his ability to cope. They include:
- the severity of the teen's AD/HD
- the family environment4
- the presence of co-morbid problems/disorders in the teen. Such conditions commonly may include learning disabilities, mood disorders, anxiety disorders, and disruptive behavior disorders, including Oppositional Defiant Disorder or Conduct Disorder.
Even if a teen doesn't meet diagnostic criteria for any of the disorders listed above, he and his family may have a hard time adjusting to this adolescent stage. Younger teens typically have the most trouble accepting that they have AD/HD, and they're often less eager to try ways to cope with it, such as classroom modifications, behavioral interventions, or medication management. Older adolescents (aged 15-19) are usually better able to acknowledge and accept their AD/HD, and are often more willing to actively deal with their problems.
Although most teens with AD/HD are not "worriers," they may experience more nervousness than when they were younger. This may actually be due to a sort of performance anxiety in the context of their new developmental tasks.4 For the first time, they may notice that they're "different" from their peers, and may lack confidence in social, family, and academic situations. When faced with an unexpected crisis or asked to perform a job/task for which they are not prepared, they may overreact emotionally and display (temporary) panic and/or anxiety symptoms. In fact, some research indicates that up to 35% of teens with AD/HD have a diagnosable co-morbid anxiety disorder (compared to 9% of their non-affected peers).1
Do AD/HD symptoms change during puberty?
During adolescence, kids with AD/HD may experience several changes, as summarized in the work of Lily Hechtman, M.D.2 While a small group of children actually seem to "outgrow" their AD/HD, the majority continues to have significant problems with regard to attention, concentration, and impulse control. These may continue to impair their functioning, both at school and at home, and negatively impact their self-esteem and their ability to achieve some of the necessary developmental tasks of adolescence.
A small group of teens with AD/HD may develop patterns of antisocial behavior and/or substance abuse. In fact, those at highest risk for the latter are those whose AD/HD has not been treated or managed properly. (Early treatment for children with AD/HD may have a direct positive effect on decreasing later substance abuse as teenagers.3)
Are there behavior differences between adolescent boys and girls with AD/HD?
Girls are more often diagnosed with the "Inattentive" subtype of AD/HD than other types. Even though boys are diagnosed with all types of AD/HD more often than girls, having the inattentive type often allows girls to get through their elementary school years relatively "normally," though they may have been struggling all along. Perhaps due in part to societal expectations, a girl with AD/HD may not be the "squeaky wheel" that gets the teacher's attention and is regularly sent to the Vice Principal due to disruptive behaviors. Contrast this to the inattentive, noisy, impulsive, fidgety boy, who is the prototypical child with AD/HD. A girl with AD/HD may begin to show the most difficulty as the school work gets harder, and when sustained attention, organization, and concentration become crucial to success (as in middle school).
Facts to consider before talking with your teen about AD/HD
Before discussing AD/HD with your teenager, you'll want to understand the cause and effects of the condition. Keep the following facts in mind:
- AD/HD has a biological basis. Brain chemicals called neurotransmitters carry signals for self-control, attention, and concentration throughout the brain. And although everyone has neurotransmitters, they need to be better regulated and rebalanced in people with AD/HD.
- AD/HD involves difficulties with paying attention, acting before thinking, and feeling/acting restless or fidgety. For example, if you have AD/HD, an idea to do or say something will pop into your head and you may have a really hard time stopping and thinking about whether it's good or bad, or about the consequences. It's like having too little brake fluid in your car; when you press the brake pedal it's a lot harder to stop than if you had a full amount of fluid.4
- Environment has a lot to do with how well a person adjusts to having AD/HD. You, other family members, school staff, and your child's friends can all help your teenager succeed. For example, if keeping schoolwork organized is a struggle for your teen, you might help him choose - and learn how to use - a personal organizer.
What to tell your teen with AD/HD
Many authors have written thoughtfully on this topic.2, 4, 5 Here are some suggestions for what to tell your teenager:
- AD/HD is nobody's fault - not yours, mine, or your teachers'!
- You're not "crazy" if you have AD/HD. Almost all people have some attention or focus problems at some point in their lives. Teens and adults with AD/HD just have much more trouble managing these symptoms than most people.2,4
- AD/HD usually lasts a lifetime, but your symptoms and manifestations may change as you get older. For example, as you grow up, you may become less hyperactive (e.g., "bouncing off the walls"), but you may experience more mental restlessness.4
- AD/HD can affect many areas of your life besides school. It can influence how you get along with others, how you do in sports and hobbies, how you feel about yourself, how organized you are, and how well you perform on the job.2,4
- AD/HD is usually inherited, so someone else in the family may have it too, even if they haven't been given a diagnosis. Your kids may have it someday as well.4,5
- Think of AD/HD as a challenge, not an excuse. You are still responsible for your actions, even though you have a condition that makes it harder for you to control your behavior and attention span.4
- Your physical health influences how much control you have over the symptoms of AD/HD. The better you take care of your body, the better you'll adjust to the challenges of living with AD/HD. So try to eat right, get enough sleep and exercise, and avoid putting harmful chemicals (like nicotine, marijuana, and alcoholic beverages) into your body.4
- At this point there is no cure for AD/HD. The good news is that there are many ways people can successfully cope with it. We're going to work with your teachers and doctor as a team, to help you to be the best you can be.4
What risky behaviors do some teens with AD/HD engage in?
There are data from scientific research to indicate that teens with AD/HD are more likely to get into car accidents, to have lower self-esteem, and to have more negative risk-taking behaviors (including substance abuse, especially if they go untreated) than their peers without the disorder. This makes it especially important that kids be assessed and treated as early as possible.
What can parents do if their teen refuses to take medication for AD/HD?
It's very important for a teen to feel that he's the "captain of the ship" regarding his treatment, and that his parents and other adults (e.g., teachers) are in more of a supporting role. This is especially true of taking medication, which can have deep psychological meaning for a teen. Selected research assessing teens' perceptions of stimulant medications showed that the two most important factors influencing whether or not they would take the medication are: 1) the perception that taking medication makes them feel as if there's something wrong with them, and 2) feelings of embarrassment about receiving the medication publicly.6 Many doctors believe teens should retain "veto power" over most, if not all, decisions regarding medication.4, 8 However, a system of checks and balances also means that parents can restrict certain privileges if the teen elects not to follow the treatment plan. For example, for safety reasons, parents may withhold driving privileges from a teen who refuses to take his medication for AD/HD.4, 8
How can parents offer their teens with AD/HD independence but still provide necessary structure and supervision?
As discussed earlier in this article, realize that it's natural for most teens to want individuation from their parents; this is a normal developmental task of adolescence. Although teens with AD/HD feel they should have exactly the same rules and privileges as their non-affected peers, parents of teens with AD/HD have good reason to be extra-vigilant. Barkley (1995) and Robin (1998) offer these supervision tips for parents of teens with AD/HD4, 9:
- Be firm but discreet. For example, if your teen's curfew is a little earlier than his peers', you might arrange to pick him up around the corner from the party where all of his friends are hanging out (thus avoid making an unexpected parental appearance).
- Hold regular family meetings to discuss problems and propose solutions to family conflicts.
- Use behavior contracts, especially those which reward positive behavior and voluntary acts of helpfulness by your teen. This is important even if the behaviors are what you "expect your kid to do anyway, without being rewarded" (e.g., doing his fair share of chores, being nice to his siblings, and speaking respectfully to adults).
- Be an authoritative parent with a firm, warm, and loving approach. Set rules which involve your teens in decision-making, provide reasons for rules, and give frequent positive regard and focused (non-lecturing!) time to your teen. Though this is probably the best style for parenting adolescents in general, it is especially good for those with AD/HD, in that it fosters independence, yet still allows parents to provide adequate structure.
AD/HD by Other Names and Acronyms
While Attention-Deficit/Hyperactivity Disorder (AD/HD) is the official term and acronym used by today's mental health care professionals, it is sometimes referred to by other names and abbreviations. For example, it is sometimes called:
ADHD (without the "slash" in the middle)
Attention Deficit Disorder (ADD)
- Biederman J, Faraone S, et al (1996): A prospective 4-year follow-up study of Attention-Deficit Hyperactivity and related disorders. Archives of General Psychiatry , 53, 437-446.
- Hechtman LT (1992): Long-term Outcome in Attention-Deficit Hyperactivity Disorder. Child and Adolescent Psychiatric Clinics of North America, 1, 553-565
- Wilens TE, Faraone SV, Biederman J, and Gunawardene S (2003): Does Stimulant Therapy of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse? A Meta-analytic Review of the Literature. Pediatrics, Jan; 111(1): p. 179-85
- Robin AL(1998): ADHD in Adolescents, NY: Guilford Press
- Guyer BP (2000): ADHD: Achieving Success in School and in Life, Boston: Allyn & Bacon
- Bowen J, Fenton T, & Rappoport L(1990): Stimulant medication and Attention-Deficit Hyperactivity Disorder: The child's perspective. American Journal of Diseases of Childhood, 145, 291-295.
- Conger JJ (1977): Adolescence and Youth: Psychological Development in a Changing World. NY: Harper
- Joshi SV, Khanzode L, Steiner H (2003): Psychological issues in pediatric medication management, in: Steiner, Handbook of Mental Health Interventions in Children and Adolescents: An Integrated Developmental Approach, SF: Jossey-Bass
- Barkley RA (1995): Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. NY: Guilford Press