AD/HD and Adolescence: A Formula for Risk and Vulnerability

By Sam Goldstein, Ph.D.

Risk and Vulnerability

Teenagers with AD/HD exhibit considerably higher frequencies of psychiatric conditions than found in the general population. These conditions fall into two broad categories: externalizing and internalizing.

Externalizing conditions cause disruption to others interacting with the child. The externalizing conditions related to AD/HD include:

• Oppositional Defiant Disorder (ODD) - a resistance to following rules and limits and a pattern of impulsive, spiteful, or vindictive behavior. In clinic studies, between half and two-thirds of teenagers diagnosed with AD/HD are also given diagnoses of Oppositional Defiant Disorder.
  
  
• Conduct Disorder (CD) - a pattern of behavior beyond simple resistance and defiance in which the rights of others and community rules are repeatedly violated. Up to a third of clinic-diagnosed youth with AD/HD also receive a diagnosis of Conduct Disorder.

Although ODD and CD are not caused by AD/HD, they can be "fueled" by the condition. The combination of AD/HD and ODD or CD places these teens at risk to develop a number of adverse personality styles, including antisocial, dependent, and borderline traits into their adult years. CD is also a strong predictor of experimentation with substances such as tobacco and alcohol, and is strongly associated with later substance dependence and abuse.

Internalizing problems cause discomfort for the affected child but not for others. The internalizing disorders related to AD/HD include:

• Depression - anywhere from one-third to two-thirds of teens with AD/HD are reported to experience at least one major depressive episode and a high rate of dysthymia (low grade chronic depression) during the teenage years.
  
  
• Anxiety - teenagers with AD/HD also experience a higher than expected rate of anxiety problems. Approximately one-third of children with AD/HD struggle with sufficient worry to warrant a diagnosis of Anxiety Disorder.

The Role of Executive Function

Compared to unaffected teens, teenagers with AD/HD have been reported to perform poorly on a variety of neuropsychological measures assessing executive functioning - the skills necessary to negotiate everyday life. Though still not well-defined, executive functions include:

• inhibition
• working memory
• resistance to distraction
• strategy development
• planning
• future-directed behavior
• flexibility
• problem solving
• organization

It's easy to understand how failure to develop efficient self-discipline leads to vulnerability in developing the functional skills listed above. It is not just that "biology is destiny," but rather it increases the risk of problems, making life - and ultimately transition into adulthood - more complex and difficult for youth with AD/HD.