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

Dr. Sam Goldstein describes the many risks and vulnerabilities teenagers with AD/HD face.

By Sam Goldstein, Ph.D.

Attention-Deficit/Hyperactivity Disorder (AD/HD) is characterized by a constellation of problems caused by symptoms related to inattention, hyperactivity, and impulsivity. These problems are developmentally inappropriate and cause difficulty in daily life. At one time AD/HD was considered a disorder of childhood, and it was thought that the symptoms of AD/HD diminished by the late adolescent years. The experiences of clinical practice and well-documented research, however, have shown that a significant number of children with AD/HD carry their symptoms and impairment into the adolescent years and on into adult life.

In many ways, the responsibilities and demands placed upon adolescents in comparison to children require an increase in competence and self-discipline, because teens in our culture are able to participate in many adult activities such as driving, surfing the Internet, and using substances (e.g., drinking alcohol and smoking).

The Nature of AD/HD

According to the revised fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) - the standard diagnostic manual used throughout the world - Attention-Deficit/Hyperactivity Disorder encompasses three basic diagnoses: AD/HD-Inattentive Type, AD/HD Hyperactive/Impulsive Type, and AD/HD-Combined Type. AD/HD is a biopsychosocial disorder, which means there are strong genetic, biological, experiential, and social factors that contribute to the severity of impairment experienced by individuals with AD/HD. (Though teenagers with the Inattentive Type of AD/HD may be somewhat less vulnerable to these problems than those with the Combined Type of AD/HD, the diagnosis, regardless of subtype, speaks to significant risk.)

Approximately one in fifteen adolescents meets the criteria for symptoms and consequent impairment for a diagnosis of AD/HD. Early identification and proper treatment has been found to dramatically reduce the family, educational, behavioral, and psychological problems and risks experienced by youth receiving this diagnosis. Such problems include:

  • school failure and dropout
  • depression
  • behavioral disorders
  • vocational problems (into the adult years)
  • relationship problems (into the adult years)
  • substance use and abuse

Fortunately, it has been demonstrated that accurate diagnosis and proper treatment help manage or prevent the myriad of life problems experienced by a significant percentage of youth with AD/HD.

The Role of Self-control

An increasing body of current research suggests that the true nature of AD/HD lies in the inability of some individuals to develop effective self-discipline or self-control. It is not so much that individuals with AD/HD cannot pay attention but that they do not effectively regulate their attention, emotions, and behavior. AD/HD interferes with a teen's ability to sustain attention, particularly when self-control is required (e.g., while performing repetitive tasks). AD/HD impairs the ability to effectively manage one's emotions, activity level, and inhibition. Inhibition is the ability to prevent the impulsive expression of dominant urges so as to permit time for self-regulation. When it comes to behavior, teenagers with AD/HD appear to know what to do but do not consistently do what they know is appropriate . This is due to their inability to efficiently stop and think before responding, regardless of the setting or task. Thus, these teenagers seem to defy common sense. They understand the risks associated with their behavior, yet their limited capacity for self-control is often quickly overwhelmed, frequently leading to "non-thinking" behavior and a myriad of problems at school, home, with peers, and in the community. There is also research that suggests individuals with AD/HD are more likely to seek novelty and stimulation leading to risky behavior.

AD/HD can be thought of as a catalyst, which, under certain conditions, can "fuel" an extreme reaction. Consider this: If you place a teenager with AD/HD in a supportive context, the symptoms of AD/HD will cause problems but may not represent a significant risk through the adolescent years. But research to date shows these symptoms certainly do not represent an asset. If you were to place that same teen with AD/HD in a dysfunctional family, expose him to a poor school environment and other significant life stresses, add to that a lack of appropriate treatment for the condition, then AD/HD would represent a significant formula for risk and vulnerability during his teen years. In the face of adversity, the capacity to plan, inhibit, and consider alternatives and actions is a significant asset - one that teenagers with AD/HD typically lack.

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.

The Impact on School Performance

Youth with AD/HD have also been found to perform lower than those without AD/HD on measures of intelligence. However, they still perform within the normal range. It is quite likely that they are not less intelligent but less efficient in taking intelligence tests. It does not appear that the problems teenagers with AD/HD experience and the risks they present result from below average intelligence.

Teenagers with AD/HD also under-perform in school relative to what would be expected based upon their academic and intellectual abilities. In fact, approximately one-third of youth with AD/HD experience academic skill weaknesses causing achievement problems consistent with learning disabilities. By high school, as many as two-thirds of teens with AD/HD fall behind in basic academic subjects due to lack of practice needed to develop academic proficiency.

Teens with AD/HD are more likely to drop out of school and not progress as far in post-high school education as would be predicted by their abilities or by their siblings'performance. Ultimately, teens with AD/HD who struggle in school enter the workforce at a lower level.

Overcoming Risk with Resilience

AD/HD leads to a failure to develop efficient self-discipline and self-regulation, critically important skills for all teenagers. Thus, impairments in all areas of life are intensified when teens struggle with AD/HD. Teenagers with AD/HD demonstrate significant levels of co-occurring psychiatric problems and are at higher risk than others to engage in risky behaviors. I will explain the most common types of risky behavior in the second article in this series.

The good news, however, is that researchers are also increasingly identifying those thoughts, feelings, behaviors, skills, and experiences that appear to protect and insulate teenagers with AD/HD, helping them develop resilient traits and mindsets and thereby increasing the probability of successful transition into adult life. Those traits - and methods for helping teens with AD/HD develop them - is the topic of the third article in this series.

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)

Attention Disorder

Sam Goldstein, Ph.D. is a Clinical Professor of Psychiatry at the University of Utah, a Research Professor of Psychology at George Mason University and Director of the Neurology, Learning and Behavior Center in Salt Lake City, Utah. He is Editor-in-Chief of the Journal of Attention Disorders, author, co-author or editor of 26 books and dozens of book chapters and peer reviewed research articles.


Comments from GreatSchools.org readers

05/31/2011:
"Very insightful information, my son and I are both diagnosed with adhd and have numerous underlining co-morbidities, which you portray brilliantly. We have both met with much adversity and it's very refreshing to read an unbiased opinion. Many thanks. "
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