Adolescence

Attention-deficit/Hyperactivity Disorder (ADHD) is a world-wide, neurodevelopmental disorder manifesting itself during early development and its prevalence in adolescence is well documented (Adler et al., 2015; World Health Organization, 2022b). This disorder may not be easily detected during adolescence due to an individual’s improved level of self-control (Wender, 2000).  Neurodevelopmental disorders frequently co-exist with one another, and ADHD is often associated with Conduct Disorder and Oppositional Defiant Disorder during adolescence (Wender, 2000). It is estimated that 45% of adolescents with ADHD will have conduct disorder, with males more likely to be diagnosed (Renzoni, 2022). ADHD is present in 7.2% of children world-wide and this number diminishes somewhat during adolescence (APA, 2013b; Wender, 2000). Symptoms of ADHD are present in all individuals, but it is the intensity, persistence and patterns which differentiates it from the norm (Wender, 2000).

Attention Deficit Hyperactivity Disorder 

Attention-deficit/Hyperactivity Disorder (ADHD) is caused by brain chemistry and genetics impacting upon the dopamine transporter gene and receptors causing varying reactions to stimuli (ADHD Support Australia, 2022; APA, 2013b). As described in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; APA, 2013b) ADHD is a condition which refers to those individuals who display inattention or hyperactivity and impulsivity or a combination of these. Individuals may present as a student with persistent and impaired difficulties in various areas including academic, motor skills, social and psychological domains (ADHD Support Australia, 2022; Rogers, 2021). However, these delays are not specific to ADHD (APA, 2013b). Often academic performance is below that of peers, whereas others may be identified as exceeding satisfactory outcomes, until tasks are completed under test conditions (ADHD Support Australia, 2022; APA, 2013b).  Generally, a decrease in blood flow in the pre-frontal cortex is responsible for impaired executive functions, such as memory, planning and attention (ADHD Support Australia, 2022).

Individuals who have ADHD may present as distractible, restless, accident prone, hasty, attention seeking, poor coordination, emotional, appear immature or even overly domineering when interacting with others (Wender, 2000). Most importantly it should be recognised that ADHD is not outgrown but can be in partial remission if some criteria is no longer experienced for over 6 months (APA, 2013b; Resnick, 2005). A key protective factor is a carer’s parenting style and their interactions with their adolescent (Wender, 2000).  A negative parenting style may be maternal, overprotective, controlling, rejecting, inconsistent, overly angry, lack involvement, critical, provide limited emotional support or intellectual stimulation which subsequently increases the likelihood of comorbidity (Wender, 2000).

Evidence of Symptoms 

The DSM-5 explains that six or more of the following symptoms must be observable, but for adolescents, at least five should be present (APA, 2013b).  Inattentive symptoms as listed include difficulty maintaining attention during various tasks, not paying close attention to detail, not listening; difficulty following instructions; trouble organising tasks, time, or things; reluctant completing activities that require concentration; easily distracted; often losing items; and poor retention (APA, 2013b). Whilst hyperactive and impulsivity behaviours include fidgeting; failure to remain seated; running or climbing at inappropriate times; difficulty being quiet; restless; talkative; turn-taking difficulties; and constantly interrupting others (APA, 2013b). To be diagnosed, some behaviours should be present before twelve years of age, appear in multiple settings, interfere with daily functioning and be present for 6 months or more. These characteristics can be mild, moderate, or severe and lean more towards either or both inattentive and hyperactive-impulsive behaviour.  Often individuals with ADHD experience difficulties with regulating emotions, motivation and arousal, with a delayed development of internal dialogue concerning events, behaviours, and feelings (ADHD Foundation, 2022). The DSM-5 also states that the disorder is relatively stable throughout adolescence, but some individuals may display an increase in antisocial behaviour. Signs of hyperactivity are less common but persist (APA, 2013b).

Symptoms may include limited working memory, set shifting, reaction time, response inhibition, vigilance, and organisation. Parents may note an unusual amount of physical activity initially.  A parent’s over-reactivity or critical behaviours may be seen as rejection or overprotection by the adolescent (Brinksma et al., 2021).  Parental warmth was found by Brinksma et al. (2021) to be a predictor of low levels of ADHD symptoms, and parental rejection a predictor of high levels of ADHD symptoms in later adolescence. Yet these symptoms may be dependent on genotype, whereby the genes of an individual influence their sensitivity to supportive or adverse environments (Brinksma et al., 2021). It is important to note that risk factors may include temperament, low birth weight, prenatal exposure to smoking or alcohol, diet reactions, exposure to toxins and infections but this is not conclusive (ADHD Foundation, 2022).

Impact on the Individual and Interactions

ADHD involves various characteristics that cluster together and tend to be less obvious with age. Consequently, for adolescents there is a need to delve into an adolescents’ history, undertake interviews and utilise rating scales as there is no specific test which can be administered to diagnose or identify ADHD (Wender, 2000). There are several rating scales available including Conners Comprehensive Behaviour Rating Scale (CBRS), Behaviour Rating Inventory of Executive Function Second Edition (BRIEF2), Vanderbilt Assessment Scale, and Vineland Adaptive Behavior Scale (Department of Education, 2021).  There is also a need to rule out any other disorders before diagnosing as ADHD (APA, 2013b).

During adolescence the risk may be that more hostile behaviours develop after rejection by peers and persistent long-term academic difficulties (Wender, 2000).  Therefore, rather than hyperactivity and lack of focus during childhood, antisocial problems come to the fore during adolescence (Wender, 2000). If left untreated, other issues such as risk-taking behaviour, anxiety, depression and angry outbursts may become more prevalent (Wender, 2000).  There is a risk of suicidal thoughts later in life, poor occupational performance, unemployment, poor social interactions, trauma, accidents, obesity, hypertension and for the adolescent this would include family discord, poor school performance and attendance (ADHD Foundation, 2022).  Overall, researchers have proven that ADHD is 74% hereditary and that effective parenting is the key factor in reducing these negative outcomes (APA, 2013b).

Suggested Interventions

ADHD can be managed in several ways and a multidisciplinary approach is necessary (ADHD Foundation, 2022). Options include medication, education, knowledge, training, psychotherapy, and a comprehensive behavioural, psychological, educational, and medical evaluation is required (ADHD Foundation, 2022).  With evidence-based treatment, support, and appropriate adjustments it is possible to function with ADHD (ADHD Foundation, 2022).

Non-medication strategies include psychological therapies, occupational therapy, coaching and more (ADHD Foundation, 2022).  Psychological treatments may be behaviour modification in the classroom and parent training in management methods, but ongoing treatment is required (ADHD Foundation, 2022).  Adolescents with ADHD may benefit from social skills training or interoception programs to help individuals identify mood changes or self-regulate their body (ADHD Foundation, 2022; Department of Education, 2021b). Treatments with little evidence of effectiveness include dietary management, psychotherapy such as biofeedback, play therapy, chiropractic treatment or sensory-integration training (ADHD Foundation, 2022).

Medication prescribed by a psychiatrist or pediatrician can include stimulants or nonstimulants with the later taking time to have an effect (ADHD Foundation, 2022).  Trialing is necessary to meet the needs of the client as the type or dosage can affect individuals in different ways (ADHD Foundation, 2022).  Medication facilitates the electrical signal transmission within the brain improving cognitive function and reducing symptoms (ADHD Foundation, 2022).

Poulton (2019) highlights the fact that the DSM is symptom-based and descriptive and does not address the individual’s experience of ADHD or cause.  It is also difficult to separate it from other disorders such as sensory processing disorder and even trauma which can produce similar symptoms (Poulton, 2019).  Questioning an adolescent about their thoughts and functioning provides more insight. Poulton (2019) states that neuroscience or neuroimaging and neurocognitive testing can determine delay aversion, executive deficits such as reasoning, making good decisions, short term memory, attention span, listening, following instructions, and controlling impulsive behaviour but none are specifically able to diagnose ADHD.

To understand and implement adjustments within the classroom Poulton (2019) suggests we must consider that usually there is a cost or an amount of effort required to complete a task, followed by achievement or reward, culminating in a good mood. However, for an ADHD adolescent, the cost is greater due to executive functioning difficulties (Poulton, 2019). A reward deficiency causes maladaptive reward seeking behaviour to achieve a good feeling or mood (Poulton, 2019).  Therefore, what is easy and satisfying for most students, requires unreasonable effort with little reward for those living with ADHD (Poulton, 2019). Consequently, screening questions should focus upon what percentage of time does an adolescent spend efficiently completing cognitive tasks (Poulton, 2019).

It is also important to undertake cognitive tests, scaled questionnaires and observations to identify behaviours, strengths and difficulties (Department of Education, 2021b; Poulton, 2019).  This can provide the knowledge required to make reasonable adjustments in the areas of curriculum presentation and behaviour management (Department of Education, 2021b). Changes may need to be made within the school environment such as sound blocking headphones; or breaking tasks down into manageable parts; implementing strategies to suit energy levels such as regular movement breaks; completing difficult tasks early; working in one-to-one situations and utilising visual timetables (ADHD Foundation, 2022; Learning Connections, 2022; Wender, 2000).

A multidisciplinary approach is needed to incorporate advice and observations from doctors, specialists and others such as parents, teachers, advisors, speech language therapists, occupational therapists and physiotherapists to produce an appropriate action plan which caters for an individual’s needs (Department of Education, 2021b). General health checks including vision, hearing, language, speech and movement, as well as developmental, learning, educational or IQ tests are important for identification (Raising Children Network, 2021c). A multimodal treatment is required so that information can be collated to develop strategies or adjustments to support those with ADHD (CHADD, 2022b).