ADOLESCENCE INTO ADULTHOOD
From Meeting the Needs of Our Adolescents, sponsored by the American Society for Adolescent Psychiatry
| ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN ADOLESCENCE —Diane Treadwell-Deering, MD, Assistant
Professor, Menninger Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Baylor
College of Medicine, and Chief, Psychiatry and Psychology Service, Texas Children’s Hospital, Houston
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| Introduction: attention-deficit/hyperactivity disorder (ADHD) begins in childhood, may continue into adolescence and
adulthood (to confirm diagnosis, some symptoms must have been present before 7 yr of age); types include predominantly
inattentive, predominantly impulsive/hyperactive, and combined (most common); in Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria focus on younger children and may not be
applicable to adolescents and adults (eg, excessive climbing); editors of DSM-IV recommend that people who no
longer meet full criteria be designated as in partial remission
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| New diagnosis in adolescence: why is patient presenting now? were symptoms present before 7 yr of age? circumstances
in which symptoms might have been missed include child’s having predominantly inattentive type of
ADHD (many parents and teachers think only of impulsivity and/or hyperactivity), girl’s being considered “dizzy”
or “ditzy” (cultural bias), and brighter child’s having been able to compensate for symptoms until encountering
more stringent demands of middle school and high school; in addition, psychiatric comorbidities may have masked
symptoms of ADHD, or their treatment may have taken precedence over ADHD
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| Making diagnosis: developmental variations in symptoms occur across lifespan; symptom cluster of hyperactivity
and impulsivity tends to decay over time; hyperactivity becomes inner sense of restlessness; symptoms of inattention
continue throughout lifespan; complaints include poor concentration, daydreaming, forgetfulness, and low tolerance
for frustration
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| ADHD in adolescence: in 66% to 75% of children with ADHD, disorder persists into adolescence, but symptoms
may no longer meet DSM-IV criteria for full syndrome; symptoms and impairment continue into adulthood in
≈50%; study found 30% of children with ADHD have “developmental delay” type of ADHD, with about half remitting
in childhood and half in adolescence; factors that predispose child to continuing symptomatology include
low socioeconomic status, low IQ, poor peer relationships, comorbid conduct disorders, parental psychopathology,
conflict and hostility in family, and poor academic achievement; DSM-IV asserts that in most cases, symptoms attenuate
during late adolescence and few cases continue into adulthood, but speaker expresses doubts
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| Academic problems for teens with ADHD: compared to teens without ADHD, those with ADHD more likely to be
in remedial English classes, have lower grade-point averages, less likely to be in advanced placement classes, and
have lower rate of completing high school and of obtaining postsecondary education; in elementary school, children
with ADHD receive much support from teachers, and structure of classes designed to help children with
ADHD, but “that really falls apart in middle school and is essentially gone in high school”; many teens with ADHD
deteriorate significantly in middle school and high school; at time when teen expected to demonstrate self-management,
self-regulation, and self-responsibility, support from school officials disappears; also, middle schools and
high schools have much lower tolerance (often zero tolerance) for behavior problems; however, small minority of
teens with ADHD seen to do better with shorter class periods and frequent changes in classes
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| Motor vehicle use in teens with ADHD: compared to teens without ADHD, teens with ADHD have increased incidence
of illegal use of cars before and after earning licenses, more likely to have licenses suspended, more likely to
get speeding tickets, and have 4 times as many accidents; on computer-simulated driving-skills tests, teens with
ADHD drive more erratically; most also admit that they do not drive as well as their friends without ADHD, but
their knowledge about driving does not differ
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| Substance-use disorder and ADHD: many school officials and parents still not aware that ADHD persists after
childhood and believe that if child continues to take stimulant medications into adolescence, it will lead to substance
use or abuse; ADHD associated with increased likelihood of substance-use disorder, but this risk more associated
with comorbid conduct disorder or bipolar disorder; no evidence to indicate that use of stimulant medication
increases risk of developing substance-use disorder; however, >50% of people with untreated ADHD develop substance-use
disorder over lifetime; if ADHD consistently treated, risk for substance abuse same as that in general
population; in fact, several studies show that treatment of ADHD protects against development of substance abuse
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| Barriers to treatment of ADHD in adolescents: teens reluctant to take medications (may be major impediment to
successful management of symptoms; speaker states use of longer-acting medications may increase teen’s compliance
and parent’s supervision in high school, while short-acting medications may work better in college); teens
sometimes think they are better friends when not taking medications (their family, friends, and teachers disagree);
many health care practitioners, parents, and school officials still do not know that ADHD persists into adolescence;
school officials may hassle teen who takes medication to school
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| Legal rights for adolescents with ADHD: Individuals with Disabilities Education Act (IDEA)—gives students with
special needs right to free and appropriate public education; pertains only to elementary and secondary schools; requires
school to identify students with special needs and to address those needs; Rehabilitation Act of 1973 (RA) and
Americans with Disabilities Act of 1990 (ADA)—make discrimination illegal against individuals with disabilities;
apply to all schools, including public and private colleges and universities, to businesses that provide goods and services
to public, to businesses that employ >15 people, and to all activities funded by government; ADA guarantees
freedom from discrimination and “reasonable accommodations” (including alterations in nonessential testing requirements,
delivery of course materials, or job requirements that enable individual to perform essential tasks); past high
school, school or business not required to identify individuals with special needs; rather, individuals must disclose
needs; armed forces—exempt from RA and ADA; ADHD does not disqualify individual per se, but medical evaluation
includes consideration of repeated inability to maintain reasonable adjustment in school, workplace, or social
groups; history of deficits in academic skills past 12 yr of age may disqualify; written aptitude tests given without accommodations;
current use of stimulant medications does disqualify
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| TRANSITION TO ADULTHOOD FOR ADOLESCENTS WITH MENTAL HEALTH PROBLEMS —John Sargent,
MD, Professor of Psychiatry and Pediatrics, Baylor College of Medicine, Houston
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| Introduction: “tremendous challenge” to help adolescent patient move into adulthood, and often very difficult to
transfer their care from pediatric medical or mental health service to adult services; adolescents with chronic physical
illness experience increased frequency of depression, posttraumatic stress disorder, and anxiety disorders, often
associated with parental anxiety; somatic symptoms may mirror physical illness (eg, patient with seizure
disorder experiences pseudoseizures; patient with diabetes experiences behavior problems); also seen are denial,
emotional immaturity (sometimes associated with defiance and refusal of treatment), emotional lability, appetite
disorders, substance use, and eating disorders (sometimes leading to severe morbidity and mortality); transition
may be further complicated by mental retardation, learning disabilities, and sensory deficits (eg, estimated that only
10% to 20% of blind children ever establish independent learning and independent living)
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| Difficulties that complicate transition: child who has private psychiatrist and independent means may be able to stay
with that psychiatrist, but most patients do not have this option; as child reaches majority, “their insurance goes
away, their care system goes away; their pediatric care system, which may have included significant psychosocial
support both for the child and for the family, can go away”; parents—may become anxious as adolescent takes
more independent role in illness care; if child neglects illness management, parents and health care professionals
may get into power struggle over illness control; these problems exacerbated when families have problems (eg, divorce
or high-conflict marriage, comorbid mental illness in adolescent with physical illness)
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| Planning transition: essential; complex and time-consuming; adolescent’s problem does not go away just because he
or she is transferred to adult health care system; instead, problem usually gets worse, and effective transition and
development of formative relationship with adult health care system “almost never happens”
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| Family risk factors: parental mental illness; substance abuse; domestic violence; postdivorce conflict; necessary to
identify family risk factors early on (eg, when adolescent 12 to 14 yr of age) and to work with families to resolve
them; adolescent’s transition plan may include family therapy, individual therapy, family social support, and mental
health care for parents
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| Transition plan must include: vocational training and support in adolescent’s finding job; insurance issues (eg, parents’
insurance usually does not cover children over certain age); access issues (eg, in pediatric world, same practice
may include pediatrician, child mental health specialist, social worker, family therapist, and other practitioners; such
groups rarely exist in adult medical setting; patient may need help in making separate appointments for medical care
and mental health care or in arranging transportation to separate appointments; may be difficult to ascertain if medical
provider and mental health provider communicate with each other)
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| More difficulties: independent and community mental health professionals often not experienced and comfortable in
dealing with patients with medical problems or physical handicaps, and frequently do not have access to services
that may improve young adult’s life; medical crises and hospitalizations may interrupt or complicate transition to
adult mental health care; families may find adult medical systems burdensome; other problems may include unprepared
college health system, loss of health insurance, poor immediate employment prospects, and lack of appropriate
housing; these problems may lead to adolescent having financial difficulties, being homeless or in
unstable living situation, and using illicit drugs; between 17 and 25 yr of age, many transitioning patients complete
suicide
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 | Illicit methods of earning money to which adolescent may resort: sex trade, drug sales, and other criminal activities;
arrest and incarceration further complicate transition (medical and mental health treatment in jails and prisons
notoriously and abysmally poor)
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| Parents: parental exhaustion and helplessness may worsen parent-child interactions
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| What to do? be aware that transition from adolescent medical system to adult system complex and difficult; address
family-interaction difficulties first and early in adolescent’s youth; provide psychoeducation for teen and family,
with emphasis on mental health treatment, independent living, exploration of higher education possibilities, relationships,
and occupational possibilities; written treatment plan assists adult health system to provide appropriate
care; allow patient and family to access medical records to present to future caretakers; assist transition with consistency
and support; agitate for changes in advocacy and policy issues to address insurance issues; if necessary,
help adolescent and family to apply for Social Security Disability benefits and Medicaid insurance coverage
(start this early too); adult system must change to be able to provide continuing care and to help families find vocational
training and family psychotherapy, access psychiatric drugs that are appropriate, available, inexpensive,
and obtainable in straightforward way, and find appropriate and affordable housing; parental supervision may be
necessary to ensure adherence to treatment plan, and parents may need help in providing that supervision while
maintaining own lives and assisting child with separation process; standards for confidentiality may need revision
so caregivers able to communicate openly with family
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| Community resources that may be helpful: police officers trained in resolving family conflicts; mobile crisis teams;
group living environments that foster independence, self-reliance, and self-management; case managers
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Educational Objectives
| The goal of this program is to educate the listener about attention-deficit/hyperactivity disorder (ADHD) in adolescents
and about helping the adolescent with mental illness make the transition from the adolescent mental health system
to the adult system. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Discuss why some children with ADHD are not identified until they are in middle school or high school.
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| 2. Compare the manifestations of ADHD in younger children and in adolescents.
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| 3. Describe some of the legal protections available for adolescents and young adults with ADHD.
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| 4. Enumerate some of the difficulties encountered by the adolescent making the transition from the child and adolescent
mental health system to the adult system.
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| 5. Counsel adolescents and their families about expediting the transition.
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Suggested Reading
Andersen SL: Stimulants and the developing brain. Trends Pharmacol Sci 26:237, 2005; Bennett DL, Towns SJ,
Steinbeck KS: Smoothing the transition to adult care. The most important need is for a change of attitude and approach.
Med J Aust 182:373, 2005; Bjornstad G, Montgomery P: Family therapy for attention-deficit disorder or attention-deficit/hyperactivity
disorder in children and adolescents. Cochrane Database Syst Rev Apr 18, 2005; Counts
CA et al: Family adversity in DSM-IV ADHD combined and inattentive subtypes and associated disruptive behavior
problems. J Am Acad Child Adolesc Psychiatry 44:690, 2005; Davis M, Sondheimer DL: State child mental health
efforts to support youth in transition to adulthood. J Behav Health Serv Res 32:27, 2005; Davis M: Addressing the
needs of youth in transition to adulthood. Adm Policy Ment Health 30:495, 2003; Ercan ES et al: Parental recall of
preschool behavior related to ADHD and disruptive behavior disorder. Child Psychiatry Hum Dev 35:299, 2005;
Farrant B, Watson PD: Health care delivery: perspectives of young people with chronic illness and their parents. J
Paediatr Child Health 40:175, 2004; Glied S, Cuellar AE: Trends and issues in child and adolescent mental health.
Health Aff (Millwood) 22:39, 2003; Hagood JS, Lenker CV, Thrasher S: A course on the transition to adult care of
patients with childhood-onset chronic illnesses. Acad Med 80:352, 2005; Jester JM et al: Inattention/hyperactivity
and aggression from early childhood to adolescence: heterogeneity of trajectories and differential influence of family
environment characteristics. Dev Psychopathol 17:99, 2005; Johansson P, Kerr M, Andershed H: Linking adult
psychopathy with childhood hyperactivity-impulsivity-attention problems and conduct problems through retrospective
self-reports. J Personal Disord 19:94, 2005; Kennemer K, Goldstein S: Incidence of ADHD in adults with severe
mental health problems. Appl Neuropsychol 12:77, 2005; Lam PY, Fitzgerald BB, Sawyer SM: Young adults in
children’s hospitals: why are they there? Med J Aust 182:381, 2005; Marcus SC et al: Continuity of methylphenidate
treatment for attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 159:572, 2005; Marczinski CA.
Self-report of ADHD symptoms in college students and repetition effects. J Atten Disord 8:182, 2005; McKusick DR
et al: Trends in mental health insurance benefits and out-of-pocket spending. J Ment Health Policy Econ 5:71, 2002;
Reiersen AM: Twin study of the longitudinal course of ADHD. J Am Acad Child Adolesc Psychiatry 44:625, 2005;
Sargent JD: Web-based assistance for physicians caring for children with ADHD. Eff Clin Pract 4:127, 2001; Shaw-
Zirt B et al: Adjustment, social skills, and self-esteem in college students with symptoms of ADHD. J Atten Disord
8:109, 2005; Stroul BA et al: The impact of managed care on mental health services for children and their families.
Future Child 8:119, 2998; Volkmar F: Toward understanding the basis of ADHD. Am J Psychiatry 162:1043, 2005;
Wolraich ML et al: Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment,
and clinical implications. Pediatrics 115:1734; 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Treadwell-Deering and Sargent were recorded at Meeting the Special Needs of Our Adolescents, held March 17-
20, 2005, in Houston and sponsored by the American Society for Adolescent Psychiatry. The Audio-Digest Foundation
thanks the speakers and the ASAP for their cooperation in the production of this program.
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