ARE THE DEVELOPMENTAL PROBLEMS OF ADOLESCENTS WITH ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) MUCH DIFFERENT FROM THOSE EXPERIENCED BY SCHOOL-AGE CHILDREN?
There are a lot of similarities, but the differences can be significant.The preteen, or early adolescent, may look somewhat like the school-age child. She may have some of the hyperactivity and impulsivity as well as the academic difficulties. She may also still experience behavior problems in the classroom. However, at this age it may look more like oppositional and defiant behavior or perhaps like anxiety and depression.By now, ADHD children are often very angry and frustrated. They have no confidence in their abilities to deal with difficult situations, and their opinion of themselves is probably that they’re stupid even if they’re quite intelligent; they have not experienced satisfaction and success from their own activities. Some of these children, if their families have been incredibly supportive, may find areas in which they are somewhat successful, such as sports or a particular academic or artistic area. But for many of these youngsters, there is an overriding sense of failure by this age.Making matters worse is what’s going on within their bodies and minds. They are beginning to think of themselves as young adults and may find themselves interested in the opposite sex, which makes the social situation much more complicated. Their bodies are changing; the peer pressure surrounding attractiveness and body changes is getting stronger. And there are internal changes. They are becoming increasingly stimulated by the hormone changes that come with the onset of puberty, and that can result in many different feelings about themselves and others.For a child who already has a fragile sense of himself and a pessimistic view of being able to control inner states, these changes can be frightening and overpowering. Boys may experience nocturnal emissions or have sudden erections or unexpected feelings of attraction to a girl. This can be very unnerving because they don’t have a secure sense of their bodily functions or mental functions. A young woman with ADHD reported to me that she was made so confused and anxious by her breast development at age thirteen that she cut up and hid the first bra her mother bought her.Around this time, age eleven or twelve, the ADHD child is often seen as immature by his peers. He is not ready to get involved in what the other children are doing socially, and he may continue certain problem patterns of behavior in an attempt to make friends, get attention, or become popular with his fellow students. But his behavior seems more and more inappropriate in the social setting because the others are moving on; they are feeling more mature, and suddenly they’re interested in the opposite sex. The hyperactive ADHD preteen is still trying to be a child, to get attention in ways that are not respected by his classmates.Very often the dramatic physical and mental changes that occur with the onset of puberty can lead to serious problems. I had one patient, a twelve-year-old boy named Allan, who was diagnosed as having ADHD and had used Ritalin. He was a very intelligent boy who did not do well in school and had no friends. He had extremely low self-esteem and was seen by his teachers as very immature. In a preadolescent surge of excitement, he had one day engaged in some inappropriate sexual play with a younger child. It was as a result of this I was asked to assess him and found that his ADHD was being inadequately treated. Psychotherapy and tutoring were added to the medication.My understanding was that his impulsive action was in response to pressures he was unfamiliar with and didn’t know how to handle. He didn’t have the social outlet of being “one of the gang” and, thus, was unable to share these normal sexual feelings with his peers and learn how to deal with them. Because he had no socially defined way of handling these experiences, Allan acted impulsively when he felt aroused.Another patient of mine, an eleven-year-old girl named Andrea, is very much caught up in her need to develop friendships. But because of her ADHD, her behavior makes her different, and her peers want nothing to do with her. As a result, Andrea feels lonely, has low self-esteem, and is angry at her peer group because she feels rejected by them, so she reaches out even more inappropriately. She tries to talk with them over and over again about the same things, giggling and laughing. She tries practical jokes and pranks, and the other girls see her behavior as more and more deviant.Andrea has no way of understanding the other girls’ changing interests, such as boys, clothes, and makeup. She’s developmentally stuck and behaves more like an immature nine-year-old than an eleven-year-old on the verge of teenage maturity. Her peers want nothing to do with her, so she suffers from increased anxiety, deeper depression, and academic problems—enhanced by the impact of this developmental period on her social relations.With older adolescents, the situation changes a bit. Frequently, by this age, ADHD children have learned to control their hyperactivity or social inappropriateness somewhat. They may be able to behave the way they’re expected to in a social or classroom situation, at least for short periods. However, their long-standing academic difficulties typically become more evident. The weak base they’ve had through elementary school seriously impairs their ability to handle high school.One of the ways this inability frequently presents itself is through a lack of motivation. By this time these young people have not had successful intellectual experiences. They don’t treasure curiosity and learning and are unable to motivate themselves to complete a project or pursue a topic of interest. All they know is that it’s required of them, and they fear failure.Often, when an undiagnosed ADHD teen is brought to my office for the first time, it’s because his parents can no longer tolerate his inexplicable lack of motivation. They have yet to realize the child’s long history and the many biological problems that are playing a role in it. All they see is the psychological outcome: depression, low self-esteem, impaired academic performance, and other symptoms.Older adolescents with ADHD often try to ease their mental anguish by looking for satisfaction elsewhere, such as experimenting with alcohol, drugs, sex, or defiant behavior.Rebecca, a sixteen-year-old high-school studentThe picture of lack of motivation was very much what brought Rebecca to treatment. She was referred by her school guidance counselor, who was concerned that she was underachieving academically. For years her teachers had felt she was a student with promise and talents, but who seemed to be unmotivated. She seemed to give up quickly, to be easily distracted and “dreamy,” and to perform well below her capabilities. Her parents focused on her lack of following through, her poor motivation, and her disorganization. They wondered if she cared at all about her schoolwork and were very frustrated with her.Neuropsychological testing had also been sought to rule out any learning disability or attentional problems. The testing revealed that Rebecca was of superior intelligence, but that while she had enormous strengths in the verbal sphere her ability to mentally manipulate math problems was very poor, as was her skill on visual organizing and visual memory tasks. Other tests showed she was very distractible and had great difficulty focusing attention, especially when the task was difficult for her, such as those tests requiring visual processing.When I met Rebecca, she struck me as a sad-looking, pretty teenager, wearing old, dark-colored clothes, and somewhat inadequately dressed for the cold. Her eyes were heavily and colorfully made up, as though to undo her otherwise unhappy and drab appearance, and to be more acceptable to her peers. It was hard for her to talk about herself, due to a combination of shyness and of an inability to put into words what she was really feeling. She spoke of not knowing what the matter was, of just knowing she felt bored and uninterested in things. Maybe school just wasn’t for her. It just didn’t seem relevant to anything. She felt her parents, both professionals with advanced degrees, and her school just expected too much from her. Neither she nor her parents understood the layers of effects of her ADHD that had occurred over the years and had certainly affected her learning and her experience in school from the very beginning.All of these issues have affected Rebecca’s peer relations.She is at risk of becoming promiscuous, which is common among ADHD girls who feel unsuccessful and unwanted. They desire very much to be accepted and loved, and one answer is to be sexually valued. However, because of difficulties establishing trust and intimacy, these relationships tend to be loveless and temporary.The situation with older adolescent boys is a little different. They’re more likely to become involved with alcohol or drugs and with behavior that gets them in trouble with the law. In fact, many followup studies have shown that by late adolescence, more of these youngsters have had some brush with the police than children who don’t have ADHD. They tend to channel their impulsivity, as well as their chronic sense of failure and lack of motivation, into areas where they may get satisfaction, though it’s usually short-lived.A variety of odd clinical problems may also be seen in adolescents with ADHD, especially those with extreme impulsivity. These include a fascination with fire, bed-wetting, excessive lying, and even food hoarding. The correlation between these acts and impulsivity remains a mystery, but a thorough history should include questions about them to find out if they are present.Older adolescents with ADHD are also more likely to be susceptible to group pressure out of their need for acceptance and value in the social scene. If they can’t feel valued as a student or athlete, another way is through daring, dangerous, and often socially unacceptable behavior.Boredom can be the gasoline tossed onto this very dangerous fire. Unmotivated and lacking in any satisfying academic achievement, many adolescents with ADHD find themselves suffering from a stifling sense of boredom that can only be cured through impulsive, often perilous acts. Studies have shown that young people with ADHD have far more automobile accidents than young people without ADHD, as well as a greater incidence of defiant behavior.
Colin, a seventeen-year-old high-school studentColin attended a boarding high school. He came from another country, where he had witnessed a fair amount of political unrest and street violence during his childhood. His parents had arranged for boarding school both as a wonderful academic possibility for him, as well as a way to remove him from a very noxious cultural environment. What they had not told the school, but became subsequently clear, was that Colin had already been expelled from school at home due to some drug use and sexual acting out and had a chronically poor academic record. His uncle had been murdered just a few weeks into Colin’s second year at this school, and his behavior and grades began to slip noticeably. This brought him to the attention of the school authorities, who referred him to me for evaluation.Colin was an expensively dressed boy, small for his age, who deliberately wore his clothes too large, slicked back his hair in an exaggerated ’50s look, and sashayed into my office with a nonchalant air. He seemed uninterested in the reasons his school had sent him to my office, but tried, in a practiced way, to charm me with observations about my office, about his drive in the taxi, and about other apparently irrelevant topics. He was not at a loss for words and spoke English fluently, even though it was his second language. When I asked about his family and why he was at boarding school, he spoke in a grandiose way about his talents, about his family’s wealth and social standing, and about his own control over the choices that had been made for him. He would jump up and down from the chair to make a point or to show me a dance move, and sometimes clicked his fingers or drammed on his knees.I knew from the school that he was disruptive in class, always talking and joking with other students and trying to one-up the teachers. He frequently lied to students and teachers. He was often fidgety in study hall and sometimes skipped it, despite the penalties imposed. Some of the girls in the school had complained that he was too forward, pressuring them to date him and even to have sex with him. All his teachers were concerned that his academic progress seemed well below what he was capable of.I arranged for neuropsychological testing to be done and interviewed Colin’s parents on the telephone. It soon became clear that he was suffering from very severe distractibility, inattention, and hyperactivity, as well as showing evidence of some specific learning disabilities. Much of his behavioral problem could be seen as both an expression of these symptoms as well as of his low self-esteem. His poor expectations of any success from academic work had diminished his motivation and convinced him that he was “dumb.” In turn, he had turned to his peers to look for the support and esteem-building that he craved. Unfortunately, in his impulsive and nonempathic way he sought to fulfill his own emotional needs, often at the expense of others.*24\173\2*
