angry teenagerI still meet parents who have been told by their doctors that children ‘outgrow’ ADHD (Attention Deficit Hyperactivity Disorder) by adolescence, and that therefore their child doesn’t require treatment beyond the age of thirteen. Having dutifully discontinued the medication, they are distraught when his school grades start to drop and he lands up in trouble for various misdemeanors and social infractions. What has happened?

There is now an abundance of research attesting to the continuity of ADHD symptoms into adolescence, and even adulthood in many cases. Whilst symptoms of hyperactivity have often improved by the teenage years, those of inattentiveness and impulsivity mostly haven’t; indeed, the effects thereof are often amplified in high school, as a result of the increased demands on the child’s organisational skills and self-discipline. This is a stage of life when higher order skills such as prioritising, planning, task initiation, response inhibition and time management play an increasingly vital role in daily functioning, both academically and socially. These higher order skills – collectively referred to as the executive functions – are typically impaired in those with ADHD. In primary school, the support of parents and teachers can sometimes mask these deficits, but by high school this is no longer sustainable; this explains why many children, especially girls, are diagnosed for the first time in their teenage years. Girls are typically less hyperactive and disruptive than boys, and thus less likely to have been ‘red-flagged’ for behavioural reasons in their formative years.

So ADHD in adolescence is a very real entity, and throws up some unique challenges. Not the least of these is the problem of compliance (or adherence, as we say nowadays) on medication. This post will address the problem of the treatment-refusing teenager.

It is normal and healthy for adolescents to increasingly assert their independence and question what they might have previously accepted without much fuss. They are entering the psychological phase and necessary developmental task of individuation. Their own world view is emerging, and it often differs from those of their parents and doctors! Teenagers are typically averse to being labelled in any way, as this is seen as a violation of their individuality and freedom of choice. So they refuse to take their medication and we have a power struggle on our hands. Sometimes this defiance reaches pathological proportions in the form of a condition known as Oppositional Defiant Disorder, which is itself commonly associated with ADHD, especially in boys. This might require its own treatment, as would other co-existing conditions, which we will address later.

Choose your weapons!
In high school, the academic day is longer and the work-load after school is greater. When immediate-acting methylphenidate (Ritalin) is used, adherence problems can emerge with top-up dosages, which are often scheduled for awkward times of the day, when the student is in the middle of lessons or extracurricular activities. It is thus usually preferable, in adolescence, to use longer-acting medications such as oros-methylphenidate (Concerta) or atomoxetine (Strattera).

What about weekends?
With many teenagers, weekends and school holidays are the most difficult times to ensure ongoing treatment compliance. “It’s Saturday: I don’t need to concentrate” is the usual refrain. Most modern guidelines now recommend continuous use of ADHD treatments. This is due to the increasing awareness of the impairing effects of ADHD in all settings, including the home, as well as the social dysfunction associated with the condition. This requires education about the rationale for continuous treatment. It is very important that the doctor addresses your child directly, enhancing her sense of being treated as an individual and as a consenting young adult. But weekend and holiday treatment is an individualised decision, and in my practice many children do have so-called drug holidays. This might be an important negotiating tool to use with your child, allowing for some sort of compromise between the need for treatment and her desire to be medication free.

Emerging comorbidity
Non-compliance on medication is sometimes a sign of an emerging comorbid (co-existing) condition. Apart from Oppositional Defiant Disorder, several other co-existing conditions can complicate adherence to medication, including Conduct Disorder, substance abuse and various mood disorders. ADHD is often comorbid with mood disorders and it is often around puberty that these conditions begin to emerge. Adolescent depression is typically associated with irritability rather than sadness, which can present with provocative, difficult behaviour of various kinds; refusing treatment is but one manifestation thereof. Similarly Bipolar Disorder is associated with irritability in both the manic and depressed phases, often coupled with a lack of insight, which would further complicate treatment adherence. The approach here is to diagnose and treat the emerging condition. A careful and empathic explanation of the condition (depression, for example), will be required to win over your child and convince him of his need to be on treatment, which would usually involve medications other than the typical ADHD agents.

Avoid power struggles
No teenager takes kindly to being controlled, and the situation just gets ugly when parents and doctors attempt to “force” a child to take medication. A far better approach is to work in a collaborative way with your child. This means hearing her out, perhaps ‘agreeing to disagree,’ and negotiating some form of a compromise. Parents are often so anxious of their child’s failure that they are not prepared to let her fail, and learn from the consequences thereof. This is an important general parenting theme, and it certainly plays out in this arena. Children need to make mistakes in order to learn; failure is a necessary part of growing up, and we do our children a disservice if we deny them the opportunity to make choices, even poor ones.

I usually say something like, “I can see we disagree on this, but I know it means a lot to you, so how about we give it a month (or a term) without medication and see how it goes? I’ll see you at the end of the term and we can make a call from there.”  Most teenagers would be satisfied with such a plan, and you have I have at least maintained the therapeutic alliance with my patient, which may be crucial in future months and years. More often than not, having experienced the consequences of his untreated symptoms, your child will accept medication again. Of course, the consequences of untreated ADD can sometimes be serious. Besides academic failure, we know that this condition is associated with various impulsive behaviours, including substance abuse and sexual indiscretions. Not every child with ADHD is at risk for these outcomes, but where relevant, these risks must be clearly explained to the young adult. Again, he may still refuse his medication, in which case we need to allow him to make his poor choice and await the consequences. When he slips up, and he probably will, he will need to do some cleaning up. This might involve, for example, foregoing access to the internet, losing out on his allowance or even repeating the academic year. At some point along this process, he is likely to come to his senses and accept treatment. These unpleasant consequences have taught him something, and he will be better equipped for it. At no point along the way have you “forced” him to take medication.

He may have a point you know…
Lastly, there are times when I have to agree with a dissenting teenager who refuses to take his medication. Some kids really battle with side-effects such as appetite suppression and subduing effects. It is after all the child who has to live with these effects. In such cases it is only appropriate to lower the dosage or switch to an alternative agent; if this doesn’t work, no medication might be the best option. Sometimes children are on medication to satisfy the unrealistic expectations of their parents and/or teachers. In the medical and bioethics communities, there is an ongoing vigorous debate about so-called ‘cognitive enhancement,’ akin to drug use in sport, or cosmetic surgery. Many feel that the stimulant medications are being inappropriately used for performance enhancement rather than properly diagnosed ADHD, contributing to the ‘trivialisation’ of the ADHD diagnosis. Perhaps even more concerning is the modern tendency to medical reductionism, whereby complex clinical problems are oversimplified by attaching a neat, one-line diagnosis. Many parents, teachers and doctors tend to seek out a diagnostic label rather than acknowledge the complexity inherent in the child’s symptoms. I have interviewed many a teenager who is aware (at least at some level) that he is being made the presenting symptom of a dysfunctional family or schooling system and, angry at the hypocrisy it represents, rejects the process.

I can’t blame him.