ADHD in Adolescents

ADHD
In Adolescence
Dr Susan Young
Symptoms
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ADHD IN ADOLESCENCE | Contents | Dr Susan Young
ADHD IN ADOLESCENCE
Contents
Overview: ADHD in Adolescence 3

Module 1: Introduction to ADHD 7
Module 2: Symptoms of ADHD 15
Module 3: Common Comorbidities 25
Module 4: Education 32
Module 5: Employment 38
Module 6: Interpersonal Relationships 46
Module 7: Delinquency and Substance Use 52
Module 8: Planned Transition 61
Appendix: Quiz 68
2
ADHD IN ADOLESCENCE | Overview | Dr Susan Young
ADHD IN ADOLESCENCE
Overview
About the Author
Dr Susan Young is a Clinical Senior Lecturer in the Centre for Mental Health, Division
of Brain Sciences, at Imperial College London and Director of Forensic Research &
Development at West London Mental Health Trust. In 1994 Susan set up the clinical
psychology service at the Maudsley Hospital National Adult ADHD service and she has
extensive clinical experience in the assessment and psychological treatment of youths and
adults with ADHD. Susan participated in the British Association of Psychopharmacology
Consensus Meeting (2007) to develop guidelines for management of transition for ADHD
adolescents to adult services. She was a member of the National Institute for Health and
Clinical Excellence (NICE) ADHD Clinical Guideline Development Group (2009); her main
contributions being to provide expert guidance on psychological treatment of children
and adults with ADHD. Susan is President of the UK ADHD Partnership (www.UKADHD.
com) and Vice President of the UK Adult ADHD Network (www.UKAAN.org). Susan
has published numerous articles in scientific journals and books. She has written and
published three psychological intervention programmes and authored three books.
Preface
In recent years, our scientific knowledge about ADHD has grown and it is now widely accepted that it is a condition
that affects many people across the life-span. However, late adolescence has been identified as a risk period with high
attrition from ADHD health services and discontinuation of medication by the age of 21 [1]. This cannot possibly relate
to spontaneous remission as studies investigating the life time prevalence of ADHD suggest that around two-thirds of
children with ADHD will continue to suffer impairment of symptoms at the age of 25 [2]. Adolescence is, therefore, a risk
period for dropout of services. Many of these young people will present later in life in other psychiatric services and/or
in the criminal justice system [3, 4].
International guidelines have led practitioners to focus on the needs of young people with persisting or remitting ADHD
symptoms in adolescence and the support that they will need in effectively transferring from child to adult services.
However, transition is not an administrative healthcare exercise as young people themselves are undergoing a personal
transition as they mature both physically and emotionally. During this period, young people become increasingly
autonomous as they move from a child to adult role and make important and defining decisions about their future,
establish key life goals and beliefs and take responsibility for their behaviour. This is paralleled by role experimentation to
form their self-concept and develop their personal and social identity. Transition between services, therefore, needs to be
seen in this context and a recognition of the issues that young people may face at this time and in the future is needed
to ensure that transition is effective.
This series sets out eight modules on the topic of adolescence and ADHD. Each module focuses on the experience
and needs of teenage service-users, and their families, as they undergo a personal journey during an often turbulent
period when they transition from childhood to adulthood. The modules focus not only on ‘what the science says’ in
the literature, but also draw on clinical experience of working with young people and their families in the health service,
and provide information from their unique perspective. The modules have been reviewed and endorsed by the CPD
Certification Service, and include a ‘Test your Knowledge’ quiz in the Appendix. 3
Dr Susan Young
www.psychology-services.uk.com
3rd January 2014
Continuing Professional Development Certification
The psychoeducational materials in this course have been independently reviewed and assessed for their learning
value by the CPD Certification Service. They were certified in November 2013 (Certification No. C984T2) as conforming
to continuing professional development principles. As such they will be useful in developing individual competencies
and provide learners with knowledge they can apply in practice.
A ‘Test your Knowledge Quiz’ is presented in the Appendix that can be completed before and after reading the
modules to assess improvement in knowledge. The answers to the quiz are as follows:
Answers:
1. A 5. B 9. C 13. A
2. A 6. C 10. A 14. B
3. D 7. B 11. B 15. D
4. D 8. D 12. B 16. C
Target Readership
The ADHD in Adolescence modules will be of use to healthcare practitioners working in a variety of services including
paediatrics, child & adolescent psychiatry and adult mental health services. It is hoped that these materials will assist
general practitioners who are the ‘gatekeepers’ to health services and who may be the only consistent health care
professionals present throughout the transition process. The modules will also assist allied professionals working with
young people in areas such as education and occupational services, and the criminal justice system. Service users
and their families may also find the resources useful for their own interest and information.
Professional Advisory/Resource Groups

UK ADHD Partnership (UKAP) - www.UKADHD.com
UK Adult ADHD Network (UKAAN) - www.UKAAN.org
National and Local Support Groups

The National Attention Deficit Disorder Information and Support Service - www.addiss.co.uk
‘The site for and by adults with ADHD’ - aadduk.org
Living with ADHD - www.livingwithadhd.co.uk
ADD / ADHD Online Information - www.adders.org
4
Mind - www.mind.org.uk/Information/Booklets/Understanding/Understanding+ADHD
ADHD Foundation - www.adhdfoundation.org.uk
Baldock/ Hitchin/ Letchworth/ Royston/ Stevenage - Angels Support Group -

www.angelssupportgroup.org.uk/index.htm
Brighton - ADHD Brighton Support Group - www.adhdbrighton.org.uk
Bristol - Adult ADHD Support Group -

www.aadduk.org/help-support/support-groups/bristol-adult-adhd-support-group
Cambridgeshire - Cambridgeshire Adult ADHD Support Group -

www.addventure-within.co.uk/support/
Chichester - The Hyperactive Children’s Support Group - www.hacsg.org.uk/page6.html
Dorset - Dorset ADHD Support Group - www.adhddorset.btck.co.uk
Essex - Chelmsford ADHD Support Group - www.adhd-support.org.uk/index.html
Gateshead - Gateshead ADHD Support - www.gatesheadadhdsupport.co.uk/whatis.html
Harrow - ADHD and Autism Support Harrow - www.adhdandautismharrow.co.uk
Hertfordshire - Understanding ASD and ADHD in Hertfordshire - www.add-vance.org
Lancashire - ADHD Lancashire Support Group - www.adhdlancashire.co.uk
Lincoln - Lincoln ADHD Support Group - www.lincolnadhd.org
Liverpool - Liverpool Adult ADHD (Ladders of Life, LOL) -

www.meetup.com/Liverpool-adult-adhd-ladders-of-life-meetup-com
London - London adult ADHD support group - sites.google.com/site/joyfivolous/home
Manchester - Manchester Region Attention Deficit Disorder Group - www.maddchester.com
Newcastle - KICK ADHD Support Group - www.netmums.com/newcastle/local/view/support-groups/

special-needs-adhd/kick-adhd-support-group-keep-including-challenging-kids
Norfolk - CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) -

www.meetup.com/CHADDHamptonRoads/ - ADD Norfolk - www.addnorfolk.com
Oxfordshire - ADHD Oxfordshire - www.adhdoxfordshire.co.uk/Support-Group.html
Richmond - Richmond ADHD Support Group - www.facebook.com/AdhdRichmond
Scotland - Central Scotland Adult ADHD Support -

sites.google.com/site/scottishadhdadultsorg/Home
5
West Yorkshire - West Yorkshire ADHD Support Group - west-yorkshire-adhd.org.uk/meetings
Acknowledgements
The author is grateful to the young people and their families who gave up their time to tell us their experiences,
for their consent to quote what they said, and for their helpful feedback on earlier versions of the modules.
The author thanks Dr Clodagh Murphy, Dr Geoffrey Kewley, Professor Peter Hill, Emily Goodwin, Ottilie Sedgwick, Gareth
Hopkin and Kiera Brown for their contribution to these modules.
Additionally, the author thanks the following for specific module contribution:
Module 4 – ADHD and Education: Mr Fin O’Regan

Behaviour Management Consultant
www.fintanoregan.com
Module 5 – ADHD and Employment: Mr Simon McKay

Solicitor Advocate
McKay Law Solicitors & Advocates
Carlshead Business Centre
Paddock House Lane
Sicklinghall
Leeds
LS22 4BJ
Tel. 0845 123 5571
Mr Chris Weaver
Assistant Solicitor
Payne Hicks Beach
10 New Square
Lincoln’s Inn
London
WC2A 3QG
Tel. 020 7465 4338
These modules have been funded and supported by Eli Lilly & Co Ltd. Lilly has reviewed the content for
medical accuracy only.
6
ADHD IN ADOLESCENCE | Introduction to ADHD Dr Susan Young
ADHD IN ADOLESCENCE
Module 1
Introduction to ADHD
I think I’m
misunderstood a lot... People
Module topics with ADHD are actually very clued
up, people don’t think they are but I
> What is ADHD? understand stuff really quickly... I find if
> How Common is ADHD? I’m strict with myself then I’m good, and
> What Causes ADHD? routine is really good. If I’m out of a routine
> Diagnostic Classification of ADHD then it just goes downhill, everything just falls
> How is ADHD Diagnosed? to pieces...It’s bizarre, as you don’t actually
> How is ADHD Treated? realise when you’re out of control... and
> Medication then when a mate says “come on
> Psychological Treatment what’s going on?” That’s when you
> Psychoeducation go uhhh, and it hits you like
> Key Points from Module 1 a ton of bricks...
> References
> Further Reading & Useful Resources
What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is frustrated because they do not reach their potential.
a highly heritable neurodevelopmental disorder Their symptoms are present from childhood and have
that starts in early childhood. It is characterised by a heterogeneous progression. For some individuals
pervasive inattention, impulsivity and hyperactivity symptoms remit with age (most commonly overt
that is inappropriate to the developmental age and it hyperactive and impulsive symptoms), while others
negatively impacts directly on social and academic/ experience persistent symptoms and associated
occupational activities. People with ADHD often find it impairment into adulthood [1,2]. As a life span
hard to sustain attention especially when doing boring condition, young people with ADHD often experience
tasks; they rush through tasks just to get them done greater difficulty coping with the life-changes they
(or fail to finish altogether); become easily distracted; will face as they mature, e.g. accepting responsibility,
lose or forget things; interrupt others and/or blurt things difficulty with exams, career decisions, leaving home,
out; fidget and find it hard to relax; find it difficult to wait gaining employment, romantic relationships, dealing
their turn and control their emotions. They experience with interpersonal conflict, having children etc. Thus
these difficulties to a greater extent than their peers, practitioners must consider the life stage of the
and this often causes them problems at home, in presenting patient and their needs at that time.
educational and/or occupational activities, and in their
interpersonal relationships. They often feel irritated and
7
How Common is ADHD?
ADHD is reported in many cultures [3] and whilst
I don’t mean to
there are a wide range of prevalence rates cited, most
converge on a figure of 5% during childhood years [4]. be offensive, like I’ll
The UK estimate is a rate of 3.6% in boys and 0.9% say to someone “wow, that
in girls [5]. Around 15% of those with childhood ADHD shirt makes you look fat” but
will still meet DSM-IV criteria for a full diagnosis at I won’t think in my head that it
age 25, and around 50% will continue to experience could hurt their feelings, when
some persistent symptoms [1]. As children, up to four
obviously a comment like
times more boys than girls are diagnosed, whereas in
that would hurt
adulthood women are just as likely to be diagnosed.
This may be because younger boys present as more their feelings.
hyperactive, which means that they are more likely to
be noticed as having a behavioural problem.
What Causes ADHD?

ADHD can run in families and genes play a significant role in brain development, with a number of different genes
thought to be involved that may be linked to brain chemicals. However, there isn’t one single explanation; a range
of environmental and psychosocial factors can interact with genetics to give large variation in symptoms [6].
Genetic factors Environmental factors Psychosocial factors

Studies of families, twins and Other factors that also affect brain The degree of nurture and
adopted children have shown that development include smoking, stimulation that a child receives in
the heritability of ADHD is substantial drinking, and substance use during early life may also have an impact,
in first degree relatives of individuals pregnancy, pre-term birth, low birth- as can early social adversity such
with ADHD [7]. A number of genes weight, birth trauma, and maternal as deprived institutional care
have been implicated such as those depression. These factors can interact and disrupted family relationships
linked to the dopamine and serotonin with genetic/neurological factors to [10]. However, the exact link
systems in the brain [8]. However, no increase the risk of ADHD. [9] between psychosocial factors and
single gene has been identified. ADHD is not known. In the case
of family relationships for example,
it is hard to tell whether disrupted
relationships lead to ADHD, or
vice versa.
Diagnostic Classification of ADHD

The Diagnostic and Statistical Manual of Mental fits more closely with clinical practice. DSM-V criteria
Disorders V (DSM-V) criteria defined by the American require onset of symptoms by age 12. For children, six
Psychiatric Association [11] are the most widely used (or more) symptoms must have persisted for at least six
and include three subtypes of ADHD: predominantly months. For older adolescents and adults (age 17 and
inattentive, predominantly hyperactive/impulsive, and older), at least five symptoms are required. Symptoms
combined presentation (see Box 1). The hyperkinetic must have persisted for at least six months to a degree
disorder criterion of the World Health Organization that is inconsistent with developmental level and must
[12] defines a subgroup of the DSM-IV category negatively impact directly on social and academic/
that represents a more restricted application of the occupational activities.
diagnostic criteria. However, most practitioners prefer
to follow the broader DSM-V criteria that allow for the 8
coexistence of comorbid psychiatric disorders as this
Box 1: Classification of DSM-V ADHD symptoms
Predominantly inattentive presentation Six out of nine inattentive symptoms rated as ‘often’
(or five symptoms if age 17 and older)
Predominantly hyperactive-impulsive presentation Six out of nine hyperactive/impulsive symptoms

rated as ‘often’ (or five symptoms if age 17
and older)
Combined presentation Six out of nine inattentive symptoms AND six out
of nine hyperactive/ impulsive symptoms rated as
‘often’ (or five symptoms respectively if age 17
and older)
How is ADHD Diagnosed?

Even though ADHD is a common childhood disorder, it A diagnosis should never be made solely on the basis of
is often undiagnosed or misdiagnosed. Early diagnosis screening questionnaires as false positive results can be
and intervention (with multi-disciplinary management) is obtained using screens, but they are useful for indicating
important to minimise negative outcomes in the longer whether a more comprehensive assessment is needed.
term [13]. International guidelines are available to assist This consists of a clinical interview with the individual
with the diagnosis, treatment and management of ADHD and often with someone who knows them well. The
[14]. In the UK, these have been made by the National interview assesses for presence of symptoms and
Institute for Health and Clinical Excellence (NICE) [6]. associated impairment.
As for many conditions, a diagnosis begins with the It is important to consider the presence of comorbid
observation of frequency and severity of characteristic symptoms and/or differential diagnosis (see Module
symptoms. Screening questionnaires are often used 2 and Module 3). If an individual meets criteria for
to indicate the presence of self-rated symptoms. ADHD but does not experience any functional problems
Wherever possible it is recommended that these are or impairment from their symptoms, a diagnosis of
supplemented by ratings from an informant, such as ADHD cannot be made. When assessing ADHD in
a parent or teacher/tutor. For adults, assessments teenagers it is important to remember that symptom
determine presence of symptoms in childhood as well presentation may change with age (e.g. remission of
as current symptoms, as meeting criteria for childhood hyperactive behaviours).
ADHD is a prerequisite for making the diagnosis
in adulthood.
When
they diagnosed
me and I finally could
take the tablets, I realised
after a while I was concentrating
at school and I wasn’t a bad kid
like they thought. That’s when I
passed my eleven plus, because I
could actually sit down and take
an exam, which was
really nice.
9
How is ADHD Treated?
Medication and psychological treatments are the most common interventions.
Medication
Around 1% of children in the UK are currently receiving medication for ADHD [15]. This usually includes stimulants
such as the various formulations for methylphenidate including Ritalin, Concerta XL, Medikinet XL, Equasym XL
or Lisdexamphetamine [Elvanase]. Non-stimulants such as atomoxetine (Strattera) are another option; the latter
being the only medication licensed for adult use.
The aim of treatment is to reduce core ADHD symptoms and improve

mood, irritability, and self confidence. It usually then creates flow
on improvement in school work, behaviour, and social skills. NICE I went six
recommend that for adults and children with severe impairment, drug months without
treatment should be the first-line intervention, with stimulants considered medication, I tried to
first due to their demonstrated effectiveness, followed by atomoxetine cope and I thought I was
[6]. However, responses to medication treatment can vary. Medications
doing well, but when I
are available in different formulations (e.g. short-acting stimulants last
3-5 hours, long-acting stimulants last up to 12 hours and atomoxetine
look back now, I just
provides 24 hour coverage) so it is important to work with clients to find feel so much clearer.
the medication and dose that suits them. Fine tuning and careful dosage
can make a great deal of difference
As with all medications some people describe side effects, which may
be physiological (e.g. stomach aches, headaches) and/or psychological
(e.g. nervousness, feeling less sociable). The most common side effects
are short term appetite loss, sleep difficulty or blunting of personality.
Psychological Treatments
For young people with mild to moderate impairments, or those who do not want pharmacological
treatment, NICE recommend CBT psychological treatments [6]. Psychological programmes are available
for a range of ages from pre-school to adulthood. These programmes include a range of techniques
most commonly based on a cognitive-behavioural paradigm that aim to develop skills in behavioural
control, emotional control, organisation, time-management, attention and memory training, and social
skills training.
For younger children programme activities are usually delivered ‘indirectly’ via parents or teachers;
as children grow older and in the teenage years these move towards more ‘direct’ work with the
individual themselves.
A large body of research suggests that psychological treatments are effective in reducing ADHD symptoms,
especially for children with mild to moderate problems and, when used in conjunction with medication, they may
also increase effectiveness for children with more severe impairment and comorbid problems [16].
In adolescence, psychological treatment may be particularly relevant to support young people who must develop
greater responsibility for self-organisation and time-management of their studies. Additionally, it is during these
years that many other associated problems may arise or become more marked such as mood and anxiety
disorders, conduct problems, social relationship problems, and low self-esteem. See Box 2 for key findings
10
about non-pharmacological interventions for ADHD [16].
Box 2: Key findings from a review of non-pharmacological interventions [15]
• As children mature, the mode of intervention (e.g. pharmacological, psychosocial) will shift to reflect the
developmental needs and circumstance of the individual.
• As children mature the agent of implementation (e.g. parent, teacher) will also shift according to the
developmental needs and circumstance of the individual.
• More Randomised Controlled Trials are needed to provide conclusive evidence for treatment efficacy.
• Parent training is recommended for preschoolers and young school-age children, who may additionally
benefit from classroom interventions.
• Multimodal interventions are recommended for middle school/adolescent children.
• CBT interventions are recommended for adults (either group or individual).
Psychoeducation
All interventions should include a psychoeducational and responsible for their own care and they may have
component as knowledge and understanding about a period of not wishing to accept treatment or not
ADHD is crucial for dispelling lay beliefs, and will attending appointments (this is not uncommon in other
alleviate anxiety for the individual about the nature health areas).
and progression of the ADHD condition. This can be
effectively achieved through the provision of written Leaving school or further education seems to be an
information that can be disseminated to families, friends, important marker as by the age of 21 most individuals
teachers and employers. This should include information with ADHD will disengage from services [19]. One
and web links about ADHD resources and support way to maintain contact is to provide young adults
groups. Further information is available from professional/ with ADHD, and their families, information and advice
practice guidelines such as those issued by the British about the longer-term problems and needs of young
Association for Psychopharmacology [17], the European people with ADHD, and provide information about the
Network Adult ADHD [18], and NICE [6]. transition process from child to adult ADHD services
(see Module 8).
It is very important that teenagers who continue to
have persistent symptoms and impairments maintain
engagement with health services. However as teenagers
become adults, they become more autonomous
11
Box 3: Key points from Module 1 - Introduction to ADHD
• ADHD is characterised by symptoms of inattention, impulsivity and hyperactivity that are associated
with significant levels of academic, occupational and social impairment.
• ADHD is reported in many cultures and 5% of children are estimated to have ADHD, with a 4:1 male
female ratio.
• Around two-thirds of those with childhood ADHD will experience persisting symptoms and impairments
at age 25.
• ADHD is caused by a combination of genetic, psychosocial and environmental factors - there is no

single cause.
• International guidelines are available to assist with the diagnosis, treatment and management
of ADHD.
• ADHD can be treated effectively with medication and psychological treatments. These should be
complemented by psychoeducation including written information about the nature and progression of
ADHD, available treatments, service provision, and service-user support groups.
12
References
[1] Faraone, S., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention deficit hyperactivity
disorder: A meta-analysis of follow-up studies. Psychological Medicine, 36(2), 159-165.
[2] Young, S., & Gudjonsson, G. (2008). Growing out of Attention-Deficit/Hyperactivity Disorder:the relationship
between functioning and symptoms. Journal of Attention Disorders, 12(2), 162-169.
[3] Hodgkins, P., Arnold, L.G., Shaw, M., Caci, H., Kahle, J., Woods, A.G., & Young, S. (2012). A systematic
review of long-term outcomes in ADHD: global publication trends. Frontiers in Psychiatry, 2, 84.
http://dx.doi.org/10.3389/fpsyt.2011.00084
[4] Polanczyk, G., de Lima, M.S., Horta, B.L., Biederman, J., & Rohde, L.A. (2007). The Worldwide Prevalence of
ADHD:A Systematic Review and Metaregression Analysis. American Journal of Psychiatry, 164, 942-948.
[5] Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and Adolescent Mental Health Survey 1999: the
prevalence of DSM-IV disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(10),
1203-1211.
[6] National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and
management of ADHD in children, young people and adults. NICE clinical guideline 72. London.
[7] Steinhausen, H.C. (2009). The heterogeneity of causes and courses of attention-deficit⁄ hyperactivity disorder.
Acta Psychiatrica Scandinavica, 120(5), 392–399.
[8] Stergiakouli, E., & Thapar, A. (2010). Fitting the pieces together: current research on the genetic basis of
attention-deficit/hyperactivity disorder (ADHD). Journal of Neuropsychiatric Disease and Treatment, 6, 551-560.
[9] Thapar, A., Cooper, M., Jefferies, R., & Stergiakouli, E. (2012). What causes attention deficit hyperactivity
disorder? Archives of Disease in Childhood, 97, 260-265.
[10] Rutter, M. (2005). Environmentally mediated risks for psychopathology:research strategies and findings.
Journal of Child Psychology and Psychiatry 44(1), 3–18.
[11] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition.
American Psychiatric Association, Washington, DC, USA.
[12] World Health Organization. (1993). The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic
Criteria for Research. World Health Organization, Geneva, Switzerland.
[13] Shaw, M., Hodgkins, P., Caci, H., Young, S., Kahle, J., Woods, A., & Arnold, L.G. (2012). A Systematic
Review and Analysis of Long-term Outcomes in Attention Deficit Hyperactivity Disorder: Effects of Treatment and
Non-treatment. BMC Medicine, 10; 99, http://dx.doi.org/10.1186/1741-7015-10-99
[14] Sexias, M., Weiss, M., & Mûller, U. (2012). Systematic review of national and international guidelines on
attention deficit hyperactivity disorder. Journal of Psychopharmacology, 26(6):753-765.
[15] Wong, I.C., Asherson, P., Bilbow, A., Clifford, S., Coghill, D., DeSoysa, R., & Taylor, E. (2009). Cessation of
13
attention deficit hyperactivity disorder drugs in the young (CADDY)-a pharmacoepidemiological and qualitative study.
Health Technology Assessment (Winchester, England), 13(50), iii-iv, ix-xi, 1-120.
[16] Young, S., & Amarasinghe, J.A. (2010). Practitioner Review: Non-pharmacological treatments for ADHD: A
lifespan approach. Journal of Child Psychology and Psychiatry, 51(2), 116-133.
[17] Nutt, D.J., Fone, K., Asherson, P., Bramble, D., Hill, P., Matthews, K., & Young, S. (2007). Evidence-based
guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and
in adults: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology,
21(1), 10-41.
[18] Kooij, S.J.J., Bejerot, S., Blackwell, A., Caci, H., Casas-Brugué, M., Carpentier, P.J., & Asherson, P. (2010).
European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD.
BMC Psychiatry, 10:67. http://dx.doi.org/10.1186/1471-244X-10-67
[19] McCarthy, S., Asherson, P., Coghill, D., Hollis, C., Murray, M., Potts, L., & Wong, I.C.K. (2009). Attention-deficit
hyperactivity disorder: treatment discontinuation in adolescents and young adults. British Journal of Psychiatry,
194(3), 273-277.
Further Reading and Useful Resources

Asherson, P. (2005). Clinical assessment and treatment of attention deficit hyperactivity disorder in adults.
Expert Review of Neurotherapeutics, 5(4), 525-539.
Young, S., Murphy, C.M., & Coghill, D. (2011). Avoiding the ‘twilight zone’: Guidance and recommendations on ADHD
and the transition between child and adult services. BMC Psychiatry. 11:174,
dx.doi.org/10.1186/1471-244X-11-174
Young, S. & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A Psychological
Guide to Practice, Second Edition. Chichester: John Wiley & Sons.
Young, S. (2013). The ‘RAPID’ cognitive behavioral therapy program for inattentive children: preliminary findings.
Journal of Attention Disorders, 17(6), 519-526.
Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An Expert White Paper on
attention-deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long term
outcomes, in support of affected individuals,
www.europeanbraincouncil.org/pdfs/ADHD%20White%20Paper_15Apr13.pdf
14
ADHD IN ADOLESCENCE | Symptoms of ADHD | Dr Susan Young
ADHD IN ADOLESCENCE
Module 2
Symptoms of ADHD
Anyone who knows
Module topics me says I’m not like other
people but they don’t really see
> Core Symptoms of ADHD the side that I struggle with, the mood
> Inattention swings and not completing things. I can
> Hyperactivity be quite impulsive and I think about things
> Impulsivity a bit differently to other people. I look at
> Emotional Lability things in a different way I suppose. When my
> Negative functioning tablets wear off I can have mood swings. It’s
> Symptom Remission hard sometimes, but I don’t really notice it
> Gender Differences so much. It’s more when I’ve got a lot
> Key Points from Module 2 going on...I get stressed easily. I can’t
> References multitask or get things completed
> Further Reading & Useful Resources on time.
Core Symptoms of ADHD
The symptoms of ADHD are inattention, hyperactivity experiences more as feelings of inner restlessness
and impulsivity leading young people to present as and fidgeting. This may have contributed to the
disorganised and chaotic, reckless and emotionally misconception that ADHD affects young children.
labile. They struggle with these behaviours more than
other children their age, and may have difficulty with Whilst some symptoms appear to spontaneously remit
these behaviours across different areas of their life; with age, relative differences that are associated with
home, school, social or leisure activities. Children and significant functional impairments may remain.
young people vary in their symptom presentation, Thus when assessing adolescents and young adults, it
leading to different diagnostic classifications, for is important that practitioners consider the
example girls more frequently present with inattentive developmental stage of the patient and compare
symptoms rather than disruptive behaviours and are the individual’s presentation with that of a normative
thus classified as ‘ADD’ (predominantly inattentive type) peer group.
[1] (see Module 1).
One difficulty that arises for practitioners when
As children mature there is often a shift in the way assessing ADHD is in young adults is that symptom
symptoms are expressed with hyperactivity and classification for ADHD was developed with children in
impulsivity modifying more than attentional symptoms mind and the symptom descriptions do not correspond
[2]. In adolescents hyperactivity is more subtle than well for older adolescents and adults. To some extent
the overactive or boisterous behaviours seen in young this has been addressed in the DSM-V, however 15
children, such as rolling around the floor or running additional helpful descriptions for adults are available
about recklessly and without purpose. It is (see Boxes 1, 2 & 3) [3]
Inattention
There are several different domains, or aspects, of Individuals with ADHD often report that they are more
attention. These include (1) selective attention, which able to maintain their focus if an activity holds a particular
is the ability to focus down on one particular thing (e.g. interest for them. This can be confusing for parents
proof reading for errors); (2) divided attention, which is and teachers who do not understand why the child
the ability to focus on two or more things at the same cannot complete an English assignment and turn this
time (e.g. driving a car and having a conversation); in on time yet can sit for hours on Facebook or arrange
(3) shifting attention, which involves moving focus a fashion show as an extra-curricula activity. This may
between two or more things (e.g. following instructions be perceived as a lack of cooperation or in some cases
to assemble flat-pack furniture); and (4) sustained rebellious behaviour.
attention, which is being able to focus on something
for any length of time (e.g. revising for exams or The key is to identify adaptive strategies that the young
doing homework). person can set and apply themselves to maintain
motivation for tedious tasks or tasks that do not hold
In today’s society the ability to multitask is central to their interest. These may include setting goals, breaking
achievement in daily life, at school, work and at home, tasks down into smaller steps, the introduction of pre-
and this requires individuals to have good attentional determined breaks, and incorporating immediate and
control and information processing skills. Young longer term reward systems to reward achievement.
children may benefit from structured school settings
and teacher-parent collaborations that aim to maximise
achievement by optimising the environment (e.g. sitting
at the front of the class, one-to-one tuition, mentoring,
support). However, this often changes in the teenage
years when youngsters strive for more autonomy.
At the same time the school environment becomes
more challenging as they are required to take greater
responsibility for self-management and organisation.
At school, for example, they have to cope with more If my mind’s not
complex timetables involving room and staff changes, being challenged you
organise homework and school projects and meet just end up doing nothing.
competing deadlines. They also start to organise their
If I don’t plan or set my day
own social activities; and many balance part-time work
with other responsibilities and chores at home.
up I’ll literally just be sitting in
a chair watching naff telly
for a whole 7 hours…
what a waste.
16
Box 1: Symptoms of inattention [3]
• Often fails to give close attention to detail: difficulty remembering where they put things. In work this may lead
to costly errors. Tasks that require details are tedious (e.g. income tax returns) and become very stressful.
This may include overly perfectionistic and rigid behaviour, needing too much time for tasks involving details
in order to prevent forgetting any of them.
• Often has difficulty sustaining attention: inability to complete tasks such as tidying room or mowing the lawn
without forgetting the objective and starting something else. Inability to persist with boring jobs. Inability to
sustain sufficient attention to read a book that is not of special interest, although there is no reading disorder.
Inability to keep accounts, write letters or pay bills. Attention, however, can often be sustained during exciting,
new or interesting activities (e.g. using the internet, chatting and computer games). This does not exclude the
criterion when boring activities are not completed.
• Often does not appear to listen when spoken to: adults receive complaints that they do not listen, and that
it is difficult to gain their attention. Even where they appear to have heard, they forget what was said and
follow through. These complaints reflect a sense that they are ‘not always in the room’, ‘not all there’ or ‘not
tuned in’.
• Fails to follow through on instructions and complete tasks: adults may observe difficulty in following other
people’s instructions. Inability to read or follow instructions in manual for appliances. Failure to keep
commitments undertaken (e.g. work around the house).
• Difficulty in organising tasks or activities: adults note recurrent errors (e.g. lateness, missed appointments or
missing critical deadlines). Sometimes a deficit in this area is seen in the amount of delegation to others such
as secretary at work or spouse at home.
• Avoids or dislikes sustained mental effort: putting off tasks such as responding to letters, completing tax
returns, organising old papers, paying bills or establishing a will. One can enquire about specifics then ask
why particular tasks were not attended to. These adults often complain of procrastination.
• Often loses things needed for tasks: misplacing purse, wallet, keys and assignments from work, where car is
parked, tools and even children!
• Easily distracted by extraneous stimuli: subjectively experience distractibility and describe ways in which
they try to overcome this. This may include listening to white noise, multitasking, require absolute quiet or
creating an emergency to achieve adequate states of arousal to complete tasks, many projects going on
simultaneously and trouble with completion of tasks.
• Forgetful in daily activities: may complain of memory problems. They head out to the supermarket with
a list of things, but end up coming home having failed to complete their tasks or having purchased
something else.
17
Hyperactivity
Younger children with ADHD typically present with greater behavioural disturbance and hyperactivity, for example they
might race about the house, run across roads without looking, answer back or talk over others, not wait their turn,
and get upset quickly over seemingly small things. They may find it difficult to sit still for long periods (e.g. at the dinner
table, or in lessons or assembly at school).
As children grow up some impulsive behaviours and hyperactivity may diminish or become more purposeful (e.g.
directed in sporting activities). Most commonly adolescents and adults describe feeling an inner restlessness and need
to fidget, as opposed to the urge to run around aimlessly. Many also describe ceaseless mental activity, saying that
their minds are always ‘on the go’.
Box 2: Symptoms of hyperactivity [3]
• Fidgets with hands or feet: this item may be observed, but it is also useful to ask about this. Fidgeting
may include picking their fingers, shaking their knees, tapping their hands or feet and changing position.
Fidgeting is most likely observed while waiting in the waiting area of the clinic.
• Leaves seat in situations in which remaining seated is usual: adults may be restless. For example, they
experience frustration with dinners out in restaurants and are unable to sit during conversations, meetings
and conferences. This may also manifest as a strong internal feeling of restlessness when waiting.
• Wanders or runs about excessively or frequently experience subjective feelings of restlessness: adults
may describe their subjective sense of always needing to be ‘on the go’, or feeling more comfortable with
stimulating activities (e.g. skiing) than with more sedentary types of recreation. They may pace during the
[assessment] interview.
• Difficulty engaging in leisure activities quietly: adults may describe an unwillingness/dislike to ever just stay
home or engage in quiet activities. They may complain that they are workaholics, in which case detailed
examples should be given.
• Often ‘on the go’ or acts as if driven by a motor: significant others may have a sense of the
exhausting and frenetic pace of these adults. ADHD adults will often appear to expect the same
frenetic pace of others. Holidays may be described as draining since there is no opportunity
for rest.
• Talks excessively: excessive talking makes dialogue difficult. This may interfere with a spouse’s sense of
‘being heard’ or achieving intimacy. This chatter may be experienced as nagging and may interfere with
normal social interactions. Clowning, repartee or other means of dominating conversations may mask an
inability to engage in give-and-take conversation.
18
Impulsivity Cognitive Impulsivity
Impulsivity can be classified as behavioural or cognitive, Cognitive impulsivity is defined as only seeing the
with individuals typically experiencing a combination of immediate short-term gain of an action. The tendency
both. A difficulty with self-monitoring their own behaviour, to jump to conclusions is debilitating because this
or poor self-regulation, is a hallmark of ADHD that for is associated with ‘errors’ in thinking and erroneous
many persists into adulthood. assumptions. This usually results in poor decision-
making as the person does the first thing that springs to
Behavioural Impulsivity mind which may not be the best.
Behavioural impulsivity is observed in actions. A Young people need to learn to engage in a functional
behaviourally impulsive person responds prematurely to process involving the generation and consideration of
situations; they act spontaneously without thinking. This different potential solutions to a problem, weighing up
may lead them to lash out at others verbally or physically; the advantages and disadvantages of each solution, and
they may blurt out hurtful comments without being able applying a consequential thinking process. If a person
to stop themselves, they may start fighting or damage learns to stop and think and generate several potential
property. They may put themselves at risk by engaging in solutions to a problem, they give themselves ‘choice’ in
reckless or dangerous behaviours such as driving at high the form of multiple options. If the first does not succeed,
speeds, promiscuity and unprotected sex. then they have others to try.
By definition, impulsive behaviours occur without planning Impulsive symptoms may lead to negative consequences
or malice, and without consideration of consequences. in adolescence. The persistence of hyperactivity/
Nevertheless, this is commonly unacceptable to family, impulsivity can result in a pathway into inappropriate
friends or school teachers for many reasons. It causes and/or reckless behaviours that often involve
hurt and distress to people they care about, leads to rule-breaking, substance use, and antisocial behaviour.
conflict and confrontation in interpersonal relationships, Thus it is important to find effective ways to manage
and the behaviour may even put themselves and others these symptoms.
at risk of harm.
Big paragraphs
are so daunting, I don’t even
like to tackle big paragraphs. They
scare me, because I know when I get
one sentence in, I won’t even know what
I’ve read. If I can’t finish an exam properly,
which affects my grades although I’m working as
hard as I can, how the hell am I going to pass my
university tests? And that scares me...I struggle
to concentrate and listen to someone. How the
hell am I supposed to learn while writing and
listening? I don’t know what I’m going to
do, this is probably the first time I’ve
talked about it. I am so scared.
I really am.
19
Box 3: Symptoms of impulsivity [3]
• Blurts out answers before questions have been completed: this will usually be observed during the
[assessment] interview. This may also be experienced by probands as a subjective sense of other
people talking too slowly and of finding it difficult to wait for them to finish. Tendency to say what comes
to mind without considering timing or appropriateness.
• Difficulty waiting in turn: adults find it difficult to wait for others to finish tasks at their own pace, such
as children. They may feel irritated waiting in line at bank machines or in a restaurant. They may be
aware of their own intense efforts to force themselves to wait. Some adults compensate by carrying
something to do at all times.
• Interrupts or intrudes on others: most often experienced by adults as social ineptness at social
gatherings or even with close friends. An example might be an inability to watch others struggle with a
task (e.g. opening a door with a key) without jumping in to try for themselves.
Emotional Lability
Many ADHD experts view mood instability, or emotional lability, to be the
fourth ‘symptom’ of ADHD. This differs from anxiety, depression or bipolar
disorders which are episodic in nature. In adult clinics emotional over-reactivity I think I’m
and temper outbursts are commonly a presenting complaint that responds to probably more prone
stimulant medication along with the ‘core’ ADHD symptoms [3].
to feeling down…Even in
In adolescence, teenagers may be especially volatile as, aside from puberty,
a day I’ll swing from being
they are developing their personal and social identity. They are vulnerable really happy and then the
at this time for developing mood and anxiety disorders and, for those with next minute being really,
unrecognised ADHD, the presence of these symptoms may mask the really down.
underlying ADHD syndrome. When conducting an assessment therefore
it is important to be mindful that ADHD symptoms start early in life; they
are persistent and non-episodic. They are more trait-like than symptom-like
since there is no clear change from a premorbid state.
Negative Functioning
For a diagnosis of ADHD, the presenting individual must experience symptoms that negatively impact on their
functioning in two or more settings (i.e. social, academic or occupational activities). Thus the symptoms must be
pervasive and present in multiple domains.
Practitioners must bear in mind that achievement and/or function is relative to potential. Some people may appear
to function quite well, for example, by obtaining mid-range GCSE qualifications, leaving school and finding unskilled
employment. However this may be disproportionate to a high IQ and family expectations, with siblings attending
university and gaining professional occupations.
Some young people, especially those with high IQ’s, may cope by applying strategies (e.g. making lists) that limit
functional impairments. These may work in some circumstances but not others such as social settings. Others
apply dysfunctional strategies, e.g. alcohol and substance misuse. Asherson (2005) [3] has provided guidance for
assessment of impairment in young people and adults (see Box 4). 20
Box 4: Assessment of impairment [2]
Impairment is a requirement for a diagnosis of ADHD. The clinician needs to assess whether an individual is
impaired relative to his or her own potential, or relative to expected norms. Some very bright individuals are
not impaired relative to expected norms, but reveal unequivocal impairment relative to their own potential. It is
important to enquire into different areas of life since someone with ADHD may be brilliant at some sorts of work
while feeling totally inadequate because of their inability to be organised or to do work around the house.
• Quality of life: mood lability, a short fuse and constant efforts to correct scatterbrained mistakes are
frustrating and demoralising.
• Family life: even where an adult with ADHD feels fine, interviewing the patient’s spouse/family may reveal
significant dysfunction.
• Work: while some ADHD individuals find work that is compatible with their symptoms, they may be impaired
by not being able to move in new directions in which they would otherwise have desired to move. Others
may be functioning in attention-demanding professions, but at great emotional cost and without much
success. Work may not be commensurate with their intelligence and educational background. This is
usually experienced as underachievement.
• Love: ADHD is hard on relationships and some adults with ADHD give up on their capacity for intimacy
and lead an isolated existence. They may be unaware of the ways in which their ADHD-caused behaviour
patterns have contributed to relationship failures.
• Education: many adults with ADHD are impeded from obtaining an education appropriate to their potential
(usually assessed by IQ). A history of academic underachievement or erratic performance represents
academic impairment.
• Activities of daily life (ADL): even a high-functioning individual with ADHD may have difficulties with
ADL, such as shopping, cleaning, dressing or managing money. The deficit is not observed in what the
individual can do, but in what they actually do, so direct observation or an informant is required to assess
this correctly.
21
Symptom Remission
For some, core symptoms may start to decline during the adolescent years. This is not a uniform remission
but a heterogeneous progression with some individuals experiencing full remission by adulthood, some
partial remission and others none at all [4,5]. In adolescence and early adulthood, symptoms of inattention
typically persist to a greater degree than hyperactivity or impulsivity (see Figure 1), and around 65% of ADHD
children will experience some persisting symptoms as young adults that will be associated with significant
impairment [4].
Age-related changes have been investigated in a cross-sectional study of a clinical sample diagnosed with ADHD and
divided into four groups based on decade of life and matched for childhood ADHD severity [6]. Symptoms improved
according to objective measures (informant ratings and neuropsychological assessment), however inattentive
symptoms increased with age according to self-ratings. Thus the subjective experience of people with ADHD was
that their symptoms worsen as they become older, and it was found that this may be associated with an increase
in symptoms of depression. The study highlights the importance of affective symptoms in older persons with ADHD
and the potential for misdiagnosis.

6
Mean number of symptoms
4
Inattention
3 Impulsivity
Hyperactivity
2
0
< 5 6 to 8 9 to 12 to 15 to 18 to
11 14 17 20
Age (years)
Figure 1. Remission of symptom groups with age (Faraone et al., 2006)
Gender Differences
In the general population, more boys than girls have ADHD with a ratio of approximately 4:1 in children [7]. However
the gender difference becomes far less skewed with age as more adult females are identified and diagnosed [8]. This
may be explained by females having fewer externalizing problems, hyperactivity, aggression and conduct problems
than boys. They suffer more from internalizing problems and inattention, and thus are less likely to present with
overt behavioural problems and to be referred for treatment. With maturity a change in referral pattern may also
influence the gender ratio within clinical populations as more adult women seek help from psychiatrists than men
(most commonly for mood and anxiety disorders).
22
Box 5: Key points from Module 2- Symptoms of ADHD
• ADHD symptoms of inattention, impulsivity and hyperactivity affect young people who may present as
disorganised, chaotic, reckless and emotionally labile.
• One difficulty with assessing ADHD in young adults is that the symptom classification was developed with
children in mind which may not correspond well with older age-groups.
• In the adolescent years, teenagers may be especially volatile in mood as, aside from puberty, this is a time
when they are developing their personal and social identity.
• For a diagnosis of ADHD, symptoms must cause negative functioning in two or more settings (e.g. home,
school, work). Impairment should be considered relative to potential.
• Around two-thirds of ADHD children will continue to experience significant impairment as young adults.
• In adolescence symptoms of inattention typically persist to a greater degree than hyperactivity

and impulsivity.
• A gradual pattern of decline in symptoms is seen as individual’s move into middle adulthood. Subjectively
however symptoms of inattention may be perceived to become worse and this may be due to comorbid
mood disorders.
23
References
[1] Biederman, J., Mick, E., Faraone, S,V., Braaten, E., Doyle, A., Spencer, T., Wilens, T.E., Frazier, E., & Johnson,
M.A. (2012). Influence of gender on Attention Deficit Hyperactivity Disorder in children referred to a psychiatric clinic.
The American Journal of Psychiatry, 159(1), 36-42.
[2] Marsh, P.J., & Williams, L.M. (2004). An investigation of individual typologies of attention-deficit hyperactivity
disorder using cluster analysis of DSM–IV criteria. Personality and Individual Differences, 36(5), 1187-1195.
[3] Asherson, P. (2005). Clinical assessment and treatment of attention deficit hyperactivity disorder in adults.
Expert Review of Neurotherapeutics, 5(4), 525-539.
disorder:A meta-analysis of follow-up studies. Psychological Medicine, 36(2), 159-165.
[5] Young, S., & Gudjonsson, G. (2008). Growing out of Attention-Deficit/Hyperactivity Disorder:the relationship
between functioning and symptoms. Journal of Attention Disorders, 12(2), 162-169.
[6] Bramham, J., Murphy, D., Xenitidis, K., Asherson, P., Hopkin, G., & Young, S. (2012). Adults with ADHD; An
investigation of age-related differences in behavioural symptoms, neuropsychological function and comorbidity.
Psychological Medicine, 42, 2225-2234.
.
[7] Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and Adolescent Mental Health Survey 1999: the
prevalence of DSM-IV disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(10),
1203-1211.
[8] Kessler, R.C., Adler, L., Berkley, R., Biederman, J., Conners, C.K., Demler, O. ... Zaslavsky, A.M. (2006). The
prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey
Replication. American Journal of Psychiatry, 163(4), 716-723.

National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management
of ADHD in children, young people and adults. NICE clinical guideline 72. London.
Young, S., Murphy, C.M., & Coghill, D.(2011). Avoiding the ‘twilight zone’: Guidance and recommendations on
ADHD and the transition between child and adult services. BMC Psychiatry. 11:174, dx.doi.org/10.1186/1471-
244X-11-174
Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A Psychological
Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An
Expert White Paper on attention-deficit hyperactivity disorder (ADHD):policy solutions to
address the societal impact, costs and long term outcomes, in support of affected individuals,
24
ADHD IN ADOLESCENCE | Common Comorbidities | Dr Susan Young
ADHD IN ADOLESCENCE
Module 3
Common Comorbidities
Module Topics
> ADHD and Comorbidity

> Disruptive Behaviour Disorders
I think she’s
> Anxiety Disorders
> Mood Disorders
more along the
> Tic Disorders autistic spectrum than
> Autistic Spectrum Disorders just ADHD. I think there’s
> Key Points from Module 3 quite few Asperger’s
> References traits in there but she
> Further Reading & Useful Resources doesn’t want any
more labels.
ADHD and Comorbidity

The last few decades have seen a substantial increase in It appears to be the rule rather than the exception for
the emotional problems experienced by adolescents in ADHD children to present with a second psychiatric
England [1]. The transition from childhood to adulthood disorder with reports of up to two-thirds of children with
is therefore difficult for many teenagers who strive for ADHD having one or more comorbid conditions, including
independence and autonomy while coping with greater oppositional defiant and conduct disorder, anxiety and
social expectations, leaving school and going into further mood disorders, tic disorders and autistic spectrum
education, making new friends, getting a job, and taking disorders [6-9]. Multiple presentations to health and social
greater responsibility for their actions and behaviour. services have been reported by individuals who were not
diagnosed until adulthood [10,11].
These transitions provoke some level of anxiety and
worry among most teenagers. Teenagers and adults Treatment with stimulant medication in childhood may not
with ADHD, however, may struggle more as they have be protective as follow-up data from 208 children with
fewer coping resources than their peers to help them ADHD who had been treated with stimulants found that
deal with the challenges and difficulties that they will face 23% had a psychiatric admission in adulthood (mean age
[2,3]; additionally their mood may be labile, for example, of 31). Conduct problems in childhood were predictive
with extreme presentations of excitement, irritability, (hazard ratio = 2.3 for boys and 2.4 for girls) [12].
frustration, anxiety and anger [4,5].
25
Disruptive Behaviour Disorders
The most common comorbid conditions in childhood are the disruptive disorders of conduct disorder (CD) and
oppositional defiant disorder (ODD) which together affect 40-60% of children and adolescents with ADHD [13]. ODD
is a recurrent pattern of negativistic, defiant disobedient and hostile behaviour towards authority figures that becomes
evident before age 8 and not later than early adolescence.
By contrast CD, which has a later onset usually after the age of 10, is characterised by a disregard for the rules and
norms of society. Problems associated with CD include physical and verbal aggression (e.g. starting fights), defiance
(e.g. staying out later than their curfew), offending (e.g. theft, vandalism or setting fires), and school truancy. ADHD
and CD occur together at a rate greater than chance [14] and together they are clinically and genetically more severe
variants of their independent disorders [15], thus presenting young people with a ‘double dose’ of self-management
problems. While boys more often have comorbid conduct problems, girls with ADHD and ODD or conduct disorder
might have more social problems than boys [16,17].
Anxiety Disorders
Teenagers with ADHD often feel different in some
way compared with their peers. Thus they may be My younger
particularly concerned with their self-image and brother, and my
desire to ‘fit in’. In addition they have a history of cousin have ADHD. My
underachieving their academic and social potential, cousin’s got Asperger’s
leading to a lack of confidence and poor self-efficacy.
as well...and my younger
This mismatch between what they want and believe
brother’s also got
they should be able to achieve and their actual
performance may lead to the development of anxiety. Oppositional
Defiant Disorder.
Anxiety disorders co-occur in approximately 20% of
adolescents with ADHD, the most common being
generalised anxiety disorder, obsessive compulsive
disorder, separation anxiety disorder and social
phobia [18].
In a survey of adults, 47% of adults with ADHD At a pub, if

had developed an anxiety disorder compared there’s like a group
with 19.5% of those without ADHD (odds ratio
of people, I don’t go
3.7) [19]. Whilst lower level anxiety may be more
into that group, I stay
pronounced, as a comorbid condition it will
exacerbate low self-esteem, stress intolerance on the outskirts of
and aspects of cognition such as impairment in the group.
working memory [20]. Symptoms such as restlessness
and inattention may appear similar in the two disorders
and it is important to determine which is primary as
this may help in deliver of effective treatment.
26
Mood Disorders
Young people with ADHD have often experienced a lot of criticism
and negative feedback in their lives. They experience disruption to
interpersonal relationships at school, and with family and friends. ... the smallest
Together with their difficulty in self-regulation, this means that they thing though will pop my
may be vulnerable to depressive symptoms. These symptoms bubble and bring me all the
may be mild but persistent leading to low mood, poor motivation
way down. I just have to fight
and a sense of hopelessness about the future. In turn this may
exacerbate concentration problems.
that I guess, I just try my hardest
not to be sad, because I don’t like
In a US nationally representative household survey of 18-44 year being sad. But as a child I was
old respondents, 38% of adults with ADHD reported they had very, very, very, very anxious
developed a mood disorder compared with 11% of those without and extremely depressed.
ADHD [19]. A gender difference may exist as major depression has
been reported to co-occur among adolescent females with ADHD
at a younger age, with a longer duration and to be associated
with greater impairment in personal, social and occupational
functioning [21].
A follow-up of Danish children into adulthood found that females

may have greater vulnerability for mood disorders leading to
inpatient admissions [12]. In cases of ADHD and comorbid
depression, it is important to bear in mind that impulsivity
may increase the risk that a young person will act out on
suicidal ideation.
Tic Disorders
Tic disorders are most commonly associated with motor tics such as repeated eye blinking and facial twitching
and/or phonic (or vocal) tics such as grunting and sniffing [22]. Up to 50% of children with tic disorders, including
Tourette’s syndrome (TS), also meet diagnostic criteria for ADHD [23] and children with these comorbid conditions are
at increased risk for externalising and internalising behaviour problems. However, the risk appears to be associated
with the co-occurrence of ADHD as children with TS alone tend to do better [29].
In contrast to previous thinking, treatment of comorbid ADHD with stimulant medication does not have an adverse
effect on tics in the majority of cases [24, 30]. Since tic disorders generally decrease in severity with age, these are
seldom a serious problem in the treatment of adults.
27
Autistic Spectrum Disorders
Autism spectrum disorder (ASD; including autism and Asperger’s syndrome) is characterised by life-long difficulties in
reciprocal social communication and stereotyped and repetitive behaviours and interests (International Classification
of Diseases, tenth edition - ICD-10) [25].
The overlap between ADHD and ASD has become increasingly recognised in
the past few years and a community twin study reported a strong genetic link
between ADHD and ASD, with 41% of children with ASD also having ADHD He recently
symptoms and 22% with suspected ADHD (based on positive screening got a diagnosis of
scales for ADHD symptoms) also had a diagnosis of ASD [31]. ASD, and I always felt
there was something
Problems with attention are common for people with ASD [27] and it has been
else besides
suggested that this may contribute towards the behavioural and cognitive
difficulties of people with ASD [28]. Overall, young people with ADHD and
the ADHD.
ASD may both have problems managing attention and emotions and those
who are diagnosed with both ADHD and ASD may experience particular
difficulties with cognitive control.
Box 1: Key points from Module 3 - ADHD and Common Comorbidities
• The extent of comorbidity associated with ADHD is high; two-thirds of children have at least one other
psychiatric disorder, including other disruptive behavioural disorders, anxiety disorders, mood disorders,
tic disorders, and autistic spectrum disorders.
• Disruptive behaviour disorders are the most common, especially for males, and up to 60%
of children and adolescents with ADHD will also have conduct disorder or oppositional
defiant disorder.
• Comorbid anxiety problems can exacerbate feelings of low self-esteem commonly experienced by those
with ADHD.
• Adolescent females with ADHD are at increased risk of major depression, which affects them at a younger
age, over a longer duration and is associated with greater impairment in personal, social and occupational
functioning.
• Children with co-occurring ADHD and Tourette’s/tics are at increased risk for externalising and internalising
behaviour problems.
• There is a strong genetic link between ADHD and autistic spectrum disorders, both of which are
characterised by problems managing attention and emotions.
• The order of treatment may depend on clinical judgement of which disorder is driving the mental state
changes and/or presenting level of behavioural impairments.
28
References
[1] Collishaw, S., Maughan, B., Natarajan, L., & Pickles, A. (2010). Trends in adolescent emotional problems in
England: a comparison of two national cohorts twenty years apart. Journal of Child Psychology and Psychiatry, 51(8),
885–894.
[2] Young, S., Heptinstall, E., Sonuga-Barke, E.J.S., Chadwick, O., & Taylor, E. (2005). The adolescent outcome
of hyperactive girls: Interpersonal relationships and coping mechanisms. European Child & Adolescent Psychiatry,
14(5), 245-253.
[3] Young, S. (2005). Coping Strategies used by ADHD adults. Personality and Individual Differences, 38(4), 809-816.
[4] Skirrow, C., McLoughlin, G., Kuntsi, J., & Asherson, P. (2009). Behavioral, neurocognitive and treatment
overlap between attention-deficit/hyperactivity disorder and mood instability. Expert Review of Neurotherapeutics,
9(4), 489-503.
[5] Gudjonsson, G.H., Sigurdsson, J.F., Adalssteinsson, T., & Young S. (2013). The relationship between ADHD
symptoms, mood instability, and self-reported offending. Journal of Attention Disorders. 17(4), 339-346.
[6] Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with
conduct, depressive, anxiety, and other disorders. American Journal of Psychiatry, 148(5), 564-577.
[7] Goldman, L.S., Genel, M., Bezman, R.J., & Slanetz, P.J. (1998). Diagnosis and treatment of attention-deficit/
hyperactivity disorder in children and adolescents. Journal of the American Medical Association, 279(14), 1100-1107.
[8] Pliszka, S.R. (1998). Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview.
Journal of Clinical Psychiatry, 59(Suppl 7), 50-58.
[9] Elia, J., Ambrosini, P., & Berrettini, W. (2008). ADHD characteristics: I. Concurrent co-morbidity patterns in children
& adolescents. Child and Adolescent Psychiatry and Mental Health, 2(15), 1-9.
[10] Huntley, Z., & Young, S. (2014). Alcohol and Substance Use History Among ADHD Adults: The Relationship
With Persistent and Remitting Symptoms, Personality, Employment, and History of Service Use. Journal of Attention
Disorders, 18(1), 82 –90.
[11] Young, S., Toone, B., & Tyson, C. (2003). Comorbidity and psychosocial profile of adults with Attention Deficit
Hyperactivity Disorder. Personality and Individual Differences, 35(4), 743-755.
[12] Dalsgaard, S., Mortensen, P.B., Frydenberg, M., & Thomsen, P.H. (2002). Conduct problems, gender and
adult psychiatric outcome of children with attention deficit hyperactivity disorder. British Journal of Psychiatry, 181,
416–421.
[13] Wolraich, M.L., Hannah, J.N., Pinnock, T.Y., Baumgaertel, A., & Brown, J. (1996). Comparison of diagnostic
criteria for attention deficit hyperactivity disorder in a county-wide sample. Journal of the American Academy of Child
and Adolescent Psychiatry, 35(3), 319-324.
[14] Waschbusch, D.A. (2002). A meta-analytic examination of comorbid hyperactive impulsive attention problems
and conduct problems. Psychological Bulletin, 128(1), 118–150.
29
[15] Thapar, A., Harrington, R., & McGuffin, P. (2001). Examining the comorbidity of ADHD-related behaviours and
conduct problems using a twin study design. British Journal of Psychiatry, 179, 224–229.
[16] Carlson, C.L., Tamm, L., & Miranda, G. (1997). Gender differences in children with ADHD, ODD, and co-
occurring ADHD/ODD identified in a school population. Journal of the American Academy of Child and Adolescent
Psychiatry, 36(12), 1706-1714.
[17] Gaub, M., & Carlson, C. L. (1997). Gender differences in ADHD:A meta-analysis and critical review. Journal of
the American Academy of Child and Adolescent Psychiatry, 36(8), 1036-1045.
[18] Geller, D.A., Biederman, J., Griffin, S., Jones, J., & Lefkowitz, T.R. (1996). Comorbidity of juvenile Obsessive-
Compulsive Disorder with disruptive behavior disorders. Journal of the American Academic of Child and Adolescent
Psychiatry, 35(12), 1637-1646.
[19] Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O., et al. (2006). The prevalence and
correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American
Journal of Psychiatry, 163(4), 716–723.
[20] Tannock, R. (2000). Attention-deficit/hyperactivity disorder with anxiety disorders. In T.E. Brown (Ed.). Attention
deficit disorders and comorbidities in children, adolescents, and adults (pp.125-170). Washington, DC: American
Psychiatric Press.
[21] Biederman, J., Ball, S.W., Monuteaux, M.C., Mick, E., Spencer, T.J., McCreary, M., et al. (2008). New insights
into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of the
American Academy of Child & Adolescent Psychiatry, 47(4), 426-434.
[22] Cath, D.C., Hedderly, T., Ludolph, A.G., Stern, J., Murphy, T., Hartmann, A., et al. (2011). European clinical
guidelines for Tourette Syndrome and other tic disorders. Part I: assessment. European Child and Adolescent
Psychiatry, 20(4), 155-171.
[23] Rothenberger, A., Roessner, V., Banaschewski, T., Leckman, J.F. (2007). Co-existence of tic disorders and
attention-deficit/hyperactivity disorder - recent advances in understanding and treatment. European Child and
Adolescent Psychiatry, 16 (Suppl 1): 1-4.
[24] Roessner, V., Plessen, K.J., Rothenerger, A., Ludolph, A.G., Rizzo, R., Skov, L., et al. (2011). European clinical
guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. European Child and
Adolescent Psychiatry, 20, 173-196.
[25] The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines.
Geneva:World Health Organization; 1994.
[26] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edn: Washington,
DC., 1994.
[27] Sturm, H., Fernell, E., & Gillberg, C. (2004). Autism spectrum disorders in children with normal intellectual levels:
associated impairments and subgroups. Developmental Medicine and Child Neurology, 46(7), 444-447.
[28] Allen, G,, & Courchesne, E. (2001) Attention function and dysfunction in autism. Front Biosci, Feb 1;6:D105-19.
30
[29] Carter, A.S., O’Donnell, D.A., Schultz, R.T., Scahill, L., Leckman, J.F., & Pauls, D.L. (2000). Social and emotional
adjustment in children affected with Gilles de la Tourette’s Syndrome: Associations with ADHD and family functioning.
Journal of Child Psychology and Psychiatry, 41(2), 215-223.
[30] Poncin, Y., Sukhodolsky, D., McGuire, J., & Scahill, L. (2007). Drug and non-drug treatments of children with
ADHD and tic disorders. European Child & Adolescent Psychiatry, 16(Suppl 1), 78-88.
[31] Ronald, A., Simonoff, E., Kuntsi, J., Asherson, P., & Plomin, R. (2008). Evidence for overlapping genetic influences
on autistic and ADHD behaviours in a community twin sample. Journal of Child Psychology and Psychiatry, 49(5),
535–542.
[32] National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management
of ADHD in children, young people and adults. NICE clinical guideline 72. London

Young, S., Murphy, C.M., & Coghill, D. (2011). Avoiding the ‘twilight zone’: Guidance and recommendations on
ADHD and the transition between child and adult services. BMC Psychiatry. 11:174,
dx.doi.org/10.1186/1471-244X-11-174
Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A
Psychological Guide to Practice, Second Edition. Chichester: John Wiley & Sons.
The National Autistic Society; Autism and ADHD:

www.autism.org.uk/about-autism/related-conditions/adhd-attention-deficit-hyperactivity-disorder.aspx
ADHD and Anxiety Disorders: www.aboutourkids.org/articles/attentiondeficithyperactivity_adhd_anxiety_disorders
31
ADHD AND ADOLESCENCE | Education | Dr Susan Young
ADHD IN ADOLESCENCE
Module 4
Education
Imagine
everyone’s got a
bit of chewing gum on their
Module Topics head and, in order to understand a
question, they write it down on a little
piece of paper and put it on the chewing
> The Educational Pathway
gum. It sticks and you can read the question
> Academic Progress
in your head and write down the answer. Well,
> Academic Performance
regardless of how easy the answer is, I will
> School and Classroom Interventions
pick it up, put it on my chewing gum and it
> Key Points from Module 4
will fall off, because my chewing gum is not
> References
sticky, and I will pick it up, put it on, it’ll
> Further Reading & Useful Resources
fall off, and I will have to proper
push it into the chewing gum
for it to stay there.
The Educational Pathway

As well as managing the core symptoms of ADHD, Still others attend further education establishments to
those with persisting symptoms often experience pursue academic goals at university or college. After
impairment throughout other areas of their lives. Indeed, this, some go on to complete post-graduate studies.
functional problems in at least two life areas are required
to meet diagnostic criteria for ADHD. This module is on Between 16-18 years teenagers undergo important
the topic of education, which is especially important in educational transitions and make decisions about their
adolescence as it paves the way for later employment. future careers. For those who continue to study, achieving
their academic potential continues to be a struggle and
Young people experience several changes during their some will opt out of further education and enter the
years of education. They may change school when job market with mixed success. Indeed, ADHD has
they move from junior to secondary school, and again been associated with a number of negative educational
after GCSE examinations. At this stage some may seek outcomes, including being less likely to graduate from
employment, while others will go on to study for A-levels College or High School [1] (see Figure 1). It has been
or other qualifications such as diplomas or BTECs. They associated with educational underachievement including
may pursue training through NVQ or apprenticeship lower exam-grade attainment, repeating academic years,
schemes to gain the experience required for skilled higher rates of school drop-out, greater remedial support
occupations (e.g. electrician, plumbing, catering). and/or special education, and a history of suspension
or expulsion [1-5].
32
100
90
80
70
60
50
40
30
20
10
0
High College Special Diagnosed Diagnosed Retained
school graduate Behaviour Learning
graduate Disorder Disability
The risk of academic failure is greatest for those whose ADHD symptoms are unidentified. Too many ADHD children,
especially those with predominantly attentional problems, still fall under the radar. Those attending selected private
educational establishments, and/or whose impairments are minimised due to high levels of parental support, may
also be missed. Their difficulties may become more apparent in secondary school when they are expected to work
more autonomously and manage a larger and more complex workload.
Academic Progress
In younger children, the transition to middle school has been shown to hinder and even briefly reverse the decline in
symptoms that may be seen with age [6], and equivalent educational transitions may arise during the teenage years
when moving to secondary school, college or university.
During adolescence, hyperactive and impulsive symptoms often remit earlier than symptoms of inattention. This
may parallel a narrowing of the curriculum when young people select fewer subjects of interest to study and hence
may perform better. Thus young people may appear to improve as their ADHD presentation becomes less overt.
Nevertheless persisting (perhaps sub-threshold) symptoms may remain and cause disruption to others (e.g. by
constant fidgeting, confrontational behaviour, speaking out without thinking, talking too much and/or ‘acting the
clown’). Behavioural disturbances of this nature are most likely to lead to sanctions such as detention and internal
exclusion from lessons. Persistent, severe disruption, oppositional behaviour and/or emotional outbursts may result
in school exclusions and, for some, expulsion.
Unsurprisingly, frequent suspensions and/or permanent exclusion significantly disrupt a young person’s education.
Compared with their peers, ADHD children are 100 times more likely to be permanently excluded from school;
research suggests that 39% of ADHD children receive fixed-term exclusions from school and 11% are excluded
permanently [7]. These exclusions, together with impairment in school performance and the need to re-sit exams and/
or repeat years, can mean that these young people take longer than their peers to graduate or to gain qualifications.
33
Excluded children are commonly schooled in Pupil Referral Units (PRUs), and around 75% of PRU children have
special educational needs, many of whom have difficulties associated with ADHD [8]. Ironically, many ADHD children
benefit from the PRU system, which provides smaller class sizes, greater individual attention, minimisation of noise/
distraction, greater structure and individual education plans and/or self-development plans. Other children with
severe ADHD impairment and additional special educational needs will attend special schools, which provide a
similar learning environment but with peers at a more equal academic level.
Academic Performance
Students are expected to attend class punctually, sit Poor organization skills are a major problem throughout
still, focus on the topic, take notes, collaborate with higher education. The issue, however, is that children
peers in group exercises, and work quietly without with ADHD ‘can’t’ as opposed to the (erroneous)
disturbing others. perception that they ‘won’t’ organise themselves and
do the work. This is frustrating for all parties, and leads
Symptoms of inattention, which are most likely to persist, to anxiety for the student, feelings of embarrassment
mean that young people often struggle to maintain their and failure, and negative comparisons of self to others.
focus on tasks and sustain attention in class. They are
easily distracted and experience interruption to their train These problems increase in adolescence as young
of thought. This interferes with their ability to express people take greater responsibility and autonomy in their
themselves in a logical and coherent way. They may school work and career, and are often expressed by
become preoccupied with lots of thoughts and ideas them arriving in class without the correct books or kit.
that are peripheral or unrelated to the topic. This flooding Outside of class students are expected to organise their
of thoughts or ideas may be functional in terms of time so they complete homework assignments and
creativity but it is tiring and often described as a meet course deadlines.
ceaseless mental activity.
Due to their ADHD symptoms, learning and revision
Loss of focus is most likely to occur when engaged skills do not come naturally to the young person with
in ‘tedious’ or repetitive tasks, or those with complex ADHD as it takes sustained effort and motivation to
concepts that are difficult to understand. In response, cope with work demands. Furthermore, they have
the young person with ADHD may ‘switch off’ and start to apply themselves against a backdrop of increasing
to ‘daydream’ or doodle. This may be perceived as a educational demands and expectations, with timetables
lack of effort. Children attending large, mainstream, becoming more complex, examinations more important,
comprehensive schools with characteristic large classes and greater autonomy being expected of them. Most
including children of mixed ability, will struggle more than likely they will receive less parental support in preparing
children who are fortunate to attend selective, private for the school day, travelling to and from school, and
education, which typically provides smaller class sizes with homework.
and greater teaching support for a more academically
homogenous group.
I was always
bright. I was never
slower than other
students. I was always just
as quick and clever as
the top of the class but I
couldn’t put
it on paper.
34
School and Classroom Interventions
Research has suggested that lifetime ADHD symptoms are a key predictor of academic performance (as measured
by GCSE performance, GCSE entries, and GCSE weighted score) [9]. While supported or special education may
enable students with ADHD to get more out their lessons, these young people are disadvantaged in test and exam
situations as they may sacrifice accuracy for speed or use the time inefficiently. Co-morbid difficulties such as
anxiety will further exacerbate symptoms and impair performance.
Teachers usually have an awareness of how basic cognitive ability or ‘intelligence’ relates to academic performance,
but they may be less aware of how ADHD hampers academic performance.
Those with special educational needs and/or ADHD may be entitled to

special arrangements in examinations. Guidelines are set by the Joint
Council for Qualifications and it is not the difficulty per se that gives the
I used to have right to special arrangements, rather the extent to which the difficulty
this little card thing. might impair the child in an exam situation. For young people with ADHD,
If I wanted to go out for common recommendations include a prompter, supervised breaks/
rest periods, and extra time (which may range from 10-25%). Other
a break I’d show it to the
potential arrangements, depending on circumstances, may be the use of
teacher and I used to be computers or word processors.
able to leave the class and
go up to the [inclusion] In addition, classroom provisions can be made. The NICE guidelines [10]
room. recommended that behavioural interventions could be provided in the
classroom, by teachers trained in the management of ADHD, to help
children and young people with ADHD. Evidence from expert opinions
and clinical experience of respected authorities suggests that classroom
interventions may particularly help to reduce off-task behaviours if they
are provided as part of a multimodal treatment plan. Indeed, a review of
the literature identified a need to provide psychoeducational information
about ADHD in educational establishments, including information about
management strategies that can be implemented in the classroom
(see Box 1) [11].
Box 1: Recommended classroom interventions and management strategies

for treating ADHD in adolescence [11]
Provide psychoeducational information, environmental and management strategies adapted for this
developmental age group, e.g., use of a Weekly Report Card instead of a Daily Report Card; tickets or
certificates of achievement can be issued to reward good behaviour and/or achievement; report tickets can
be awarded for breaking predetermined rules; teach study skills, including test-taking strategies; implement
homework completion sessions; reward systems can be extended to introduce longer-term rewards (the
accumulation of several small rewards can be exchanged for a larger desired reward).
Establish regular sessions attended by parents, teachers and counsellors initially to identify the child’s needs
and formulate an intervention plan and subsequently to monitor and evaluate the progress of the intervention
programme (including addressing any obstacles that may arise).
Implementation of individualised programmes if the child does not respond to standard treatment, e.g.,
provision of one-to-one support, remedial and/or revision sessions, if appropriate.
35
If young people with ADHD are to reach their potential and achieve academic success, educational establishments
need to develop greater awareness about ADHD and how this may impede academic progress. Indeed for the
first time, NICE guidelines included representation from education on the Guideline Development Group, which
emphasises the importance of joint working with the educational sector for this patient group. In particular, children
who receive fixed-term exclusions from school should be assessed for ADHD, and this could be introduced
through greater involvement of Special Educational Needs Co-ordinators (SENCOs) and referrals to educational
psychologists. The provision of school and classroom interventions may support many young people to succeed in
mainstream education.
Box 2: Key points from Module 4 - ADHD and Education
• ADHD is associated with educational underachievement including lower exam-grade attainment, repeating
academic years, higher rates of school drop-out, greater remedial support and/or special education, and
a history of suspension or expulsion.
• Symptoms of inattention, which are most likely to persist, mean that young people often struggle to
maintain their focus on tasks and sustain attention in class.
• Poor organisational skills are a major problem throughout higher education.
• As they grow up, symptomatic remission of hyperactivity and impulsivity, together with
a narrowing of the curriculum, means their academic skills may superficially appear to
have improved.
• ADHD children may benefit from selective private or special educational systems which
typically provide smaller class sizes and greater teaching support for a more academically homogenous
group.
• ADHD students may be entitled to special arrangements in examinations such as a prompter, supervised
breaks/rest periods and extra time.
• Classroom interventions that are provided as part of a multimodal treatment plan are considered by expert
groups to be beneficial.
References
[1] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The Guilford
Press.
[2] Barbaresi, W.J., Katusic, S.K., Colligan, R.C., Weaver, A.L., Jacobsen, S.J. (2007). Long-Term School Outcomes
for Children with Attention-Deficit/Hyperactivity Disorder: A Population-Based Perspective. Journal of Developmental
and Behavioral Pediatrics, 28(4), 265–273.
[3] Bauermeister, J. J., Shrout, P. E., Ramirez, R., Bravo, M., Alegria, M., Martinez-Taboas, A., et al. (2007). ADHD
correlates, comorbidity, and impairment in community and treated samples of children and adolescents. Journal of
Abnormal Child Psychology, 35(6), 883–898.
36
[4] Biederman, J., Faraone, S. V., Taylor, A., Sienna, M.,Williamson, S., & Fine, C. (1998). Diagnostic continuity
between child and adolescent ADHD: findings from a longitudinal clinical sample. Journal of the American Academy
of Child and Adolescent Psychiatry, 37(3), 305–313.
[5] Frazier, T. W., Youngstrom, E. A., Glutting, J. J., & Watkins, M. W. (2007). ADHD and achievement: meta-analysis
of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning
Disabilities, 40(1), 49–65.
[6] Langberg, J.M., Epstein, J.N., Altaye, M., Molina, B.S.G., Arnold, L.E., & Vitiello, B. (2008). The Transition to
Middle School is Associated with Changes in the Developmental Trajectory of ADHD Symptomatology in Young
Adolescents with ADHD. Journal of Clinical Child and Adolescent Psychology, 37(3), 651–663.
[7] O’Regan, F. (2009). Persistent disruptive behaviour and exclusions. ADHD in Practice, 1(1), 8-11.
[8] Department for Children, Schools and Families. (2008). Back on track: a strategy for modernizing alternative
provision for young people. Command Paper; Cm 7410.
[9] Birchwood, J., & Daley, D. (2012). Brief report: The impact of Attention Deficit Hyperactivity Disorder (ADHD)
symptoms on academic performance in an adolescent community sample. Journal of Adolescence, 35(1), 225-231.
[10] National Institute for Health and Clinical Excellence (NICE). (2009). Attention deficit hyperactivity disorder:
Diagnosis and management of ADHD in children, young people and adults. NICE Clinical Guideline 72. London.
[11] Young, S., & Amarasinghe, J.M. (2010). Practitioner Review: Non-pharmacological treatments for ADHD: A
lifespan approach. Journal of Child Psychology and Psychiatry, 51(2), 116–133.

244X-11-174
Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A Psychological
Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An Expert White Paper on attention-
deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long term outcomes,
in support of affected individuals, www.europeanbraincouncil.org/pdfs/ADHD%20White%20Paper_15Apr13.pdf
Special exam arrangements: jcq.org.uk/exams_office/access_arrangements/
ADHD and the school day: www.addiss.co.uk/schoolreport.pdf
Practical advice for dealing with ADHD in schools (for parents and teachers):
www.education-support.org.uk/parents/special-education/adhd/
37
ADHD IN ADOLESCENCE | Employment | Dr Susan Young
ADHD IN ADOLESCENCE
Module 5
Employment
Module Topics
I didn’t tell them
[employer] that I had
> ADHD in the Workplace ADHD, because I personally
> Applying for Work don’t feel like it’s that big a deal.
> Disclosure of ADHD Status Don’t get me wrong, it impacts on
> Reasonable Adjustments my life really badly sometimes but I
> Working Relationships don’t feel it should affect my working
> Key Points from Module 5 life, although it really does. I just
> References feel that if they knew that they
> Further Reading & Useful Resources wouldn’t have given
me a job.
ADHD in the Workplace

Adolescents are usually employed in one of two forms of work: (1) part-time employment to financially support further
education (e.g. weekend sales assistant); or (2) full-time employment for those leaving full-time education. In both
cases people with ADHD are more likely to exhibit behaviour problems in the workplace, and are more likely to be
disciplined or experience dismissal.
A large US study reported that, compared with controls, those with ADHD in childhood only (i.e. remitted by adulthood)
and those experiencing persisting ADHD symptoms may be fired or disciplined at work, or quit work as a result of
their own hostility. Those with persisting symptoms had more frequent work problems than controls and those whose
symptoms remit (see Figure 1) [1].
38
50
45
40
35
30
25
20
15
10
5
0
ed
ed
Fi r
in
ipl
sc
Di
Occupational impairment has become such a topic of concern that in 2008 the World Health Organisation led a
large-scale international initiative to assess the prevalence and correlates of mental disorders and occupational
problems [2]. Across the countries surveyed, ADHD was associated with a significant and costly impact on work
with an estimated 143.8 million days of productivity lost each year. It is therefore in the interests of both employers
and employees to address this problem.
How can we prevent these adverse occupational outcomes? Of course

some young people with ADHD will find work that is less affected by, or ...you’ve got
even suited to, their characteristics such as work in creative or sports
a lot of things going
industries. The natural creativity of people with ADHD can be a great asset
to many organisations; the downside is that all jobs include some aspect
on and I’ll maybe lose
of less engaging work and it is rare that tedious and/or menial tasks can something or I’ll say ‘I’ll do
be completely avoided. Some people are employed in work that means that in a second’ and then I
they are able to delegate this aspect of their work to secretarial and/ don’t, but, yeah, that can
or administrative staff, but others are less fortunate. Nevertheless there be quite an issue
is a responsibility for both employers and employees to recognise and sometimes.
understand the occupational problems faced by people with ADHD and
make reasonable work adjustments that will maximise the potential of the
employee. This is clearly a shared initiative.
39
Applying for Work
People with ADHD often avoid tedious tasks that may People with ADHD often forget their appointments,
include completing forms and applications. Attention double-book themselves, or turn up late. If they miss a
to detail is required to complete job applications job interview they may not be offered a second chance
effectively and without errors. It is often necessary to so it is important that they use a diary, and set alarms
attach a personal statement and/or a comprehensive and reminders to prevent this from happening. It is
Curriculum Vitae to an application, and it may be helpful natural to feel anxious during a job interview and anxiety
for parents or friends to look over application forms to exacerbates attentional problems, so arriving late
ensure that they are completed correctly, concisely and or unprepared can add to the stress. Individuals can
are relevant to the job of interest. Aside from paper- prepare for a job interview by finding out as much as
based applications, young people often additionally possible about the job role and the organisation. They
interact with employment advisors (e.g. at Job Centres) should seek information from family, friends, employment
and, as with job interviews, it is important to give the advisors, school career advisors and/or other sources
‘right’ impression and communicate effectively [3]. of career advice (e.g. see Useful Resources) about this
and get advice on how to conduct themselves in job
interviews. A mock interview can be very helpful as this
will prepare the young person for likely questions that
may be posed and provides an opportunity to rehearse
appropriate and constructive communication skills
and behaviour.
Disclosure of ADHD Status

Job Centre
At some point between applying for a job and starting work, an individual may have to make a decision about
whether to disclose their ADHD status and this can be a difficult choice. The concern is that this will be negatively
regarded by employers and/or a source of stigma and discrimination.
People with ADHD are protected by disability discrimination laws [4,5] and during the recruitment process, the
questions employers can ask about disability are limited and there must be a reason for asking. Thus disclosure
about ADHD will often be a matter of personal choice. Advice can be sought at Job Centres.
Employers may be apprehensive about offering employment to someone they perceive as suffering with a
serious and chronic condition [3] and may be unaware that, with minimal effort, a number of simple and practical
accommodations can be made for ADHD employees. If the diagnosis is disclosed, this provides an opportunity for
employers to work with employees to take appropriate steps to maximise the employee’s potential whilst minimising
obstacles. In turn, this is likely to ensure a positive employment outcome for both parties.
40
Reasonable Adjustments
The Equality Act 2010 imposes a duty on employers to make reasonable adjustments to premises or working
practices to help disabled job applicants and employees. An employer has a duty to make reasonable adjustments
where it knows (or ought reasonably to know) that a person has a disability and there is a provision, criterion
or practice (PCP), a physical feature or lack of auxiliary aids which place the disabled person at a substantial
disadvantage compared to those who are not disabled. Failure to make reasonable adjustments amounts to
unlawful disability discrimination.
Whether there is a breach of the duty to make adjustments will depend on whether a particular adjustment was
‘reasonable’ in the circumstances. This is an assessment which is very much fact-sensitive. Factors which may
be taken into account by an Employment Tribunal when deciding what steps are reasonable for an employer to
have taken include:
l the extent to which the adjustment would have …the majority

ameliorated the disadvantage; of the time I don’t tell
people because I don’t feel they
l the extent to which the adjustment was practicable;
need to know. I feel it’s none of
their business. They’ve probably got
l the financial and other costs of making the
adjustment, and the extent to which the step would things that they don’t want to tell me;
have disrupted the employer’s activities; they might have a deficiency with their
health or something. I don’t want to
l the financial and other resources available to know about it. I don’t feel I should
the employer; know about it, so I don’t feel that
I should tell them about my
l the availability of external financial or other
problems.
assistance; and
l the nature of the employer’s activities and the size of

the undertaking.
The duty to make reasonable adjustments applies to all

employers, irrespective of their size and resources. However, what is reasonable in the circumstances may vary
according to the size of the organisation, the nature of its activities and the resources available.
New employees working in large companies are usually referred to an Occupational Health service for
assessment. Existing employees may also be referred for a needs assessment, advice and/or forward
referral in the course of their employment. Hence, Occupational Health practitioners need to be aware
of the needs of ADHD staff in order to recognise related problems and suggest what reasonable
adjustments, if necessary, can be applied to support the individual. It is important that both employee
and employer work together to establish what may be helpful and reasonable within the work context
(see Box 1).
41
Box 1: Potential workplace adjustments for people with ADHD
Symptom Possible Adjustments
Attention and distractibility Consider the working environment and how it presents
an opportunity for distraction, e.g. move to a private
office, quieter room or quieter positioning of work
space (e.g. not facing a corridor). Use of telephone
headphones. Consider a flexi-time arrangement.
Introduce regular supervision meetings, mentoring,
written instructions (in addition to verbal) and use of
visual cues/reminders.
Impulsivity Devise clear and detailed work plans. Set targets and
break these down into goals and the smaller steps
required to achieve them. Specify deadlines for goals
and steps. Schedule these into a daily and weekly/
monthly work plan. Add reminders to prompt self-
monitoring and revision of outstanding tasks and
establish a buddy/mentor to monitor progress.
Hyperactivity and restlessness Allow productive movements at work by introducing

regular structured breaks in long meetings, work
plans that introduce change in tempo (e.g. tasks
requiring intense concentration are interspersed with
tasks involving movement) and shifts in topic.
Disorganisation, time management, and Introduce a buddy system and/or regular supervision.
memory problems Use electronic devices, beepers and alarms,
reminders, structured agendas, note taking in
designated book, diaries, calendars and colour coded
filing systems. Delegate tedious tasks and introduce
an incentives and reward system (including both
immediate and longer term rewards).
42
Adjustments for employees with ADHD may include ensuring that their working environment has limited potential
for distraction (e.g. by locating their desk in a quiet area of the office and away from corridors). In order to aid
concentration, short breaks can be factored in to allow the individual to maintain a better ability to focus and
concentrate. Mentoring systems or, in some cases, buddy systems with peers may be helpful for impulse control,
organisation, planning and time-management. Regular meetings will assist the employee to develop achievable work
plans and ensure targets are met within set deadlines. There should be regular and structured reviews to identify
and address difficulties early on. Information that is given verbally in supervision sessions should be endorsed in
written format, especially instructions. It is important that feedback is constructive and includes positive feedback
and encouragement. Ironically, some people with ADHD can become hyperfocused, especially when completing
incentivised work, in such cases it is important that the right balance is obtained in order to avoid burnout [3].
It is not the sole responsibility of the employer to take steps to enhance the functionality of their staff. There
are a number of strategies that individuals with ADHD can use to counter the problems they face in the
workplace. These include making work-plans, writing lists of tasks and instructions, using memory aids such
as a diary to structure the day or alarms (on computers, phones, watches) as reminders for meetings; removing
potentially distracting material from working space to reduce the likelihood they will go off-task, and asking for
help and advice if they are struggling (specific techniques for improving organisation, time-management,
attention, memory and impulse control skills can be found in Young and Bramham [6]). Effective employment
will rely on good collaboration between employer and employee but, of course, this requires disclosure of their
ADHD status.
Working Relationships
The interpersonal and social relationship problems Young people seek full-time employment after
experienced by children with ADHD have been well completing their education and many seek part-
documented (see Module 6). As they grow up and time employment during their studies. Whilst ADHD
move into the world of work interpersonal difficulties should not limit career choices, there is no doubt
often present in the workplace with peers and/or line that young people with ADHD are disadvantaged
management. The emotional volatility of young people by the condition from the initial application
with ADHD may hamper the development of functional process through to maintaining employment and
work relationships as they have a ‘short fuse’. They longer-term career progression. ADHD employees
become easily frustrated and irritated when things don’t may be perceived as being unreliable, inefficient and
work out and they are prone to emotional outbursts. temperamental and it is not commonly recognised that
As in school (see Module 4), they may also experience they have a disability for which reasonable adjustments
anxiety about their performance as they are aware of can be made. This need not be an onerous task, rather
their perceived weaknesses compared to peers. it is a matter of understanding the condition and making
reasonable adjustments to improve functionality. In
the longer-term this will keep individuals gainfully and
productively employed.
43
Box 2: Key points from Module 5 - ADHD and Employment
• Occupational problems are common for young people who are more likely to be disciplined
or dismissed.
• Costs to employers are high due to loss of productivity.
• Application and interview processes are challenging for those with ADHD who may find it difficult to
complete forms accurately and/or to engage appropriately in interview.
• Some individuals are successful in obtaining work in which their ADHD characteristics can be
harnessed in a positive way (e.g. sports or creative industries); others may manage their problems
through delegation of routine and tedious tasks to administrative staff.
• Those with ADHD are protected within disability discrimination laws, although disclosure is a matter of
personal choice.
• If disclosed, a number of reasonable adjustments can be made to improve performance.
44
References

[1] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The Guilford
Press.
[2] de Graaf, R., Kessler, R.C., Fayyad, J., ten Have, M., Alonso, J., Angermeyer, M., et al. (2008). The prevalence
and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the
WHO World Mental Health Survey Initiative. Journal of Occupational and Environmental Medicine, 65(12), 835–842.
[3] Adamou, M., Arif, M., Asherson, P, Aw, T., Bolea, B., Coghill, D., Gudjonsson, G., Halmoy, A., Hodgkins, P.,
Muller, U., Pitts, M., Trakoli, A., Williams, N., & Young, S. (2013). Consensus statement: Occupational issues of adults
with ADHD. BMC Psychiatry, 13(1), 59, dx.doi.org/10.1186/1471-244X-13-59
[4] Great Britain, Parliament. Disability Discrimination Act 2005. London: HMSO.
www.legislation.gov.uk/ukpga/2005/13/contents
[5] Great Britain, Parliament. Equality Act 2010. London: HMSO.

www.legislation.gov.uk/ukpga/2010/15/contents
[6] Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A

National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder:Diagnosis and management
244X-11-174
Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An
Expert White Paper on attention-deficit hyperactivity disorder (ADHD): policy solutions to
address the societal impact, costs and long term outcomes, in support of affected individuals,
Citizens Advice: www.adviceguide.org.uk/index/your_money/employment.htm
ADHD Support Group: www.adders.org/info78.htm

aadduk.org/living-with-adhd/workplace-issues
Government websites:
www.legislation.gov.uk
www.direct.gov.uk/en/Employment/index.htm
nextstep.direct.gov.uk/PLANNINGYOURCAREER/Pages/default.aspx
www.direct.gov.uk/en/DisabledPeople/Employmentsupport/LookingForWork/DG_4000219
www.adviceguide.org.uk/england/work_e/employment_advice_in_bslv2.htm 45
ADHD IN ADOLESCENCE
ADHD IN ADOLESCENCE
Module 6
Interpersonal Relationships
Module Topics
This weekend
> Interpersonal Relationships we had a really massive
| Interpersonal Relationships | Dr Susan Young

> Family Relationships bust-up. Huge. It was really bad.
> Parenting and the Cycle of ADHD I just went wild. I was asked to leave
> Sibling Relationships home this weekend. My Dad said “go
> Peer Relationships on just pack your bags, go pack up”,
> Intimate and Romantic Relationships and I was like “right I will, see you. I
> Managing Interpersonal Problems don’t care. I’ll see you in a couple of
> Key Points from Module 6 days and we’ll sort it out then”. The
> References problem is nobody cares…nobody
> Further Reading & Useful Resources talks… and all the emotions
come out.
Interpersonal Relationships
People with ADHD often have difficulties maintaining positive relationships within their family, with peers and romantic
partners. In addition to these problems, ADHD may influence the type of people with whom relationships are formed,
and the nature of these relationships. Both the behaviour of the person with ADHD and the reactions of others
towards them are important in determining the success of their interpersonal relationships.
Family Relationships
ADHD can impact on the whole of family life and can cause strain in relationships with parents and siblings. Children
and adolescents with ADHD have been reported to display significantly more attention seeking, disruptive and
aggressive behaviour than those without, and this can have a negative effect on relationships within the home [1]. This
may be because they lack self-regulation and can be emotionally labile. This can lead to negative and confrontational
cycles within families and, if effective strategies are not implemented to understand and manage the behaviour of the
young person with ADHD, then ‘typical’ family disagreements may escalate rapidly and frequently, and cause tension
within the family. It is important that when ADHD is diagnosed, parents are made aware of ways that symptoms can
be managed at home in order to reduce the impact of the condition on other family members.
46
ADHD IN ADOLESCENCE
Parenting and the Cycle of ADHD
ADHD is a highly heritable condition with prevalence among first degree relatives in the range of 20-50% [2].
Thus young people with ADHD are likely to become parents with ADHD and have ADHD children. Parents often
remain symptomatic as around two-thirds of adults experience persisting ADHD symptoms [3]. Many parents present
to services in adulthood because their children have been diagnosed and they recognise the symptoms and history
in themselves.
This cycle of ADHD means that parent-child relationships are characterised by ADHD-related difficulties on both
sides, with each probably exacerbating the other. For example, one study of mothers with and without ADHD
(all of whom had children with ADHD) reported that mothers with the condition were poorer at monitoring their
child’s behaviour, less consistent with discipline, and less effective at problem solving around child behaviour issues
[4]. These findings persisted even after controlling for child oppositional and conduct-disordered behaviours. This
parental style may be a risk factor for accidental injuries and contribute to elevated rates for accidental injuries in
ADHD children [5]. The risk may not be limited to ADHD parent/child relationships, but also influence the parent/child

relationships of non-ADHD siblings.
Sibling Relationships
Children with ADHD are reported to experience greater interpersonal conflict

with siblings, and those with comorbid externalising problems experience I think it puts
less close and more aggressive sibling relationships [6]. ADHD children
a big strain on the
demand more time and attention from parents than their non-ADHD siblings
family - a really, really
which leads siblings to feel peripheral and less important within the family
and, in turn, this can cause tension both between siblings and with parents. big strain on the family
Siblings of ADHD children may thus experience increased disruption in when you’ve got an
their own lives [7] as the home may be a chaotic place, characterised by ADHD child.
unpredictable emotional outbursts and inconsistent parenting. Furthermore
they may be expected to share responsibility to monitor their ADHD sibling,
help with schoolwork and keep them out of trouble.
Peer Relationships
Relationships outside of the family can also be affected by ADHD. Children and adolescents who are inattentive
may come across as distant or shy, whilst those with high levels of hyperactivity/impulsivity may alienate others
through disruptive behaviours such as difficulty waiting their turn in games or conversations. Adolescents with ADHD
may experience peer rejection due to aggressive behaviour, yet lack insight into how their behaviour is perceived
by others. Many adolescents know that they are ‘different’ in some way to their peers and they feel confused and
misunderstood. They do and say things without thinking things through which often upsets people they care about.
They look back with many regrets and wish things had been different, but feel frustrated that they can’t seem to
change the situation. These kinds of problems can lead to feelings of low self-esteem, and may lead to teenagers
with ADHD forming more superficial friendships than those enjoyed by their peers [8,9].
47
ADHD IN ADOLESCENCE
The consequences of peer rejection and failure to form appropriate peer relationships
can push a ‘rejected’ individual to seek membership of peer groups wherever they
are available [8]. This may be involvement in street gangs where impulsive, reckless I don’t have
and risky behaviours that, in other settings would lead to school exclusions and arguments with my
conflict at home, are seen as desirable interpersonal qualities (see Module 7 on friends, but I’d say I
antisocial behaviour and delinquency). While this may be more typical for males, struggle to keep friends,
females may also fall into relationships of this nature and, if these are perceived as contact wise, so I lose
rewarding, may lead to antisocial behaviour to maintain the relationships with the
contact with people
view that any friends are better than no friends.
a lot.

Intimate and Romantic Relationships
I just split up
The effort to obtain peer acceptance may lead some young people to
with my girlfriend, ex engage in promiscuous sexual behaviour. Research has shown that those
girlfriend now obviously. growing up with ADHD begin having sex earlier, are more likely to be
I do have relationships, but involved in an unwanted pregnancy and contract a sexually transmitted
it’s very difficult for me to infection [10,11].
uphold them because of
Within their romantic relationships those with ADHD may be more likely to
my distractions.
experience conflict and arguments with partners. While research has been
inconclusive in terms of marriage and divorce rates, results from a large
study in the USA suggest that those with ADHD experience poorer quality
dating relationships or, if married, lower marital satisfaction than their non-
ADHD peers [10].
Managing Interpersonal Problems

It is normal for family relationships to become challenged as teenagers become independent from parental control
but in ADHD families, these ‘normal’ problems may escalate to intolerable levels. At the same time, peer group
membership changes in the teenage years as children select their own friendships. At this age there is a lot of
pressure to ‘fit in’ and be accepted which can be hard for a child who has always felt ‘different’ insome way.
Of course, not all individuals with ADHD will fail to form successful relationships, but many experience negative
family and social outcomes. It is important that negative family cycles are avoided and positive peer relationships are
facilitated through constructive social activities, such as membership of sports and social clubs.
ADHD children may perceive positive parenting relationships [8] and one positive relationship with a family member or
peer is better than many superficial relationships and/or membership of a ‘bad crowd’. Parents can play a proactive
role in helping younger children who find peer relationships difficult but this becomes problematic in the teenage years
when young people want more freedom and less interference from parents in their lives. Nevertheless parents can
show an interest in their child’s friendships and encourage positive behaviour and interactions in these relationships.
A variety of programmes and information packages exist to help parents and families affected by ADHD (see Useful
48
ADHD IN ADOLESCENCE
Resources) and there is a large evidence base supporting parenting interventions for
younger ADHD children. In adolescence and adulthood interventions are delivered
directly to the individual [12, 13]. However the severe family disruption that may If I’ve had
be encountered during adolescence may require direct interventions involving the an argument I’ll go
ADHD child and other members of the family. Family therapy, for example, may out and do a sport as
improve family relationships by addressing the problem behaviours of the ADHD afterwards I need to
child and the way that parents and siblings respond to these behaviours. This do something.
may include helping siblings feel less marginalised, improving parenting styles and
monitoring techniques, development of disciplinary consistency, and mediation of
sibling problems.

Box 1: Key points from Module 5 - ADHD and Interpersonal Relationships
• ADHD can impact on the whole of family life and cause strain in relationships with parents and siblings;
direct interventions such as family therapy may be helpful.
• ADHD is highly heritable and a parenting cycle may exist with ADHD children becoming ADHD parents
who lack the skills to effectively manage young children.
• A failure to fit in with peers can lead to feelings of rejection and low self-esteem.
• Teenagers may compensate by seeking membership of delinquent peer groups and/or attempt to obtain
peer acceptance by engaging in promiscuous behaviours.
• Teenagers with ADHD become sexually active at a young age; they are more likely to contract sexually
transmitted diseases and have unwanted pregnancies.
• Positive peer relationships can be facilitated through constructive social activities, such as membership
of sports and social clubs.
• Parenting programmes and/or direct intervention programmes for young people are helpful in providing
prosocial competence.
49
ADHD IN ADOLESCENCE
References
[1] Coghill, D., Soutullo, C., d’Aubuisson, C., Preuss, U., Lindback, T., Silverberg, M., & Buitelaar, J. (2008). Impact of
attention-deficit/hyperactivity disorder on the patient and family: results from a European survey. Child and Adolescent
Psychiatry and Mental Health, 2(1), 31-46.
[2] Faraone S.V., Biederman, J., & Monuteaux, M.C. (2000). Toward guidelines for pedigree selection in genetic
studies of attention deficit hyperactivity disorder. Genetic Epidemiology, 18(1), 1-16.
disorder: A meta-analysis of follow-up studies. Psychological Medicine, 36(2), 159-165.
[4] Murray, C., & Johnston, C. (2006). Parenting in mothers with and without attention-deficit/ hyperactivity disorder.
Journal of Abnormal Psychology, 115(1), 52-61.

[5] Barkley, R.A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.)
New York: Guilford Press.
[6] Mikami, A.Y., & Pfiffner, L.J. (2008). Sibling relationships among children with ADHD. Journal of Attention Disorders,
11(4), 482-492.
[7] Kendall, J. (1999). Sibling accounts of attention deficit hyperactivity disorder (ADHD). Family Process, 38(1), 117-
136.
[8] Young, S., Heptinstall, E., Sonuga-Barke, E.J.S., Chadwick, O., & Taylor, E. (2005). The adolescent outcome
of hyperactive girls: Interpersonal relationships and coping mechanisms. European Child & Adolescent Psychiatry,
14(5), 245-253.
[9] Young, S., Heptinstall, E., Sonuga-Barke, E.J.S., Chadwick, O., & Taylor, E. (2005). The adolescent outcome of
hyperactive girls: Self-report of psychosocial status. Journal of Child Psychology and Psychiatry, 46(3), 255-262.
[10] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The
Guilford Press.
[11] Flory, K., Molina, B.S.G., Pelham, W.E, Gnagy, E., & Smith, B. (2006). Childhood ADHD predicts
risky sexual behaviour in young adulthood. Journal of Clinical Child and Adolescent Psychology,
35(4), 571-577.
[13] Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A
50
ADHD IN ADOLESCENCE
Bramham, J, Young, S., Bickerdike, A., Spain, D., MacCartan, D., & Xenitidis, K. (2009). Evaluation of group cognitive
behavioural therapy for adults with ADHD. Journal of Attention Disorders, 12(5), 434-441.
Emilsson, B., Gudjonsson, G., Sigurdsson, J.F., Einarsson, E., Baldursson, G., Olafsdottir, H., & Young., S. (2011).
R&R2 Cognitive Behaviour Therapy in Medication-Treated Adults with ADHD and Persistent Symptoms: A randomized
controlled trial. BMC Psychiatry, 11:116, http://dx.doi.org/10.1186/1471-244X-11-116
National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management
Young, S.J., & Ross, R.R. (2007). R&R2 for ADHD Youths and Adults with ADHD: A Prosocial Competence Training
Program. Ottawa: Cognitive Centre of Canada (www.cognitivecentre.ca)

Young, S., Hopkin, G., Perkins, D., Farr, C., Doidge, A., & Gudjonsson, G.H. (2013). A controlled trial of a cognitive
skills program for personality disordered offenders. Journal of Attention Disorders, 17(7), 598-607,
www.addiss.co.uk/final.pdf
www.additudemag.com/channel/parenting-adhd-children/index.html
www.adhd-made-simple.com/adhd_peer_relationships.html
www.adders.org/research59.htm
www.helpforadd.com/add-impact-on-siblings
51
ADHD AND ADOLESCENCE
ADHD IN ADOLESCENCE
Module 7
Delinquency and Substance Use
A couple of
Module Topics years ago I got caught
with cannabis on me, got a
> ADHD and the Pathway to Delinquency fine through that...I’ve smoked
> Risky and Dangerous Behaviour cannabis for about five years
| Delinquency and Substance Use | Dr Susan Young

> Driving and Traffic Violations now. I started smoking it because
> Offending my medications weren’t right so I
> Substance Use used to self-medicate. Now that
> Key Points from Module 7 my medication’s right I’m still
> References smoking it, but I’m
> Further Reading and Useful Resources cutting down.
ADHD and the Pathway to Delinquency

The symptoms of ADHD and the difficulties that may be associated with the condition can sometimes lead to
problems with antisocial and/or reckless behaviours including dangerous driving, alcohol and substance use
and, in serious cases, crime. Not all young people with ADHD will present with these behaviours, but a sizeable
subgroup has antisocial co-morbid difficulties [1]. Indeed, comorbid ADHD and conduct disorder together comprise
a more severe condition than either disorder alone [2] and this co-occurrence may contribute to violent and
antisocial behaviour.
Retz and Rösler [3] have developed a theoretical framework to explain the relationship between ADHD (combined
and hyperactive/impulsive subtypes), early-onset conduct disorder, and both conditions with the subsequent
development of Antisocial Personality Disorder. It is proposed that this developmental subtype of Antisocial
Personality Disorder is more frequently associated with impulsive aggression as a reaction to a situation, rather than
with premeditated, proactive aggression, whereas ADHD without comorbid conduct disorder is more associated
with social problems and rule breaking behaviour (e.g. traffic infractions). In the model, substance use disorders also
impact on ADHD-related antisocial behaviour (see Figure 1).
52
Risky and Dangerous Behaviour
Participation in reckless behaviours that involve pushing social boundaries and rule-breaking is more common
in ADHD adolescents than adults. These behaviours can place young people at risk of harm; ADHD has been
associated with a greater number of accidental injuries and presentations to hospital Accident and Emergency, and a
greater number of injuries [4-6]. This may be explained by individuals seeking highly stimulating activities, combined
with poor consequential thinking skills and/or an underestimation of the likelihood of injury.
Risky sexual behaviour is also more common in adolescents with ADHD (see Module 6 in this series), who report
more casual, unprotected sex than controls and, as a result, they are more likely to contract sexually transmitted
infections [7]. In part these behaviours may be due to a difficulty in forming meaningful relationships with peers,
leading young people to seek peer acceptance through sexual promiscuity and/or antisocial behaviours.

ADHD Age
7
10
disorder
18
Dis
10%
Figure 1. Pathways from ADHD to delinquent behaviour; the percentage values

refer to the total population of those with ADHD [3].
53
Driving and Traffic Violations
Symptoms of inattention and impulsiveness may lead young people with ADHD to be prone to driving errors [8].
Research looking at the driving ability of young adults with ADHD has found that they are more likely to have
‘scrapes’ and accidents than controls, who have better concentration and are less likely to be distracted or lose
attention whilst driving.
Research suggests that people with ADHD are significantly more likely
to have a history of driving without a license as adolescents [8]. Once
they gain a driving license, they are more likely to be caught speeding
or committing other traffic violations leading to ‘points’ and license
I do get road
suspensions. Other more serious, illegal driving behaviours, such rage. Sometimes when
as drink-driving, are also found to be more common in people with you’re in the car its that
ADHD [9,10]. power, the adrenaline buzz.
You need something to keep you
Thus it is important that young people with ADHD are aware of the going when you’re sitting there

risks that their symptoms pose when driving and they put strategies
for two hours, like when I do
in place to reduce risk when driving. Simple adjustments to the
driving environment, such as asking passengers to be quiet and
120 on my motorbike it just
not distract the driver, and avoiding multi-tasking when driving (e.g. keeps me buzzing.
speaking on the mobile phone or changing music) can be helpful
to maximise responsible driving and road safety. The DVLA list a
number of conditions that they require a driver to inform them of if
they are diagnosed; this does include ADHD and it is important that
people with ADHD should disclose this to the DVLA.
Offending
Around 45% of youth offenders and 30% of adult male A community study in the United States [15] found a
offenders have ADHD [11-13]. They are more likely direct relationship between ADHD symptoms for all
to have contact with the police, younger age of first categories of offending (see Figure 2). Those with a
conviction, higher rates of recidivism and, if incarcerated, history of childhood ADHD had significantly greater
to be involved in a greater number of critical incidents rates of offending than community controls, but less
within the institution [11,12,14]. Mood instability, a low than those with persisting symptoms. Another study
tolerance of frustration, a need for stimulation and poor however has reported that offending may be associated
response inhibition may all be associated with offending with both childhood and persisting ADHD symptoms
behaviours, and the combination of these characteristics [14]. Nevertheless, risk may be mediated by conduct
can lead to unplanned or opportunistic criminal acts of a disorder, and while ADHD presents a greater risk for
violent or acquisitive nature. aggressive behaviour within prison establishments, it
appears to be the association with conduct disorder,
substance use and delinquent peers that leads them to
offend [16].
54
80
70
60
50
40
30
20
10
0
ed
g
ed
ly
rin
er
st
il
Ja
te
re
rd

en
Ar
so
g/
Di
kin
ea
Br
2
[15].
ADHD is a treatable condition with both pharmacological and psychological interventions [17, 18]. However, specific
interventions may need to be applied for ADHD antisocial youths that address their underlying cognitive problems in
addition to their antisocial behaviours and attitudes. One such programme is the R&R2 for ADHD Youths and Adults,
which has shown a large treatment effect when delivered in the community [19] and in incarcerated adults [20]. It
is important that mental health and criminal justice agencies work together to ensure early identification of ADHD
antisocial youths because, as for many disorders, early intervention may interrupt the antisocial pathway.
Substance Use
Smoking has been reported to be more common and to have an earlier onset among adolescents with ADHD
compared with those without ADHD. In particular, those with predominantly inattentive symptoms may be at risk for
later development of nicotine dependence, especially in the absence of constructive coping mechanisms [21, 22].
Although the specific nature of this relationship requires further investigation, research has highlighted an increased
vulnerability in those with ADHD to smoking, and it is speculated that this may be due the additive effect of ADHD
symptoms and increased novelty seeking behaviour [23].
The association between ADHD and substance abuse is complex. Impulsive behaviour may lead to an increased
risk of drug-taking and excessive alcohol consumption, as well as greater use of a number of other substances
(including illicit sedatives) compared to those who are not symptomatic for ADHD [24] (see Figure 3). Low self-
esteem and poor self-confidence may additionally play a part, together with peer pressure and a desire to ‘fit in’ with
those around them. The tendency of people with ADHD to seek new experiences and minimise their perception of
risk may also influence their decision to experiment with illicit substances.
55
An epidemiological study of over eleven thousand young
people in Iceland reported that, after controlling for gender
and school grade, poly-substance use was incrementally In my everyday
related to ADHD symptoms with a large effect size. activity if I’m playing
This study focused on early drug use rather than substance X-Box or something, I’m
dependence, and the findings suggest there is a specific used to smoking a joint before
pathway into initial substance use for young persons
so I concentrate. That’s kind
with ADHD symptoms, possibly as a means of self-
of how my mind thinks now
medication, aside from unconventional attitudes and poor
socialization [24]. - smoke a joint then play
X-Box, otherwise I won’t
There have been concerns that pharmacological treatment concentrate.
of ADHD will lead to abuse of, and addiction to, medication
or other substances later on. Evidence suggests that the
opposite is the case and that stimulant medication reduces
substance abuse in later life by treating the problems related

to ADHD [25-27].
56
Box 1: Key points from Module 7 - ADHD, antisocial behaviour and substance
misuse
• ADHD and comorbid conduct disorder may be more associated with impulsive, reactive aggression rather
than premeditated behaviours.
• ADHD without comorbid conduct disorder may be more associated with social problems and rule-
breaking behaviours.
• ADHD is associated with higher rates of accidental injury and presentations to hospital Accident
and Emergency.
• A greater incidence of traffic violations has been recorded by people with ADHD, including driving without
a licence, minor scrapes, accidents and drink-driving.

• Around 45% of male youth offenders and 30% of male adult offenders in prison have ADHD symptoms.
ADHD is associated with greater police contact, younger age of first conviction, higher rates of recidivism
and critical incidents within prison establishments.
• The relationship between ADHD and substance misuse is complex and some young people may abuse
substances as a form of self-medication.
• Treatment with stimulant medication has been shown to reduce substance misuse and therefore may
be protective.
57
References
[1] Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O. et al. (2006). The prevalence and
correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American
Journal of Psychiatry, 163(4), 716–723.
[2] Thapar, A., Harrington, R., & McGuffin, P. (2001). Examining the comorbidity of ADHD-related behaviours and
conduct problems using a twin study design. British Journal of Psychiatry, 179, 224–229.
[3] Retz, W., & Rösler, M. (2009). The relation of ADHD and violent aggression: What can we learn from
epidemiological and genetic studies? International Journal of Law and Psychiatry, 32(4), 235–243.
[4] Barkley, R.A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.)
New York: Guilford Press.
[5] Hoare, P., & Beattie, T. (2003). Children with ADHD and attendance at hospital. European Journal of Emergency

Medicine, 10(2), 98-100.
[6] Rowe, R., Maughan, B., & Goodman, R. (2004). Childhood psychiatric disorders and unintentional injury:
Findings from a national cohort study. Journal of Paediatric Psychology, 29(2), 119-130.
[7] Flory, K., Molina, B.S.G., Pelham, W.E, Gnagy, E., & Smith, B. (2006). Childhood ADHD predicts risky sexual
behaviour in young adulthood. Journal of Clinical Child and Adolescent Psychology, 35(4), 571-577.
[8] Barkley, R.A., Murphy, K.R., DuPaul, G.J., & Bush, T. (2002). Driving in young adults with attention deficit
hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. Journal
of the International Neuropsychological Society, 8(5), 655-672.
[9] Barkley, R.A., & Cox, D. (2007). A review of driving risks and impairments associated with attention deficit/
hyperactivity disorder and the effects of stimulant medication on driving performance. Journal of Safety Research,
38(1), 113-28.
[10] Jerome, L., Segal, A., & Habinski, L. (2006). What we know about ADHD and driving risk: A literature review,
meta-analysis and critique. Canadian Academy of Child and Adolescent Psychiatry,
15(3), 105-125.
[11] Young, S., Gudjonsson, G., Misch, P., Collins, P., Carter, P., Redfern, J., & Goodwin, E. (2010). Prevalence
of ADHD symptoms among youth in a secure facility: the consistency and accuracy of self- and informant-report
ratings. Journal of Forensic Psychiatry & Psychology, 21(2), 238-246.
[12] Young, S., Gudjonsson, G.H., Wells, J., Asherson, P., Theobald, D., Oliver, B., Scott, C., & Mooney, A. (2009).
Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population. Personality and
Individual Differences, 46(3), 265–269.
[13] Young, S.J., Adamou, M., Bolea, B., Gudjonsson, G., Müller, U., Pitts, M., et al. (2011). The identification
and management of ADHD offenders within the criminal justice system: a consensus statement from the UK Adult
ADHD Network and criminal justice agencies. BMC Psychiatry, 11:32,
dx.doi.org/10.1186/1471-244X-11-32
58
[14] Young, S., Wells, J., & Gudjonsson, G. (2011). Predictors of offending among prisoners: the role of attention-
deficit hyperactivity disorder and substance use. Journal of Psychopharmacology, 25(11), 1524-32.
[15] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The
Guilford Press.
[16] Gudjonsson, G.H., Sigurdsson, J.F., Sigfusdottir, I.D., & Young, S. (2014). A national epidemiological study
of offending and its relationship with ADHD symptoms and associated risk factors. Journal of Attention Disorders,
18(1), 3-13.
[17] National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and
management of ADHD in children, young people and adults. NICE clinical guideline 72. London.

[19] Emilsson, B., Gudjonsson, G., Sigurdsson, J.F., Baldursson, G., Einarsson, E., Olafsdottir, H., et al. (2011).
Cognitive behaviour therapy in medication-treated adults with ADHD and persistent Symptoms: A randomized
controlled trial. BMC Psychiatry, 11:116, dx.doi.org/10.1186/1471-244X-11-116
[20] Young, S., Hopkin, G., Perkins, D., Farr, C., Doidge, A., & Gudjonsson, G.H. (2013). A controlled trial of a
cognitive skills program for personality disordered offenders. Journal of Attention Disorders, 17(7), 598-607, dx.doi.
org/10.1177/1087054711430333
[21] Rodriguez, D., Tercyak, K. P., & Audrain-McGovern, J. (2008). Effects of inattention and hyperactivity/
impulsivity symptoms on development of nicotine dependence from mid adolescence to young adulthood. Journal
of Pediatric Psychology, 33(6), 563-575.
[22] Young, S. (2005). Coping Strategies used by ADHD adults. Personality and Individual Differences,
38(4), 809-816.
[23] Tercyak, K. P., & Audrain-McGovern, J. (2003). Personality differences associated with smoking
experimentation among adolescents with and without comorbid symptoms of ADHD. Substance Use and Misuse,
38(14), 1953-1970.
[24] Gudjonsson, G.H., Sigurdsson, J.F., Sigfusdottir, I.D., & Young, S. (2012). An epidemiological study of ADHD
symptoms among young persons and the relationship with cigarette smoking, alcohol consumption, and illicit drug
use. Journal of Child Psychology and Psychiatry, 53(3), 304–312.
[25] Wilens, T.E. (2003). Does the medicating ADHD increase or decrease the risk for later substance abuse?
Revista Brasileira de Psiquiatria, 25(3), 127-128.
[26] Wilens, T.E., Faraone, S.V., Biederman, J., & Gunawardene, S. (2003). Does stimulant therapy of attention-
deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics,
111(1), 179-185.
[27] Faraone, S.V., & Upadhyaya, H.P. (2007). The effect of stimulant treatment for ADHD on later substance abuse
and the potential for medication misuse, abuse, and diversion. Journal of Clinical Psychiatry, 68, e28.
59
Gudjonsson, G.H., & Young, S. (2011). Predictors of Offending and Critical Incidents among Prisoners. European
Psychiatric Review, 4(1), 15-17.
Harpin, V., & Young, S. (2012). The Challenge of ADHD and Youth Offending. Focus Issue: The Management of
ADHD in Children, Young People and Adults. Cutting Edge Psychiatry in Practice, 2, 138-143.
Young, S.J., & Ross, R.R. (2007). R&R2 for ADHD Youths and Adults: A Prosocial Competence Training Program.
Ottawa: Cognitive Centre of Canada, www.cognitivecentre.ca/rr2adhd
Young, S., & Goodwin, E. (2010). Attention-deficit/hyperactivity disorder in persistent criminal offenders: the need
for specialist treatment programs. Expert Review of Neurotherapeutics, 10(10), 1497-1500.
Young, S., & Thome, J. (2011). ADHD and offenders. SWBP World Journal of Biological Psychiatry
12(S1): 126–130

attention-deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long
term outcomes, in support of affected individuals,
Behaviour Disorders and ADHD: www.helpforadd.com/co-occurring-disorders/
Youth Crime Action Plan: ADHD and its links to antisocial behaviour: www.addiss.co.uk/YouthCrime30.pdf
ADHD and Substance Misuse: www.adhdandsubstanceabuse.org/adhd-and-substance-abuse
60
ADHD IN ADOLESCENCE | Planned Transition | Dr Susan Young
ADHD IN ADOLESCENCE
Module 8
Planned Transition
I think to get the
child service you were
registered with (because you’ve
Module Topics always known them) and then
go and meet the new adult services
> The Need for Planned Transition together and sort of have a ‘pass-over’
> Service Disengagement would be very beneficial because then
> Service Provision
you’ve got someone who’s known
> Key Points from Module 8
> References you for years... Yeah, a ‘meet
> Further Reading and useful resources and greet’ session would be
really good.
The Need for Planned Transition

There has been increased recognition of ADHD as a With this in mind, the transition period is an important
condition that can affect people across the lifespan, and with time during which service engagement is important in
this comes recognition of the need for the planned transfer of minimising the impact of ADHD on their lives. However,
care between child, adolescent and adult services. However, research has demonstrated that by age 21 young people
this increased awareness has not been paralleled in practice have almost completely disengaged from health care
by developments in the services for those with symptoms services [1], with very few receiving treatment at all.
persisting beyond childhood. One overlooked group in this
regard has been the young people who are transitioning Guidance is available outlining a number of general
between child and adult services. practice points that should be taken into account across
services [2,3] (see Boxes 1 and 2), which may help
At this crossroad in their care young people are experiencing to reduce the number of those who discontinue their
their ADHD symptoms within the context of increasing engagement with services altogether and promote a
demands in their school-life and workload, decisions about more positive transition between services.
further education and career choices (see Module 4),
managing extra-curricular activities such as part-time jobs
(see Module 5), and trying to maintain social and personal
relationships (see Module 6).
61
Service Disengagement
There may be several explanations for service
disengagement. Firstly, young people may seek greater
autonomy from parents and take on responsibility for I think it’s
their own healthcare as mental health services are no very important to have
longer obliged to involve parents/guardians. On the communication because I think
one hand, this will help develop a positive alliance you feel as though you need that
between the practitioner and the young person and in
attention…I haven’t known much
turn foster a frank discussion about the young person’s
attitudes, beliefs, behaviours and feelings. However,
about it but my mum’s had awful trouble
this may also feel overwhelming and/or intimidating. with the transition, with regards to
Taking personal responsibility for healthcare may not medication and stuff like that. Getting
be a priority for young people against the backdrop of the right prescriptions and people to
other personal and social changes. prescribe them when I’ve been
away from home and stuff.
Secondly, the actual experience of ADHD often
changes in adolescence. A decline in overt hyperactive
symptoms and a decrease in cognitive demands once
compulsory education ends may lead to a perception
both from parents and the individual that treatment is
no longer required (see Module 4). Thirdly young people
may develop greater awareness of perceived stigma
about the ‘label’ of ADHD and need for medication.
Fourth, negative service experiences may discourage

the young person from continuing to engage. For
example there may be complications due to unclear I went through
child/adult service boundaries and/or variation in a period [when I was]
protocols between services [3, 4]. This may lead to about 17 when I decided I
service-users feeling excluded and let down, and feel wasn’t ADHD anymore and just
that they are unable to participate in decisions about stopped taking everything... At
their own care.
school I was throwing away my
tablets… I wanted to be normal,
like every other girl in
my school.
62
Box 1: NICE Guidelines - recommendations for transition [2]
• Transfer from CAMHS/paediatrics to adult services if patients continue to have significant symptoms of
ADHD or other coexisting conditions that require treatment.
• Transition should be planned in advance by referring and receiving services.
• Patients should be reassessed at school-leaving age and, if treatment is necessary, arrangements should
be made for a smooth transition to adult services.
• Timings of transition may vary but should be completed by 18 years.
• During transition, CAMHS/paediatrics and adult services should consider meeting and full information
about adult psychiatric services should be made available to the young person.
• For young people age 16 or over the Care Programme Arrangements [CPA] should be used as an aid
to transfer.
• After transition a comprehensive assessment should be carried out and patients should also be assessed
for any coexisting conditions.
• Trusts should ensure that specialist ADHD teams for children, young people and adults jointly develop
age-appropriate training programmes for diagnosis and management of ADHD.
Service Provision
The provision of care by child services has traditionally ended in adolescence. However, many of these services now
provide care beyond the age of 16, and in some cases beyond 18 years of age. While this provides some security
for young people obtaining care throughout their teenage years, once they become young adults there is still a lack
of clarity regarding how their transition will be facilitated, and indeed where they will move on to.
Services vary widely across the country. For example, a questionnaire survey conducted with community
paediatricians in the UK reported that while the vast majority (90%) of clinicians identified the need for access to
dedicated adult ADHD services, only around 1 in 5 reported this service was available in their area [5]. Thus aside
from purposeful disengagement of the patient, service providers may contribute to the gap in transitional care. For
example, there may be a lack of familiarity among child health professionals of the presentation of ADHD in older
teenagers and young adulthood.
ADHD is not included in mainstream training for many healthcare professionals, and this may contribute to
under-recognition of ADHD symptoms in this age-group and a lack of understanding of the changing presentation
of ADHD in young people. In turn this may lead to premature termination of treatment or failure to transition to
adult services. For these reasons, psychoeducation for both practitioners and service-users about ADHD,
an understanding of the progression of the condition from childhood to adulthood, and the need for young people
(and their families if appropriate) to fully participate in their own care are essential prerequisites to a smooth and
positive transition.
63
It is unlikely that a rigid referral pathway will be effective for all young people making the transition from child to adult
ADHD services. However the need for this transition to be planned should not be overlooked, given the anxiety that
this period can provoke for service-users and the unacceptably high level of disengagement that has been reported.
There is guidance and recommendations available (see Box 1 and 2) that aim to promote a more positive transition
experience for patients and their families and, importantly, reduce the number of young people with ADHD who
disengage from health services.
Box 2: Recommendations for commissioners and clinicians [3]
• ADHD often continues into adulthood. A significant proportion of young people with ADHD will continue
to need support and treatment from health service professionals when they reach adulthood.
• Transition should be planned in advance by both referring and receiving services.
• Timings of transition may vary but should ordinarily be completed by 18 years. Transition between teams
should be a gradual process, e.g. a minimum period of six months.
• ADHD services for children and adolescents vary considerably between regions (e.g. CAMHS, paediatrics,
availability of shared care). It is essential that commissioners take local resources into account when
designing a transition service.
• Clinicians involved in delivering both specialist and local ADHD care pathways and services for children,
young people and adults should include training in evidence based up-to-date recommendations
regarding the diagnosis and management of ADHD at age-appropriate points of development as part of
their continuing professional development.
• A planned transfer to an appropriate adult service should be made if the young person continues to have
significant symptoms of ADHD or other co-existing conditions that require treatment.
• Appropriate adult services should include primary care, adult community mental health teams and access
to specialist adult ADHD services.
• Clear transition protocols should be developed jointly by commissioners, CAMHS/paediatric services,

AMHS and primary care to facilitate transition and ensure standards of care are maintained during the
transition period.
• These transition protocols should be available to all clinical teams and should include psychosocial material
that provides high quality, comprehensive, impartial and appropriately written information for both young
people and their parents/carers.
64
Box 2 (continued): Recommendations for commissioners and clinicians [3]
• Information should also be developed in a media format that is readily accessed by young people, e.g.
use of phone applications and internet sites.
• Pre-transition: young people with ADHD should be reassessed at school leaving age by the service
managing their care. They should be informed of the outcome of this assessment and transitioned
according to need, e.g. to GP services, adult community mental health teams (community, learning
disability or forensic as appropriate), specialist adult ADHD teams, or adult physical health teams where
required. Both the patient and all adult/GP teams receiving referrals should be jointly informed of the
patient’s initial transition.
• During transition: child and adult services should ideally have a joint transition appointment. Full
information about adult psychiatric and GP services should be made available to the young person and
their family. Full information about the young person’s paediatric/CAMHS care should be available to the
adult teams, including a detailed clinical transition report.
• CAMHS practitioners and paediatricians should foster engagement with AMHS through
open discussion and psychoeducation about ADHD, the benefit of evidenced based
psychological and pharmacological treatment where appropriate, and the risks of
disengagement. It is important to address concerns about stigma associated with referral
to AMHS.
• Joint meetings between child and adult services must ensure the needs of the young person will
be appropriately met. This may involve further discussion and collaboration with educational and/or
occupational agencies.
• For young people age 16 or over in CAMHS care in the UK, Care Programme Arrangements (CPA)
should be used as an aid to transfer. CPAs are not available in paediatric practice and so a planned
assessment of need with the young person and their parent and a clearly documented plan of action is
recommended.
• Parents and carers need to be prepared and facilitated to aid their children’s gradually increasing
independence and autonomy with their ADHD and it’s treatment. Referring child and receiving adult/GP
teams should be mindful of possible parental ADHD and support and manage this appropriately.
65
Box 2 (continued): Recommendations for commissioners and clinicians [3]
• Post transition: a comprehensive assessment should be carried out by the receiving service. Patients
should be re-assessed for any coexisting conditions and referred for assessment/treatment/support of
associated difficulties, including co-morbid mental health/learning/educational/employment support.
• Shared care arrangements between primary and secondary care services for the prescription and
monitoring of ADHD medications should be continued into adulthood.
• Direct psychological treatment should be considered (individual and/or group CBT) to support young
people during key transitional stages. This should have a skills development focus and target a range of
areas including social skills, interpersonal relationship problems (with peers and family), problem solving,
self-control, listening skills and dealing with and expressing feelings. Active learning strategies should be
used (e.g. see [54, 55]).
• Direct psychological treatment should be considered (individual and/or group CBT) to support young
people experiencing symptom remission and/or stopping medication.
Box 3: Key points from Module 8 – Recommendations for Planned Transition
• By age 21 young people with ADHD have almost completely disengaged from services with very few
receiving ongoing treatment.
• Disengagement may reflect young people seeking greater autonomy from parents as they mature and the
expectation that they will gradually take responsibility for their healthcare.
• The presentation of ADHD changes as young people mature, with decline in hyperactive and
impulsive symptoms.
• There may be a lack of familiarity among child and adult health professionals of the changing presentation
of ADHD as children mature.
• Published evidence and recommendations are available to assist a positive and effective transition.
• Transition should be planned in advance with involvement of all parties (e.g. service-users and if appropriate
their family, child and adolescent health care professionals, GP practitioners) and using Care Programme
Arrangements [CPA].
66
References
[1] McCarthy, S., Asherson, P., Coghill, D., Hollis, C., Murray, M., Potts, L., et al. (2009). Attention-deficit hyperactivity
disorder: treatment discontinuation in adolescents and young adults. The British Journal of Psychiatry, 194(3),
273-277.
[2] National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management
[3] Young, S., Murphy, C.M., & Coghill, D. (2011). Avoiding the ‘twilight zone’: Guidance and recommendations on
244X-11-174
[4] Singh, S.P. (2009). Transition of care from child to adult mental health services: the great divide. Current Opinion
in Psychiatry, 22(4), 386–390.
[5] Marcer, H., Finlay, F., & Baverstock, A. (2008). ADHD and transition to adult services: the experience of community
paediatricians. Child: Care Health Development, 34(5), 564–566.

244X-11-174
Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults:
A Psychological Guide to Practice, Second Edition. Chichester: John Wiley & Sons.
AADDUK, Transitions from Adolescence to Adulthood:

aadduk.org/2012/03/06/adhd-transition-from-adolescence-to-adulthood
67
ADHD IN ADOLESCENCE |
ADHD IN ADOLESCENCE
Appendix
Test Your Knowledge
1. The recommended first-line treatment for ADHD in adolescents with severe impairment is...
A Stimulant medication
B Psychological treatment
C Antidepressant medication
D Atomoxetine
E Don’t Know
Appendix | Dr Susan Young

2. How common is ADHD (using DSM-IV criteria) in the UK?
A ADHD affects around 5% of children

B ADHD affects around 10% of children
C ADHD affects around 15% of children
D ADHD affects around 20% of children
E Don’t Know
3. Which of the following must be present in order for ADHD to be diagnosed?
A Negative impact in at least one setting

B Problems at school or college
C Negative impact in all life areas
D Negative impact in at least two settings
E Don’t Know
4. ADHD is caused by….
A Only genetic factors

B Smoking, drinking and substance use by mother during pregnancy
C Bad parenting
D An interplay of environmental, psychosocial and genetic factors
E Don’t Know
68
5. Approximately, what proportion of children with ADHD have a comorbid disorder?
A 10%
B 50%
C 65%
D 1%
E Don’t Know
6. What is the most common comorbid condition in children with ADHD?
A Autistic spectrum disorders

B Tics
C Disruptive disorders
D Anxiety
E Don’t Know
7. What special provision is commonly made for individuals with ADHD taking exams?

A Assessed coursework instead of exams
B Up to 25% extra time
C Unsupervised breaks
D Shorter papers
E Don’t Know
8. During a job interview, a person with ADHD…
A Should never speak about their condition

B Must disclose their condition, but only if the job involves public interaction
C Must disclose their condition regardless of the role
D Can usually decide whether or not to disclose
E Don’t Know
9. If they know that a person has ADHD, employers have a responsibility to…
A Make contact with the employee’s GP

B Arrange for the employee to have regular reviews by occupational health
C Make reasonable adjustments to premises or working practices
D Do nothing
E Don’t Know
69
10. What is the approximate prevalence of ADHD in first degree relatives?
A 20-50%
B 80-95%
C 70-80%
D 10-30%
E Don’t Know
11. ADHD mothers who have children with ADHD...
A Are more aware of their children’s behaviour and therefore are better at monitoring it
B Have greater difficulty in problem solving child behavioural issues
C Are equally as effective at giving discipline as non-ADHD mothers
D Are more effective at giving discipline than non-ADHD mothers
E Don’t Know
12. The rate of ADHD in male prisoners is estimated to be…

A 80%
B 30%
C 10%
D 5%
E Don’t Know
13. According to UK research, by what age have most young people with ADHD disengaged
from health services?
A 21
B 18
C 16
D 29
E Don’t Know
14. Transition of young people with continuing symptoms of ADHD from child to adult services:
A Is organised by the young person and their family

B Should be planned between child and adult teams in advance
C Is the responsibility of child services to arrange
D Is the responsibility of adult services to arrange
E Don’t Know
70
15. Medication for young people with ADHD:
A Cannot be prescribed by a GP/family physician

B Is not recommended
C Can only be prescribed by an ADHD specialist
D Can be prescribed by a GP/family physician but can only be started under the guidance of an ADHD
specialist team
E Don’t Know
16. NICE recommended psychological management for young people with ADHD that involves:
A Counselling
B Coaching
C Cognitive behavioural therapy
D Neurofeedback
E Don’t Know
See overview for answers.
71
Contact us for more information:
psychltd@aol.com
www.psychology-services.uk.com

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ADHD

Overview: ADHD in Adolescence 3

Professional Advisory/Resource Groups

UK Adult ADHD Network (UKAAN) - www.UKAAN.org

National and Local Support Groups

‘The site for and by adults with ADHD’ - aadduk.org

Living with ADHD - www.livingwithadhd.co.uk

ADD / ADHD Online Information - www.adders.org

ADHD Foundation - www.adhdfoundation.org.uk

Baldock/ Hitchin/ Letchworth/ Royston/ Stevenage - Angels Support Group -

Brighton - ADHD Brighton Support Group - www.adhdbrighton.org.uk

Bristol - Adult ADHD Support Group -

Cambridgeshire - Cambridgeshire Adult ADHD Support Group -

Chichester - The Hyperactive Children’s Support Group - www.hacsg.org.uk/page6.html

Dorset - Dorset ADHD Support Group - www.adhddorset.btck.co.uk

Essex - Chelmsford ADHD Support Group - www.adhd-support.org.uk/index.html

Gateshead - Gateshead ADHD Support - www.gatesheadadhdsupport.co.uk/whatis.html

Harrow - ADHD and Autism Support Harrow - www.adhdandautismharrow.co.uk

Hertfordshire - Understanding ASD and ADHD in Hertfordshire - www.add-vance.org

Lancashire - ADHD Lancashire Support Group - www.adhdlancashire.co.uk

Lincoln - Lincoln ADHD Support Group - www.lincolnadhd.org

Liverpool - Liverpool Adult ADHD (Ladders of Life, LOL) -

London - London adult ADHD support group - sites.google.com/site/joyfivolous/home

Manchester - Manchester Region Attention Deficit Disorder Group - www.maddchester.com

Newcastle - KICK ADHD Support Group - www.netmums.com/newcastle/local/view/support-groups/

Norfolk - CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) -

Oxfordshire - ADHD Oxfordshire - www.adhdoxfordshire.co.uk/Support-Group.html

Richmond - Richmond ADHD Support Group - www.facebook.com/AdhdRichmond

Scotland - Central Scotland Adult ADHD Support -

Module 4 – ADHD and Education: Mr Fin O’Regan

Module 5 – ADHD and Employment: Mr Simon McKay

What Causes ADHD?

Genetic factors Environmental factors Psychosocial factors

Diagnostic Classification of ADHD

Predominantly hyperactive-impulsive presentation Six out of nine hyperactive/impulsive symptoms

How is ADHD Diagnosed?

The aim of treatment is to reduce core ADHD symptoms and improve

• Multimodal interventions are recommended for middle school/adolescent children.

• CBT interventions are recommended for adults (either group or individual).

• ADHD is caused by a combination of genetic, psychosocial and environmental factors - there is no

Further Reading and Useful Resources

Core Symptoms of ADHD

Box 2: Symptoms of hyperactivity [3]

• In adolescence symptoms of inattention typically persist to a greater degree than hyperactivity

Further Reading and Useful Resources

> ADHD and Comorbidity

ADHD and Comorbidity

In a survey of adults, 47% of adults with ADHD At a pub, if

A follow-up of Danish children into adulthood found that females

Box 1: Key points from Module 3 - ADHD and Common Comorbidities

Further Reading and Useful Resources

The National Autistic Society; Autism and ADHD:

ADHD and Anxiety Disorders: www.aboutourkids.org/articles/attentiondeficithyperactivity_adhd_anxiety_disorders

The Educational Pathway

Those with special educational needs and/or ADHD may be entitled to

Box 1: Recommended classroom interventions and management strategies

Box 2: Key points from Module 4 - ADHD and Education

• Poor organisational skills are a major problem throughout higher education.

Further Reading and Useful Resources

Special exam arrangements: jcq.org.uk/exams_office/access_arrangements/

ADHD and the school day: www.addiss.co.uk/schoolreport.pdf

ADHD in the Workplace

How can we prevent these adverse occupational outcomes? Of course

Disclosure of ADHD Status