If Your Adolescent Has ADHD: An Essential Resource for Parents (Adolescent Mental Health Initiative)

by Thomas J. Power

The first order of business is creating and maintaining a strong parent–child relationship.

Communication and negotiation. Clear communication allows you and your teen to share information, express opinions, and put feelings into words. Negotiation is the give-and-take of communication, helping you resolve an issue when the two of you don’t see eye to eye. Examples of specific skills that you and your teen might need to work on include being a good listener, expressing yourself clearly, not monopolizing the conversation, and avoiding lecturing and blaming. •Parental supervision. Now that your child is growing up and gaining more independence, you might feel as if your parenting job is done. The truth is, a teen needs your guidance and supervision. You can gradually loosen the reins as your child shows that he or she is ready for greater

freedom and responsibility. But you should still stay involved in a developmentally appropriate way.

Managing Antecedents

Antecedents are things preceding a behavior that make it more likely to occur.

These are some tried-and-true methods of managing antecedents: •Goal setting. At home, you and your teen can work together to identify goals for your child’s behavior. If the two of you are new to the process or have trouble agreeing on goals, input from a mental health professional is often helpful. The goals should be specific, realistic, and attainable in a reasonable amount of time. At school, your teen and a teacher may collaborate on goals for classroom behavior and academic performance. •Action planning. Once you and your teen have identified goals, you need to devise a plan for putting them into action. Talk about when, where, and how your teen will enact the behavior. To help your teen stay on track, you may use prompts, such as posting a schedule on the fridge or setting a daily alarm on your teen’s phone. Or you may establish a routine, such as always doing homework immediately after dinner. •Behavioral contracts. Often, it helps to formalize your plan in a written behavioral contract. This is an agreement between you and your teen. It lays out which behaviors are being targeted for change and what the consequences of achieving or not achieving a behavioral goal will be. Behavioral contracts between a teacher and student may also be used in a school setting.

Managing Consequences

Consequences are things following a behavior that make it more or less likely to occur again.

These are the options at your disposal: •Positive reinforcement. When a behavior is followed by something rewarding, it’s more likely to be repeated. This is known as positive reinforcement. Your attention, approval, and praise are powerfully reinforcing. You could also set up a reward system in which your teen can earn an allowance or privileges by completing specified tasks. •Negative reinforcement. When a behavior is followed by the removal of something unpleasant, it’s also more likely to be repeated. This is known as negative reinforcement. For example, let’s say you tell your teen to clean the bathroom. Your teen flips out, and you say, “Forget it; I’ll do it myself.” When you respond this way, your teen learns that flipping

out is an effective way of avoiding something he or she doesn’t want to do. This increases the chance that your teen will fly off the handle again when asked to do a chore. Of course, it’s human nature to try getting out of disliked tasks. But adolescents with ADHD have a heavy dose of human nature, at least when it comes to avoiding tasks that are boring or require sustained attention. You need to be extra-vigilant to make sure you aren’t inadvertently encouraging this kind of behavior with negative reinforcement. •Strategic punishment. In general, positive reinforcement is a more effective tool for promoting behavior change than punishment. But for deterring serious rule infractions or unsafe behavior, an appropriate punishment, such as being grounded or losing privileges, may be in order. For punishment to be effective, make sure your teen understands how his or her behavior led to these consequences. Use punishment in a deliberate, judicious way and give your child much more positive reinforcement than punishment. •Planned ignoring. One way to reduce or eliminate a less serious behavior problem is by making sure your teen doesn’t receive attention for it. Attention of any kind—even annoyed or disapproving attention—can be a potent form of positive reinforcement. When you strategically refuse to offer attention for an unwanted behavior, the behavior will often get worse before it gets better. Eventually, however, it will start to fade away.

Fine-Tuning the Plan

These are some strategies that can help with the fine-tuning: •Self-monitoring. To determine whether your teen is meeting a stated goal, it’s necessary to keep track of the target behavior. Teens can do much of this monitoring themselves. For example, let’s say the target behavior is staying focused while doing homework. Your teen might set an alarm to beep every two minutes. Each time it beeps, your teen would then check “yes” or “no” on a checklist to indicate whether he or she is paying attention. Other behaviors might be tracked with a journal or on a chart. The information gleaned this way helps your teen see how much progress he or she has made over time, which can often be encouraging. If progress is lacking, that’s a sign that you and your teen might need to adjust your plan. •Problem-solving. Once your teen has made good progress toward changing a target behavior, it’s time to start setting your sights on the next target. First, you and your teen identify another behavior that needs to be changed. Then, you consider alternative strategies that could be used. Finally, you start the process all over again, from setting goals and making plans to delivering consequences and monitoring progress.

The combination of behavioral therapy with low-dose medication may work as well as or better than a high dose of medication.

Classroom interventions can boost your teen’s academic performance and enhance the school experience. They make all those hours spent at school seem more successful and meaningful to your teen. That may translate into improved self-esteem as well as a more positive attitude toward getting a good education.

The Flip Side

Finding a Qualified Therapist Behavioral strategies are relatively straightforward.

Ideally, you’re looking for a therapist who frequently works with adolescents, has expertise in behavioral therapy, and has experience treating ADHD.

You can also check the professional directory and the list of hospital and university ADHD centers on the Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) website (chadd.org). Or you can search the directory of therapists provided by the Association for Behavioral and Cognitive Therapies (findcbt.org).

To decide whether a therapist offers the type of services your teen requires, these are some questions you may want to ask:

•How experienced are you at working with adolescents who have ADHD? Look for a therapist whose background and experience are a good match for your teen’s needs. •What therapeutic approach do you use for treating ADHD? You are looking for an expert in behavioral treatment. Therapists who provide this type of treatment may refer to what they do as behavioral therapy or solution-focused therapy. Sometimes they may refer to their approach as cognitive-behavioral therapy, which is fine as long as they place a strong emphasis on using behavioral approaches. Keep in mind that the word behavior is found in the names of other types of therapy as well. •Will you work with my child alone, me alone, or both of us at once? The best answer is “all of the above.” Let’s say your family embarks on an initial course of family behavioral therapy for 10 sessions or so. In a typical scenario, about one-third of the time in therapy would involve your teen meeting one-on-one with the therapist. This gives your teen a chance to start developing goals, engaging in problem-solving, and improving communication skills. About one-third of the sessions would involve you meeting with the therapist. This gives you an opportunity to learn some behavior management strategies and hone your own communication skills. And about one-third of the time would involve you and your teen seeing the therapist together. This allows the two of you to do more work on communication, negotiation, and collaborative problem-...

disorders that my child may have? A therapist who does not have training and expertise in treating a coexisting disorder should refer you to a qualified treatment provider. The therapist should be willing to coordinate care with the other prov...

For adolescents with ADHD, however, pretty good parenting isn’t good enough. You need to shoot for excellence. Just as in other jobs, when you’re aiming for the top of your field, you may need to undertake advanced training.

The therapist can help you learn new parenting skills and dust off old ones that may have fallen into disuse.

Executive Function Training

The frontal lobes are parts of each half of the brain, located behind the forehead, that are involved in cognitive activities and motor control. The front part of the frontal lobes, called the prefrontal cortex, plays an especially important role in executive functioning—the brain processes involved in organizing information, planning future actions, and regulating behavior and emotions.

Executive function training—also called brain training or cognitive training—aims to address this limitation. It uses computer-based activities involving extensive repetition and practice to strengthen specific executive functioning skills. For example, some training programs are intended to target working memory. This is a limited-capacity brain system for temporarily holding and manipulating information, much like the clipboard on a computer.

For many teens, a combination of behavioral therapy and medication is optimal.

Just bear in mind that the one constant in child development is change—and that’s never more true than during adolescence.

It’s also a period when coexisting conditions—such as depression, anxiety, oppositional defiant disorder (ODD), and conduct disorder—may be getting worse. In some cases, your teen’s ADHD symptoms may no longer respond to the same medication, dose, and dosage schedule that worked out well before.

Teens may start questioning why they need to take medication. Parents may begin worrying about the potential for teens to abuse certain drugs or to sell or give away medication to friends.

Medication is an integral part of treatment for many adolescents with ADHD.

The medications used to treat ADHD can be divided into two broad categories: stimulants and non-stimulants.

Dopamine and norepinephrine, two chemical messengers in the brain, are thought to play key roles. Research suggests that abnormalities in dopamine and norepinephrine activity within the brain are involved in causing the attentional and behavioral symptoms of ADHD.

there are liquid syrups,

Adderall XR

Concerta

ProCentra

In many cases, teens who don’t respond well to a particular stimulant medication may respond better to another medication within the same group. In other cases, teens who fail to improve on an amphetamine compound may have a good response to a methylphenidate compound,

Stimulants: Pros and Cons

A large body of research shows that these medications can help reduce inattention, hyperactivity, and impulsivity in many children and teens with ADHD. And that, in turn, may reduce many of the problems associated with ADHD, including academic underachievement, peer relationship problems, family conflict, and low self-esteem.

Even after a medication has been identified as effective, it’s common for medication to work less effectively over time. Often, an adjustment in dose can address the concern, but sometimes a change in medication is needed.

Potential for abuse. When taken in greater quantities or a different manner than prescribed, stimulants can be addictive. In addition, selling these medications or sharing them with others is a crime. Impress upon your teen the importance of using stimulant medications responsibly. Let the doctor know if your teen has a history of abusing drugs or alcohol.

Heart health risks. Stimulants can slightly raise blood pressure and increase heart rate.

Circulatory problems. Impaired circulation in the fingers and toes has also been reported in some individuals taking stimulant medications.

Mental health problems. Sometimes, use of stimulants may trigger or worsen anxiety or depressive symptoms. If this occurs, discuss the situation with your teen’s doctor. In very rare cases, use of stimulant medications may set off symptoms of psychosis (e.g., losing touch with reality, hearing voices, being paranoid) or mania (e.g., experiencing overly “up” moods, acting extremely euphoric or irritable).

Growth delays. Although there is evidence that children’s growth may slow down while taking stimulant medication, more recent research indicates that this problem is usually only temporary. Studies have shown that there were no differences in final adult height among teens who took stimulant medications and those who did not.

Clonidine and guanfacine have also been FDA approved for use as an adjunctive therapy—a treatment that’s added to another treatment to boost its effects. Some teens with ADHD who take stimulants find that their symptoms decrease a little, but not enough. Adding clonidine or guanfacine to the stimulant may lead to greater improvement than either medication alone.

Atomoxetine: Side Effects and Safety Issues

Suicidal thinking. Research in more than 2,200 children and teens with ADHD suggests that atomoxetine may slightly increase the risk for suicidal thoughts and behavior,

Clonidine ER and Guanfacine ER: Pros and Cons