Skip to main content
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2017 Aug 30.
Published in final edited form as: J Adolesc Health. 2016 May 18;59(2):135–143. doi: 10.1016/j.jadohealth.2016.03.025

DIAGNOSIS AND TREATMENT OF ADHD DURING ADOLESCENCE IN THE PRIMARY CARE SETTING: REVIEW AND FUTURE DIRECTIONS

Khyati Brahmbhatt 1, Donald M Hilty 2, Mina Hah 3, Jaesu Han 4, Kathy Angkustsiri 5,6, Julie Schweitzer 6,7
PMCID: PMC5576000  NIHMSID: NIHMS889912  PMID: 27209327

Abstract

Introduction

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school age children.

Objective

The goal of this review is to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents.

Methods

PubMed, PsychInfo and Science Citation Index databases were searched from March 1990–2015 with the key words: attention deficit hyperactivity disorder, primary care/pediatrics and children/adolescents, abstracts addressing diagnosis and/or treatment with 105 citations identified including supplementary treatment guidelines/books.

Results

Adolescent ADHD presents with significant disturbances in attention, academic performance and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis and limited training and time for PCPs to conduct thorough evaluations. The evidence-base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification and treatment of conditions associated with ADHD that emerge during adolescence as substance use disorders.

Conclusions

Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care-psychiatric models, to assist in determining the optimal care for patients at this critical period.

Keywords: ADHD, adolescent, attention deficit hyperactivity disorder, primary care, treatment, evaluation

Introduction

Attention deficit hyperactivity disorder (ADHD) 1 is a neurodevelopmental disorder with prevalence rates in school-aged children of about 5% worldwide 2 and 7–9% in the United States 3. Primary Care providers (PCPs), including pediatricians, family medicine and other physicians, nurse practitioners and mid-level professionals are increasingly, screening and treating ADHD.. There is some concern that insufficient training for PCPs caring for these youth contributes to the increasing prevalence rates for the diagnosis and treatment of ADHD 4, which calls for greater education for PCPs serving persons with ADHD. Reviews addressing the assessment and management of pediatric and adult ADHD 5,67 in primary care have been published though none of these have focused on adolescents. Given the unique challenges in assessing and managing ADHD in this age group, a focused review addressing adolescent ADHD can fill this gap. About 80–85% of pre-teens continue to experience symptoms into the adolescent years and 60% into adulthood 810. Adolescents with ADHD have difficulties in sustaining attention in routine tasks 1, academic performance 11, peer relations (e.g., increased victimization), and family cohesiveness 1215. Untreated patients have higher rates of risky sexual behaviors 12, suicidal thoughts in college 16, incarcerations 13, automobile accidents 17,18, occupational difficulties and medical burden 19. They have lower self-esteem, social functioning, economic achievement and higher rates of substance use 20,21. Medical problems include smoking, obesity, non-adherence and comorbid medical illnesses 19. These risks associated with ADHD lead to a higher demand for assessment and treatment in the teenage years and the primary care setting is at the heart of service delivery 2224. Pediatricians and family medicine providers are increasingly conducting more screening, treating more patients and maintaining treatment longer 25. However there is wide variability in the care provided by pediatricians for mental health issues 26. In order to provide optimal care for adolescents with ADHD, PCPs have to consider symptom progression and treatment interventions in adolescence and adulthood within a developmental framework. There are two key junctures of care transitions: 1) the child’s transition to a health care system geared for adolescents; and 2) the adolescent’s transition to the adult system that may be less familiar with the disorder. Child-adolescent-adult systems are beginning to employ the use of a range of ages (e.g., 18–21), rather than stopping at a fixed age (e.g., 18 years) in recognition of these challenges. Regardless, the care plan is more complex and often requires a multidisciplinary approach, including input from mental health, primary health, education/vocation, social services and legal/correctional perspectives.

The goal of this review is to identify challenges to the evaluation and treatment of adolescents for ADHD in the primary care setting and present findings to inform a course to address those challenges. We begin by discussing the most common challenges encountered by PCPs in working with adolescents with ADHD. Next, we describe a suggested developmental framework to assist in the diagnostic and treatment decision-making. Specific diagnostic and treatment quandaries as well as potential solutions are presented followed by a discussion of practical aspects of treatment modalities for adolescents. Finally, we provide a guide for referring adolescents to a specialist, because even with the best efforts, expertise by a care provider with specialized training in adolescence and ADHD may be necessary.

Common Challenges

There are many factors that affect PCPs’ comfort and ability to screen, diagnose and treat adolescent ADHD. Historically, treatment providers thought children outgrew ADHD during adolescence. By the 1990s, longitudinal studies 2732 firmly established that ADHD persisted for a significant number of children through adolescence into adulthood 20 and is associated with significant disability 3336 Furthermore, many are uncomfortable prescribing stimulant medication, the best supported treatment for ADHD due to concerns regarding lack of documentation of the disorder 37.

Unfortunately, there is no standardized acceptable minimum of training via didactics, supervised caseloads or access to peers/specialists to which PCPs are exposed to in order to continue learning about ADHD over the lifespan 38. Over 90% of pediatricians report familiarity with published ADHD guidelines though only about 60% of family physicians acknowledge fluency with the basic guidelines for the disorder 39. The most significant barriers cited for making the diagnosis were limited experience with ADHD in adults and difficulty in distinguishing ADHD from other conditions 40. All of this may lead PCPs to view ADHD as a disorder outside of their scope of practice. It may also result in PCPs missing diagnoses when they are warranted.

Further, ADHD during adolescence may be challenging for the PCP to diagnose and treat because the most noticeable, observable symptom associated with the disorder, hyperactivity, wanes in adolescence, and other hallmark symptoms, impulsivity and inattention, may be hard to distinguish from typical adolescent behavior. Furthermore, demands for all adolescents grow with expected increases in responsibility, planning, future-orientation and organization, yet these are the key areas that are problematic for those with ADHD. Thus, it can be difficult to determine if the adolescent is exhibiting “typical immaturity” within the range of the healthy adolescence or ADHD. The consequences of poor inattention and higher risk taking during the adolescent years can have profound long-term impact for both teens with or without ADHD. Thus, these issues warrant careful consideration, but determining whether or not they are associated with ADHD will guide the type of intervention required.

Developmental Framework

Development viewed from a bio-psycho-social framework can help explain the changes of adolescence and their impact on ADHD including gender-based differences. Normative biological development includes hormonal and physical changes with a tendency for sexual and substance experimentation 41,42 that may partially be driven by a relatively immature prefrontal cortex and/or a heightened reward sensitivity 4345. Psychologically, teens grapple with forming a sense of identity with an increasing need for independence, while managing internal and external (family, peer & societal) expectations. Sexual maturity with a growing focus on interpersonal relationships becomes increasingly prioritized. There is greater sensitivity to peer evaluation and a heightened degree of emotional intensity associated with activation in socio-affective brain regions and circuits 46. In today’s environment, access to technology, such as cell phones and tablets, presents new modes for immediate gratification that may have serious consequences for the adolescent with ADHD. The overlay of ADHD on top of typical adolescent development presents additional challenges. The core symptoms of ADHD and their presentation in the context of adolescence are described in Table 1.

Table 1.

Attention Deficit Hyperactivity Disorder Diagnostic Criteria from The Diagnostic And Statistical Manual, Fifth Edition (DSM-5)

Contextual issues and examples related to attention deficit hyperactivity disorder (ADHD) in adolescence

ADHD symptom Presentation in adolescence
Inattention
  • Inattentive symptoms may exceed coping mechanisms and result in academic problems prompting the adolescent or college student [50–51] to seek out the primary care provider

  • Makes careless mistakes and errors in tasks, may not attend to details resulting in poor school /work performance and can impact extracurricular activities

  • Detailed and tedious tasks are stressful and often incomplete

  • Avoidance of tasks and chores at home and in school

  • Challenges in remaining focused for extended periods of time (e.g., lectures, reading, tasks with minimal interactive component)

  • Jumping from page to page when browsing the Internet or when researching a topic for homework

  • May compensate by selecting tasks/jobs that require less sustained attention and are more active (e.g., field jobs vs desk jobs)

  • Poor follow-through with task completion and deadlines and/or messy work

  • Easily distracted by external social and nonsocial distractors that impairs task performance and completion

  • Frequently does not pay attention during conversations or when given instructions, as may be distracted by other thoughts

  • Poor or insufficient planning (e.g., waits until last minute to complete tasks, does not have necessary materials, does not follow logical, sequential steps in task completion)

  • Poor organization in home or work tasks (e.g., may not keep track of homework assignments, cannot find materials for home or work tasks)

  • Difficulty with time management and meeting deadlines

  • Over scheduled

  • Aware of social impairment but can do little about it due to poor inhibition

  • Loses valuable items such as cellphones, homework, books, keys, or clothes

  • Forgets to complete regular duties or activities (e.g., turning in homework, chores at home, meeting friends or colleagues)

Hyperactivity/Impulsivity
  • Answering questions without full instructions; interrupting peers, teachers, and family members

  • Interrupting others in conversations/excessive talking, often with tangents/making impulsive comments to others

  • Engaged in frequent or intense physical activity and/or talking

  • Trouble staying seated for long periods of time (e.g., movies, plays, lectures, religious functions)

  • Fidgety and has trouble sitting still or keeping hands or feet still; may have restless thoughts

  • Impulsivity including not thinking through decisions and long-term consequences, abrupt actions in school or work, impatience and interrupting of peers, parents, and teachers, and engaging in sexual activities without considering risks

  • Is loud or makes excessive noise while engaged in leisure activities

  • Impatience for others or waiting

  • Seeking out highly rewarding activities and peer approval and engaging in risky actions related to driving [14] and substance use due to the differences in the development of heightened response to reward during adolescence and an underdeveloped cognitive control system that, theoretically, monitors and modulates responses to rewards [55-59]

  • Acts with emotion resulting in interpersonal arguments

  • Quits jobs, ends relationships

  • Emotional liability/loses temper easily (e.g., road rage)

Gender differences

In addition to stage of development, the sex of the adolescent can also impact the diagnosis of ADHD and its symptom expression. Males are more likely to be diagnosed with ADHD during childhood due to the predominance of hyperactivity/impulsivity symptoms, while females are more likely to be diagnosed with ADHD, inattentive presentation 21,47. Differences in the rates of diagnosis between males and females decline during adulthood, with an approximately equivalent rate of women receiving the diagnosis as men 48. Thus, it is likely during adolescence that ADHD symptoms become more prominent in females that may not have been evident during childhood.

Diagnosis of Adolescent ADHD

Diagnostic challenges

ADHD impacts functioning at home, school and other social settings in complex ways and requires coordination between multiple players/providers creating challenges in diagnosing and treating ADHD 37,49. Inattention is often the predominant symptom during adolescence 20, yet impulsivity and hyperactivity may be present in more subtle ways. Parents and teachers expect greater independence around completion of school work in the teen years. Organizational impairments may increase in severity when the patient has to manage being in multiple classrooms, being taught by several teachers and being required to use a locker. Academic underachievement becomes a significant concern for parents who are often apprehensive about their adolescent’s potential for graduating high school and being admitted to college. PCPs are advised to ideally obtain input from all the involved parties: family, agency, teacher(s) and/or after school program staff. Adolescents are key contributors to the evaluation for their ADHD and good reporters about their negative social behaviors 50, however, they are not reliable and valid reporters of their ADHD symptoms. Collecting and integrating information from the teen, parent(s) and school personnel to make an accurate diagnosis and treatment plan is often a significant barrier to successful management in primary care. The “myADHDportal®” 51 is an important tool that aggregates information via an online system. The product provides basic information for parents and teachers (e.g., education resources and referral lists) and also facilitates communication, automatically scores ADHD rating scales and provides personalized health information. Use of the portal increases implementation of American Academy of Pediatrics-recommended care practices and improves the quality of ADHD treatment in community-based settings 51,52.

When considering a diagnosis of ADHD, it is important to screen for other disorders and factors that can mimic ADHD, such as stress and poor sleep. Adolescents tend to underreport symptoms 50,53 and parents may be less accurate in rating symptoms as they often spend less time with teens than they do with younger children 23. There are prominent rates of co-morbidity with learning, mood 54,55 and anxiety disorders, which cloud the presentation and diagnosis. Furthermore, delinquency and interpersonal conflict become more prevalent during this developmental period. With DSM-5, autism may also now be diagnosed with ADHD. It is crucial to arrive at a correct diagnosis(es), as an antidepressant used for the wrong disorder (e.g., bipolar disorder) could lead to symptom exacerbation or a misdiagnosis. Screening for substance use (SU), including prescribed medications, is critical with adolescent patients. ADHD is highly comorbid and predictive of substance abuse 5659 related to alcohol, marijuana and other drugs. SU often is higher in ADHD 6062 as persons with ADHD use illicit substances with less awareness of their negative effects 63,64. Environmental context also affects vulnerability for SU in ADHD, including low parental monitoring and warmth 6567 as well as peer group affiliation and rejection 54. Thus, interview questions or observations regarding parent-child interactions and peer group affiliation may be helpful.

Finally, parents often have questions regarding the readiness of their teen with ADHD for automobile driving. ADHD is associated with a number of negative driving outcomes including more accidents, citations, poor driving habits and skills 20. Thus, assessing the readiness of adolescents with ADHD to drive an automobile is a critical issue and the PCP should be ready to have frank discussions about the risks and readiness for a teen with ADHD to be driving.

The fairly recent publication of the Diagnostic and Statistical Manual 1 is more responsive to some of the challenges in diagnosing ADHD in adolescence and emerging adulthood. Similar to the previous DSM, in DSM-5, adolescents must still meet criteria for at least 6 symptoms from one of the symptom lists for inattention and/or hyperactivity/impulsivity. A change in this edition, is that persons 17 years or older can be diagnosed with ADHD with fewer symptoms (i.e., 5 instead of 6). Another, significant change from the earlier version, which required presentation before age 7, is that symptoms need to be present prior to 12 years of age. These symptoms do not need to cause impairment at younger ages with impairment at the time of evaluation being the only requirement. This last change recognizes that symptoms may change over time and become problematic during adolescence and may not have reached that threshold earlier in childhood.

The majority of rating scales used with children also have normative information for adolescents, including the ADHD:RS DSM 5 68, Conners’ Parents and Teachers Rating Scales 69 and several others. Most ADHD rating scales screen for depression and anxiety, such as the Vanderbilt 70 and these items should be closely reviewed. Other measures such as the Child Behavior Checklist 71 or Behavior Assessment System for Children 72 provide a broader evaluation of functioning and have subscales to assess co-morbid issues. PCPs may also find a review of the adolescent’s report cards from their child’s elementary school years helpful to substantiate a history of ADHD symptoms before the age of 12 years of age and assist in establishing the trajectory of the symptoms. PCPs should also be aware of “Sluggish Cognitive Tempo SCT,” in which teens may present as “hypoactive,” with poor attention and co-morbid anxiety or depression 73,74. The symptoms overlap with inattention problems in ADHD and is being increasingly discussed in the literature as a subset of ADHD or overlapping, yet distinct disorder, however, SCT is not in DSM-5 and it is not confirmed as a disorder.

Treatment of Adolescent ADHD

Treatment Challenges

PCPs may be successful in working with adolescents with ADHD due to the longitudinal nature of their relationship. The adolescent may feel more comfortable with their PCP over a specialist 63 as there may be more stigma associated with receiving treatment from a psychiatrist, psychologist or other mental health professionals. However, even in situations where a PCP is able and willing to provide care for ADHD, poor insurance coverage or limited mental health resources limits assessment, treatment and follow-up - and amplifies PCP’s time concerns at each visit as was endorsed by 50% of providers in a survey 39,75. A challenge in treating the adolescent with ADHD is the minimization of ADHD by teens in comparison to how their parents or teachers perceive it. Compared to other ages, adolescents are less accepting and adherent to parts of the treatment plan 76. Stigma often plays a role in this 77 and psychosocial interventions that directly address stigma may be necessary 78. Adolescents’ increased ability to make decisions independent of their caregivers, needs to be sensitively balanced with the recognition that they are still minors. Empowering them to be instrumental in the process and respect for their confidentiality can be helpful in improving their willingness to engage in treatment.

Many physicians are reluctant to initiate treatment in adolescents with ADHD due to concern it will increase later risk of substance use; however, evidence does not support this concern 62. A recent comprehensive meta-analytic review demonstrated that stimulant treatment has a neutral effect on developing later substance use disorders 62. The issue of stimulant misuse and diversion is warranted. About 25% of patients with ADHD are approached by others to buy stimulants, and 11% of patients with ADHD have sold their stimulant medications 79 and studies have evaluated middle and high school students 80 and college students 81 with similar results. Diversion of stimulant medication is slightly increasing for regular release stimulants, but not for sustained release preparations (e.g., roughly 0.2/100,000 prescriptions) 82. PCPs should have a discussion with the patient preemptively about the dangers of diverting stimulants and using them without any physician oversight including the possibility of developing a severe side effect, a psychotic response or in those with predisposing risks, development of cardiac problems including death.

The presence of comorbidities in the adolescent with ADHD presents additional significant challenges to the PCP. Depending on the diagnoses involved and the relative impairment from each, this might mean co-treating or using stepped care, initiating treatment for the most impairing disorder first followed by a gradual expansion to involve all comorbid illnesses. Co-morbidities such as depression and anxiety are the common co-occurring disorders that PCPs are familiar with and can initiate pharmacological treatment for, when indicated. Referrals to specialists for interpersonal or cognitive-behavioral therapy should be considered for depression 83 and anxiety 84 as they are efficacious in adolescents and have fewer associated side-effects 83. For bipolar disorder, autism, substance dependence, a consultation, co-treatment or referral may be appropriate. The benefits of nonpharmacologic factors including regular exercise, sleep hygiene, and nutrition, while avoiding substance use should be considered as well. Finally, there are pervasive reports and concerns that there is an over prescribing of stimulant medication for ADHD, including for adolescents. Over diagnosis and treatment is likely due to the absence of a thorough, comprehensive evaluation 4. Thus, those PCPs who are reluctant to treat teens with ADHD out of concerns that they have inadequate training in ADHD or find a particular case warrants more thorough evaluation and expertise should refer those patients to colleagues or a specialist.

ADHD Treatment

Stimulant Medication

Several reviews of stimulant medications that include adolescents are published though few focus specifically on this age group 85,86,23,87,88. Stimulant medications are considered the most effective treatment for ADHD symptoms reduction 89, have an effect size of 0.73–0.86 or higher and are effective in adolescents as well as children 90. Interestingly, similar to children, adolescents with ADHD are relatively poor at discerning when they are on a placebo versus a stimulant medication in a clinical trial (i.e., 40% accuracy) and furthermore, they are unlikely to attribute either good or negative performance to whether or not they were taking medication 91. Thus, they may have diminished motivation to follow recommendations from their PCP to take their medication if they do not discern that it helps their functioning 90. It is key to assess and track changes in side effects and symptoms using rating scales (e.g., Conners’ Parent or Teacher Rating Scale 69 or Vanderbilt Rating Scale 70) with evidence pointing to moderate correlation between reduction in clinical scores and functional outcomes 92.

Stimulants vary in their pharmacokinetic and pharmacodynamic profiles and can be broadly divided into methylphenidate (Ritalin; others) and amphetamine products (Table 2). Given that methylphenidate-based medications demonstrate more sustained and equivalent effects on norepinephrine and dopamine compared to amphetamines, they are considered first line treatment options in most adolescent patients 93. For patient with co-occurring substance use disorders, lisdexamphetamine - a pro-drug 94 that becomes active after first pass metabolism–maybe an option. Being aware of alternate formulations including liquid, capsules that can be opened up and sprinkled, and transdermal patches (e.g., Quillivant XR, Adderall XR, Daytrana patch) may be helpful in providing adolescents with choices and getting buy-in. A common side effect of stimulant medications is appetite reduction. The majority of children prescribed stimulant medication experience little to no overall growth slowing secondary to the appetite reduction; however, individual patients may be more susceptible 95,96. This can be of concern to adolescents who frequently socialize around food. Frequent snacks and calorie dense food choices may help mitigate these issues. Sleep disturbances are also a common side effect, particularly with longer acting formulations. Baseline sleep differences of adolescents and abnormalities seen in ADHD even without the addition of medications must be considered. Moving up the dosing time or switching to a shorter acting medication may address this issue. Tics, independent of ADHD, has its highest incidence at ages 7–13 97. There is no “definitive and causal” relationship of the emergence of tics with stimulant use, though, some patients’ tics may worsen 97. In these patients, replacement of or the addition of a non-stimulant such as clonidine or guanfacine may be helpful 95.

Table 2.

Attention deficit hyperactivity disorder (ADHD) medication treatment options: methylphenidate and amphetamine products

Short or Immediate Acting Formulations
Drug Name Trade name/s Duration of action (approx.) Usual dose range* Comments/Tips
Methylphenidate Ritalin 3–4 hours 2.5mg–60 mg Generic
Methyin 3–4 hours 2.5mg–60 mg Branded generic for Ritalin- available in liquid and chewable tablets
Focalin 3–4 hours 5 mg–30 mg Twice as potent as mixed salts/use half doses. Beads can be sprinkled
Ritalin SR 4–6 hours 20mg–60 mg Generic
Methlyin SR/Metadate ER 4–6 hours 20 mg–60mg Branded generic for Ritalin SR
Amphetamine salts Adderall 4–5 hours 2.5–60 mg Generic. Can be crushed
Dexedrine 4–5 hours 5–30 mg Twice as potent as mixed salts/ use half doses
Sustained or Long Acting Formulations
Drug Name Trade Name/s Duration of action (approx.) Dose range Comments/Tips
Methylphenidate Ritalin LA 8–10 hours 10–60 mg Beads can be sprinkled
Focalin XR 6–8 hours 5–40 mg When switching to Focalin -use half the dose of previous medication and vice versa. Can be sprinkled
Metadate CD 6–8 hours 10–60 mg -
Concerta Up to 10 hours 18–54 mg Generic, has to be swallowed whole due to osmotic pump
Daytrana Up to 15 hours 10–60 mg Daily 9 hour patch. Patches can be cut.
Amphetamines Adderall XR 8–12 hours 5–60 mg Can be sprinkled
Vyvanse Up to 14 hours 20–70 mg Pro-drug, safer in case of substance abuse

Providers may be hesitant to prescribe stimulants due to uncertainty about cardiac side effects; however, the risk for sudden cardiac death in children and adolescents taking stimulants is lower than the risk in the general population (1.3–4.6/100,000 person years) 98. The routine practice of obtaining baseline EKGs before starting stimulant medication is not recommended, although a thorough personal and family history of cardiac disease should be obtained 99. While there are some small statistically significant, although not clinically significant, elevations in blood pressure and heart rate in children taking stimulants 100 there is no evidence for increased risk of QT prolongation 101 or sudden cardiac death 99 due to stimulant treatment. A review for family physicians summarizes many of these data sets and suggestions 102.

Approximately 70% of adolescents will respond to a stimulant medication trial 88,85,87. For no response in an adherent patient at a therapeutic or maximal dose, a switch to another medication is warranted87. It is advisable to start with longer acting formulation first and use shorter acting formulations later in the day to extend the duration of action or in cases where it is preferable to have shorter acting medications. Follow-up care is critical to ensure adequate treatment as most patients who receive adequate treatment reach remission. The American Association of Pediatrics recommends monthly visits for adjusting medication, followed by at least semiannual visits until steady progress toward behavioral and functional goals has been achieved. Routine monitoring should include measurements of height, weight, blood pressure, and heart rate. Adverse reactions may change over time and should be assessed routinely. The duration of medication use depends on its effects on behavior and function over time.

Non-stimulant medications (Table 3)

Table 3.

Attention deficit hyperactivity disorder (ADHD) medication treatment options: antidepressant and other medications

Drug Name Trade name/s Duration of action (approx.) Usual dose range* Comments/Tips
Atomoxetine Strattera Ongoing 5–100 mg Antidepressant- discuss black box warning
Start at 0.5mg/kg/day and max of 1.2 mg /kg/day
Will take weeks for effect
Bupropion Wellbutrin Ongoing 20–60 mg Anti-depressant-discuss black box warning
Risk for lowering seizure threshold
Guanfacine Tenex Short acting 0.5–4 mg Can cause sedation and decreased blood pressure
Can be used in divided doses
Intuniv Long acting 1–4 mg Do not crush. Use once/day typically at bedtime
Clonidine Catapres Short acting 0.05–0.3 mg More sedating than guanfacine
Taper down to avoid rebound hypertension
Catapress patch Week 0.1–0.3 mg Once weekly patch
Kapvay Long acting 0.1–0.4 mg Do not crush. Use once/day typically at bedtime

Non-stimulant medications may be used as monotherapy or as adjunct medications. The most commonly prescribed medications include atomoxetine 103, bupropion, and alpha-adrenergic agonist agents such as guanfacine104 and clonidine 105. Due to atomoxetine’s classification as an antidepressant, an FDA black box warning for the potential for increased risk for suicidal thoughts in teens and young adults under 25 years of age should be discussed.

Many studies show that children and adolescents switch forms of treatment over time and often discontinue the use of medication after 2 to 3 years 106. Follow-up of the MTA cohort 6 to 8 years after the trial, when participants were 13 to 18 years of age, showed that the original study groups did not continue to receive their randomly assigned treatment and did not differ significantly from each other with respect to any variables, including grades, arrests, and psychiatric hospitalizations 107. These findings underscore the importance of considering ADHD as a chronic condition and checking in with the adolescent throughout the teen years to reintroduce options for treatment.

Psychosocial treatments

Non-pharmacological interventions for adolescents can address self-efficacy, co-morbid diagnoses, other issues commonly present in ADHD and may permit lower doses of medication when used together 108. It may be advisable to consider initiating both treatments in close proximity to achieve the best outcomes and requires increased coordination with mental health clinics or private practitioners (e.g., therapists) 39. One of the primary targets for treatment with the adolescent involves conflict management between the teen and their parents. These conflicts are often related to the adolescent’s desire for greater freedom and independence from their parents. Coercive interactions between the adolescent with ADHD and their parents, with each striving to accomplish their own goal can spiral out of control to clinically significant levels. Barkley has developed a four-factor model to characterize these interchanges that include: 1) the adolescent’s characteristics; 2) parent characteristics; 3) family environment and stressors and 4) parenting practices 109. Barkley and Robin 109 have developed and tested a manualized therapy (e.g., Defiant Teens) to address teen-parent conflict based on this model 109. This approach includes educating parents and teens about ADHD and how it affects the adolescent’s functioning and their interactions, teaching parents to “choose their battles” and reward positive behavior and follow-through with appropriate punishment, help parents and teens develop realistic expectations of one another, implement a problem solving approach to negotiate disagreements and learn to use more effective communication skills (e.g., avoid use of ultimatums and extreme comments) 109,110.

The Barkley and Robin treatment package 109 includes both problem solving communication training (PSCT) and behavior therapy (BT), with a greater emphasis on BT than cognitive therapy interventions. The intervention has demonstrated moderate effectiveness in improving conflict between parents and teens, however the authors note that medication was not maximized for the adolescents participating in the training and they stress that combining medication in addition to their treatment package needs to be tested. Studies have reviewed various components of behavior therapy including organizational skills coaching111,112 conducted individually and in the school setting113 and have found these to be beneficial.

Newer models of cognitive-behavior therapy (CBT) are being tested in adolescents with ADHD 114 based on small scale success with adult trials of cognitive-behavior therapy for adults with ADHD, and there appears to be some suggestion for positive results on functional domains 115. These results diverge from the child CBT studies that were not found to be effective for ADHD. Further evaluation of CBT for adolescents is required including identifying what particular adolescent (e.g., age, presence or absence of comorbidity and type of comorbidity) and parent characteristics (e.g., stress, psychological health) are likely to engender greater success. The development of executive functioning processes and neural substrates that support them in the adolescent and young adult years may be associated with the potential for greater success of CBT during this developmental period. The wide variation in neural, physical and emotional maturity present in the adolescent years likely requires some tailoring of the strategies within the adolescent therapy approaches that match the individual adolescent characteristics, their parent characteristics and their pattern of interacting with one another.

Cognitive Training

Approaches such as working memory training (WMT), are being increasingly tested to target both the symptoms and the underlying neuropsychological deficits in patients with attention-deficit/hyperactivity disorder (ADHD). There are now 14 RCTs with ADHD outcomes; and there is some inconsistency of extant findings 116 with more research needed.

When to Refer

For providers in a system that does not have access to specialty consultation, integrated behavioral health or feature a medical home model (i.e., PCP with a team approach), it may be more reasonable to refer patients to specialists 117. There are many different reasons to refer adolescents for further evaluation and or treatment of ADHD. If at any time the provider feels uncomfortable with determining a diagnosis or treating an adolescent, it is appropriate to refer to another physician and or ask for a consultation. Common reasons for referral include unclear diagnosis, multiple comorbid disorders, failure to respond to treatment and difficulties with side effect management. Further evaluation is often indicated if an adolescent patient presents with their first significant symptoms subsequent to 12 years or older. If an individual fails both classes of stimulants (methylphenidate and amphetamine) it might be time to think about referral. Common referral sources are child and adolescent psychiatrists, general psychiatrists, and developmental pediatricians/neurologists.

Discussion

It is critical to be educated about the unique challenges of evaluating and treating adolescent ADHD due to the potential morbidity and later functional impairments when adolescent ADHD goes untreated. PCPs are best suited to be the first point of contact for adolescents because they often have a long-term relationship with the teen that is crucial for successful engagement. Implementing an effective treatment plan will require a good relationship between the teen and the PCP with a healthy alliance. Providers will need to be well-acquainted with the specialized needs and practical aspects to provide care for this developmental stage in relation to ADHD. This includes how to address co-morbidity with other mental health issues, medication seeking and diversion issues and substance abuse. There is still limited research available on how to align clinical practice, particularly for PCPs with evidence-based guidelines, for this developmental period.

Summary and Implications and Contributions

Adolescent ADHD is a challenging condition presenting to PCPs, which requires a perspective unique from childhood and adult ADHD. Ultimately, there is a need for new primary care-psychiatric models that take into account the complexity of working with this population and the challenges working in a primary care setting.

Footnotes

There is no potential, perceived, or real conflict of interest for any of the authors.

References

  • 1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 5th Edition. Washington DC: American Psychiatric Association; 2013. [Google Scholar]
  • 2.Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. The American journal of psychiatry. 2007 Jun;164(6):942–948. doi: 10.1176/ajp.2007.164.6.942. [DOI] [PubMed] [Google Scholar]
  • 3.Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child and Adolescent Psychiatry. 2014 Jan;53(1):34–46. e32. doi: 10.1016/j.jaac.2013.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Hinshaw S, Schleffer R. The ADHD Explosion: Myths, Medication, Money and Today's Push for Performance. New York: Oxfor University Press; 2014. [Google Scholar]
  • 5.Culpepper L. Primary care treatment of attention-deficit/hyperactivity disorder. The Journal of clinical psychiatry. 2006;67(Suppl 8):51–58. [PubMed] [Google Scholar]
  • 6.Culpepper L, Mattingly G. Challenges in identifying and managing attention-deficit/hyperactivity disorder in adults in the primary care setting: a review of the literature. Primary care companion to the Journal of clinical psychiatry. 2010;12(6) doi: 10.4088/PCC.10r00951pur. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Montano B. Diagnosis and treatment of ADHD in adults in primary care. The Journal of clinical psychiatry. 2004;65(Suppl 3):18–21. [PubMed] [Google Scholar]
  • 8.Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria. I: An 8-year prospective follow-up study. Journal of the Am Acad of Child and Adoles Psychiatry. 1990;29:546–557. doi: 10.1097/00004583-199007000-00007. [DOI] [PubMed] [Google Scholar]
  • 9.Biederman J, Faraone S, Milberger S, et al. Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry. 1996 Mar;35(3):343–351. doi: 10.1097/00004583-199603000-00016. [DOI] [PubMed] [Google Scholar]
  • 10.Faraone SV, Biederman J, Mennin D, Gershon J, Tsuang MT. A prospective four-year follow-up study of children at risk for ADHD: psychiatric, neuropsychological, and psychosocial outcome. Journal of the American Academy of Child and Adolescent Psychiatry. 1996 Nov;35(11):1449–1459. doi: 10.1097/00004583-199611000-00013. [DOI] [PubMed] [Google Scholar]
  • 11.Breslau J, Miller E, Breslau N, Bohnert K, Lucia V, Schweitzer J. The impact of early behavior disturbances on academic achievement in high school. Pediatrics. 2009 Jun;123(6):1472–1476. doi: 10.1542/peds.2008-1406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Scholtens S, Rydell AM, Yang-Wallentin F. ADHD symptoms, academic achievement, self-perception of academic competence and future orientation: a longitudinal study. Scandinavian journal of psychology. 2013 Jun;54(3):205–212. doi: 10.1111/sjop.12042. [DOI] [PubMed] [Google Scholar]
  • 13.Harpin V, Mazzone L, Raynaud JP, Kahle J, Hodgkins P. Long-Term Outcomes of ADHD: A Systematic Review of Self-Esteem and Social Function. Journal of attention disorders. 2013 May 22; doi: 10.1177/1087054713486516. [DOI] [PubMed] [Google Scholar]
  • 14.Klein RG, Mannuzza S, Olazagasti MA, et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Archives of general psychiatry. 2012 Dec;69(12):1295–1303. doi: 10.1001/archgenpsychiatry.2012.271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Loe IM, Feldman HM. Academic and educational outcomes of children with ADHD. Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association. 2007 Jan-Feb;7(1 Suppl):82–90. doi: 10.1016/j.ambp.2006.05.005. [DOI] [PubMed] [Google Scholar]
  • 16.Patros CH, Hudec KL, Alderson RM, Kasper LJ, Davidson C, Wingate LR. Symptoms of attention-deficit/hyperactivity disorder (ADHD) moderate suicidal behaviors in college students with depressed mood. Journal of clinical psychology. 2013 Sep;69(9):980–993. doi: 10.1002/jclp.21994. [DOI] [PubMed] [Google Scholar]
  • 17.Barkley RA, Cox D. 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. 2007;38(1):113–128. doi: 10.1016/j.jsr.2006.09.004. [DOI] [PubMed] [Google Scholar]
  • 18.Narad M, Garner AA, Brassell AA, et al. Impact of distraction on the driving performance of adolescents with and without attention-deficit/hyperactivity disorder. JAMA Pediatr. 2013 Oct;167(10):933–938. doi: 10.1001/jamapediatrics.2013.322. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Nigg JT. Attention-deficit/hyperactivity disorder and adverse health outcomes. Clinical psychology review. 2013 Mar;33(2):215–228. doi: 10.1016/j.cpr.2012.11.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Barkley RA, editor. Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. 4. New York: Guilford; 2015. [Google Scholar]
  • 21.Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics. 2012 Jul;9(3):490–499. doi: 10.1007/s13311-012-0135-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Mandell DS, Thompson WW, Weintraub ES, Destefano F, Blank MB. Trends in diagnosis rates for autism and ADHD at hospital discharge in the context of other psychiatric diagnoses. Psychiatric services. 2005 Jan;56(1):56–62. doi: 10.1176/appi.ps.56.1.56. [DOI] [PubMed] [Google Scholar]
  • 23.Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005 Jun;115(6):1734–1746. doi: 10.1542/peds.2004-1959. [DOI] [PubMed] [Google Scholar]
  • 24.Copeland WE, Adair CE, Smetanin P, et al. Diagnostic transitions from childhood to adolescence to early adulthood. Journal of child psychology and psychiatry, and allied disciplines. 2013 Jul;54(7):791–799. doi: 10.1111/jcpp.12062. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Walkup JT, Stossel L, Rendleman R. Beyond rising rates: personalized medicine and public health approaches to the diagnosis and treatment of attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2014 Jan;53(1):14–16. doi: 10.1016/j.jaac.2013.10.008. [DOI] [PubMed] [Google Scholar]
  • 26.Ghanizadeh A, Zarei N. Are GPs adequately equipped with the knowledge for educating and counseling of families with ADHD children? BMC family practice. 2010;11:5. doi: 10.1186/1471-2296-11-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Biederman J, Faraone SV, Taylor A, Sienna M, Williamson S, Fine C. Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample. Journal of the American Academy of Child and Adolescent Psychiatry. 1998;37(3):305–313. doi: 10.1097/00004583-199803000-00016. [DOI] [PubMed] [Google Scholar]
  • 28.Hechtman L, Weiss G. Long-term outcome of hyperactive children. The American journal of orthopsychiatry. 1983 Jul;53(3):532–541. doi: 10.1111/j.1939-0025.1983.tb03397.x. [DOI] [PubMed] [Google Scholar]
  • 29.Weiss G, Hechtman L. Hyperactive children grown up. Guilford Press; 1993. [Google Scholar]
  • 30.Ernst M, Zametkin AJ, Phillips RL, Cohen RM. Age-related changes in brain glucose metabolism in adults with attention-deficit/hyperactivity disorder and control subjects. J Neuropsychiatry Clin Neurosci. 1998;10(2):168–177. doi: 10.1176/jnp.10.2.168. [DOI] [PubMed] [Google Scholar]
  • 31.Mannuzza S, Klein RG, Bessler A, Malloy P, Hynes ME. Educational and occupational outcome of hyperactive boys grown up. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(9):1222–1227. doi: 10.1097/00004583-199709000-00014. [DOI] [PubMed] [Google Scholar]
  • 32.Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M. Adult psychiatric status of hyperactive boys grown up. The American journal of psychiatry. 1998;155(4):493–498. doi: 10.1176/ajp.155.4.493. [DOI] [PubMed] [Google Scholar]
  • 33.Barkley R, Murphy K, Fischer M. ADHD in Adults: What the Science Says. Guilford Press; 2007. [Google Scholar]
  • 34.Barkley R, Murphy K, Kwasnik D. Psychological adjustment and adaptive impairments in young adults with ADHD. Journal of attention disorders. 1996:141–154. [Google Scholar]
  • 35.Castellanos FX, Margulies DS, Kelly C, et al. Cingulate-precuneus interactions: a new locus of dysfunction in adult attention-deficit/hyperactivity disorder. Biol Psychiatry. 2008;63(3):332–337. doi: 10.1016/j.biopsych.2007.06.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Hinshaw SP, Owens EB, Zalecki C, et al. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of consulting and clinical psychology. 2012 Dec;80(6):1041–1051. doi: 10.1037/a0029451. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Foy JM, Earls MF. A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder. Pediatrics. 2005 Jan;115(1):e97–104. doi: 10.1542/peds.2004-0953. [DOI] [PubMed] [Google Scholar]
  • 38.Rushton JL, Fant KE, Clark SJ. Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder. Pediatrics. 2004 Jul;114(1):e23–28. doi: 10.1542/peds.114.1.e23. [DOI] [PubMed] [Google Scholar]
  • 39.Goodman DW, Surman CB, Scherer PB, Salinas GD, Brown JJ. Assessment of physician practices in adult attention-deficit/hyperactivity disorder. The primary care companion for CNS disorders. 2012;14(4) doi: 10.4088/PCC.11m01312. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Wolraich ML. Attention-deficit/hyperactivity disorder: issues for the pediatric office. Pediatric annals. 2002 Aug;31(8):469–470. doi: 10.3928/0090-4481-20020801-06. [DOI] [PubMed] [Google Scholar]
  • 41.Castellanos-Ryan N, O'Leary-Barrett M, Conrod PJ. Substance-use in Childhood and Adolescence: A Brief Overview of Developmental Processes and their Clinical Implications. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2013 Feb;22(1):41–46. [PMC free article] [PubMed] [Google Scholar]
  • 42.Forbes EE, Dahl RE. Pubertal development and behavior: hormonal activation of social and motivational tendencies. Brain and cognition. 2010 Feb;72(1):66–72. doi: 10.1016/j.bandc.2009.10.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Galvan A. The Teenage Brain: Sensitivity to Rewards. Current directions in psychological science. 2013;22(2):88–93. doi: 10.1177/0963721413476512. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Galvan A, Hare TA, Parra CE, et al. Earlier development of the accumbens relative to orbitofrontal cortex might underlie risk-taking behavior in adolescents. The Journal of neuroscience. 2006;26(25):6885–6892. doi: 10.1523/JNEUROSCI.1062-06.2006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.van den Bos W, Rodriguez CA, Schweitzer JB, McClure SM. Adolescent impatience decreases with increased frontostriatal connectivity. Proceedings of the National Academy of Sciences of the United States of America. 2015 Jul 21;112(29):E3765–3774. doi: 10.1073/pnas.1423095112. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Somerville LH. Special issue on the teenage brain: Sensitivity to social evaluation. Current directions in psychological science. 2013 Apr 1;22(2):121–127. doi: 10.1177/0963721413476512. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Barkley RA. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. New York: The Guilford Press; 2006. [Google Scholar]
  • 48.Quinn PO, Madhoo M. A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders. 2014;16(3) doi: 10.4088/PCC.13r01596. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Power TJ, Blum NJ, Guevara JP, Jones HA, Leslie LK. Coordinating Mental Health Care Across Primary Care and Schools: ADHD as a Case Example. Advances in school mental health promotion. 2013 Jan 1;6(1):68–80. doi: 10.1080/1754730X.2013.749089. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Smith BH, Pelham WE, Jr, Gnagy E, Molina B, Evans S. The reliability, validity, and unique contributions of self-report by adolescents receiving treatment for attention-deficit/hyperactivity disorder. Journal of consulting and clinical psychology. 2000 Jun;68(3):489–499. doi: 10.1037/0022-006X.68.3.489. [DOI] [PubMed] [Google Scholar]
  • 51.Epstein JN, Langberg JM, Lichtenstein PK, Kolb R, Simon JO. The myADHDportal.com Improvement Program: An innovative quality improvement intervention for improving the quality of ADHD care among community-based pediatricians. Clinical practice in pediatric psychology. 2013 Mar 1;1(1):55–67. doi: 10.1037/cpp0000004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Epstein JN, Langberg JM, Lichtenstein PK, Mainwaring BA, Luzader CP, Stark LJ. Community-wide intervention to improve the attention-deficit/hyperactivity disorder assessment and treatment practices of community physicians. Pediatrics. 2008 Jul;122(1):19–27. doi: 10.1542/peds.2007-2704. [DOI] [PubMed] [Google Scholar]
  • 53.Miller CJ, Newcorn JH, Halperin JM. Fading memories: retrospective recall inaccuracies in ADHD. Journal of attention disorders. 2010 Jul;14(1):7–14. doi: 10.1177/1087054709347189. [DOI] [PubMed] [Google Scholar]
  • 54.Marshal MP, Molina BS, Pelham WE., Jr Childhood ADHD and adolescent substance use: an examination of deviant peer group affiliation as a risk factor. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2003 Dec;17(4):293–302. doi: 10.1037/0893-164X.17.4.293. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Fischer M, Barkley RA, Smallish L, Fletcher K. Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. Journal of abnormal child psychology. 2002 Oct;30(5):463–475. doi: 10.1023/a:1019864813776. [DOI] [PubMed] [Google Scholar]
  • 56.Clure C, Brady KT, Saladin ME, Johnson D, Waid R, Rittenbury M. Attention-deficit/hyperactivity disorder and substance use: symptom pattern and drug choice. The American journal of drug and alcohol abuse. 1999 Aug;25(3):441–448. doi: 10.1081/ada-100101871. [DOI] [PubMed] [Google Scholar]
  • 57.King VL, Brooner RK, Kidorf MS, Stoller KB, Mirsky AF. Attention deficit hyperactivity disorder and treatment outcome in opioid abusers entering treatment. The Journal of nervous and mental disease. 1999 Aug;187(8):487–495. doi: 10.1097/00005053-199908000-00005. [DOI] [PubMed] [Google Scholar]
  • 58.Levin FR, Evans SM, Kleber HD. Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment. Drug and alcohol dependence. 1998;52(1):15–25. doi: 10.1016/s0376-8716(98)00049-0. [DOI] [PubMed] [Google Scholar]
  • 59.Molina BS, Pelham WE., Jr Attention-deficit/hyperactivity disorder and risk of substance use disorder: developmental considerations, potential pathways, and opportunities for research. Annual review of clinical psychology. 2014;10:607–639. doi: 10.1146/annurev-clinpsy-032813-153722. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Lee SS, Humphreys KL, Flory K, Liu R, Glass K. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clinical psychology review. 2011 Apr;31(3):328–341. doi: 10.1016/j.cpr.2011.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Szobot CM, Rohde LA, Bukstein O, et al. Is attention-deficit/hyperactivity disorder associated with illicit substance use disorders in male adolescents? A community-based case-control study. Addiction. 2007 Jul;102(7):1122–1130. doi: 10.1111/j.1360-0443.2007.01850.x. [DOI] [PubMed] [Google Scholar]
  • 62.Molina BS, Hinshaw SP, Eugene Arnold L, et al. Adolescent substance use in the multimodal treatment study of attention-deficit/hyperactivity disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. Journal of the American Academy of Child and Adolescent Psychiatry. 2013 Mar;52(3):250–263. doi: 10.1016/j.jaac.2012.12.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Weafer J, Fillmore MT, Milich R. Increased sensitivity to the disinhibiting effects of alcohol in adults with ADHD. Experimental and clinical psychopharmacology. 2009 Apr;17(2):113–121. doi: 10.1037/a0015418. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Roberts W, Milich R, Fillmore MT. Reduced acute recovery from alcohol impairment in adults with ADHD. Psychopharmacology. 2013 Jul;228(1):65–74. doi: 10.1007/s00213-013-3016-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Molina BS, Marshal MP, Pelham WE, Jr, Wirth RJ. Coping skills and parent support mediate the association between childhood attention-deficit/hyperactivity disorder and adolescent cigarette use. Journal of pediatric psychology. 2005 Jun;30(4):345–357. doi: 10.1093/jpepsy/jsi029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Tandon M, Tillman R, Spitznagel E, Luby J. Parental Warmth and Risks of Substance Use in Children with Attention-Deficit/Hyperactivity Disorder: Findings from a 10–12 Year Longitudinal Investigation. Addiction research & theory. 2014 Jun 1;22(3):239–250. doi: 10.3109/16066359.2013.830713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Walther CA, Cheong J, Molina BS, et al. Substance use and delinquency among adolescents with childhood ADHD: the protective role of parenting. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2012 Sep;26(3):585–598. doi: 10.1037/a0026818. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.DuPaul GJ, Power TJ, Anastopoulos AA. ADHD Rating Scale–5: Checklists, Norms, and Clinical Interpretation. Guilford Press; 2016. [Google Scholar]
  • 69.Conners CK. Conners 3 Conners. 3. Toronto, CA: Multi Health Systems; 2014. Vol DSM 5 Scoring update. [Google Scholar]
  • 70.Wolraich ML, Lambert W, Doffing MA, Bickman L, Simmons T, Worley K. Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of pediatric psychology. 2003 Dec;28(8):559–567. doi: 10.1093/jpepsy/jsg046. [DOI] [PubMed] [Google Scholar]
  • 71.Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age Forms & Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families; 2001. [Google Scholar]
  • 72.Reynolds CR, Kamphaus RW. Behavior Assessment System for Children. 3. San Antonio, Texas: Pearson; 2015. [Google Scholar]
  • 73.Lee S, Burns GL, Snell J, McBurnett K. Validity of the sluggish cognitive tempo symptom dimension in children: sluggish cognitive tempo and ADHD-inattention as distinct symptom dimensions. Journal of abnormal child psychology. 2014 Jan;42(1):7–19. doi: 10.1007/s10802-013-9714-3. [DOI] [PubMed] [Google Scholar]
  • 74.McBurnett K, Villodas M, Burns GL, Hinshaw SP, Beaulieu A, Pfiffner LJ. Structure and validity of sluggish cognitive tempo using an expanded item pool in children with attention-deficit/hyperactivity disorder. Journal of abnormal child psychology. 2014 Jan;42(1):37–48. doi: 10.1007/s10802-013-9801-5. [DOI] [PubMed] [Google Scholar]
  • 75.Management ASoA-DHDSCoQI. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1–16. doi: 10.1542/peds.2011-2654. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Charach A, Fernandez R. Enhancing ADHD medication adherence: challenges and opportunities. Current psychiatry reports. 2013 Jul;15(7):371. doi: 10.1007/s11920-013-0371-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 77.Barkley RA. Adolescents with attention-deficit/hyperactivity disorder: an overview of empirically based treatments. Journal of psychiatric practice. 2004 Jan;10(1):39–56. doi: 10.1097/00131746-200401000-00005. [DOI] [PubMed] [Google Scholar]
  • 78.Bussing R, Zima BT, Mason DM, Porter PC, Garvan CW. Receiving treatment for attention-deficit hyperactivity disorder: do the perspectives of adolescents matter? The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2011 Jul;49(1):7–14. doi: 10.1016/j.jadohealth.2010.08.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 79.Upadhyaya HP. Managing attention-deficit/hyperactivity disorder in the presence of substance use disorder. The Journal of clinical psychiatry. 2007;68(Suppl 11):23–30. [PubMed] [Google Scholar]
  • 80.McCabe SE, Teter CJ, Boyd CJ. The use, misuse and diversion of prescription stimulants among middle and high school students. Substance use & misuse. 2004 Jun;39(7):1095–1116. doi: 10.1081/ja-120038031. [DOI] [PubMed] [Google Scholar]
  • 81.McCabe SE, West BT, Teter CJ, Boyd CJ. Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: Connecting the dots. Addictive behaviors. 2014 Jul;39(7):1176–1182. doi: 10.1016/j.addbeh.2014.03.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82.Sembower MA, Ertischek MD, Buchholtz C, Dasgupta N, Schnoll SH. Surveillance of diversion and nonmedical use of extended-release prescription amphetamine and oral methylphenidate in the United States. Journal of addictive diseases. 2013;32(1):26–38. doi: 10.1080/10550887.2012.759880. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83.Zhou X, Hetrick SE, Cuijpers P, et al. Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis. World psychiatry. 2015;14(2):207–222. doi: 10.1002/wps.20217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety. Journal of clinical child and adolescent psychology, American Psychological Association, Division 53. 2015 Jun 18;:1–23. doi: 10.1080/15374416.2015.1046177. [DOI] [PubMed] [Google Scholar]
  • 85.Biederman J, Spencer T, Wilens T. Evidence-based pharmacotherapy for attention-deficit hyperactivity disorder. The international journal of neuropsychopharmacology. 2004;7(1):77–97. doi: 10.1017/S1461145703003973. [DOI] [PubMed] [Google Scholar]
  • 86.Spencer TJ. ADHD treatment across the life cycle. The Journal of clinical psychiatry. 2004;65(Suppl 3):22–26. [PubMed] [Google Scholar]
  • 87.Katragadda S, Schubiner H. ADHD in children, adolescents, and adults. Primary care. 2007 Jun;34(2):317–341. doi: 10.1016/j.pop.2007.04.012. abstract viii. [DOI] [PubMed] [Google Scholar]
  • 88.Evans SW, Pelham WE, Smith BH, et al. Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD. Experimental and clinical psychopharmacology. 2001 May;9(2):163–175. doi: 10.1037//1064-1297.9.2.163. [DOI] [PubMed] [Google Scholar]
  • 89.The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of general psychiatry. 1999 Dec;56(12):1073–1086. doi: 10.1001/archpsyc.56.12.1073. [DOI] [PubMed] [Google Scholar]
  • 90.Findling RL, Childress AC, Cutler AJ, et al. Efficacy and safety of lisdexamfetamine dimesylate in adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2011 Apr;50(4):395–405. doi: 10.1016/j.jaac.2011.01.007. [DOI] [PubMed] [Google Scholar]
  • 91.Pelham WE, Jr, Gnagy EM, Sibley MH, et al. Attributions and Perception of Methylphenidate Effects in Adolescents With ADHD. Journal of attention disorders. 2013 Jul 26; doi: 10.1177/1087054713493320. [DOI] [PubMed] [Google Scholar]
  • 92.Buitelaar JK, Wilens TE, Zhang S, Ning Y, Feldman PD. Comparison of symptomatic versus functional changes in children and adolescents with ADHD during randomized, double-blind treatment with psychostimulants, atomoxetine, or placebo. Journal of child psychology and psychiatry, and allied disciplines. 2009 Mar;50(3):335–342. doi: 10.1111/j.1469-7610.2008.01960.x. [DOI] [PubMed] [Google Scholar]
  • 93.Heal DJ, Smith SL, Findling RL. ADHD: current and future therapeutics. Current topics in behavioral neurosciences. 2012;9:361–390. doi: 10.1007/7854_2011_125. [DOI] [PubMed] [Google Scholar]
  • 94.Jain R, Babcock T, Burtea T, et al. Efficacy of lisdexamfetamine dimesylate in children with attention-deficit/hyperactivity disorder previously treated with methylphenidate: a post hoc analysis. Child and adolescent psychiatry and mental health. 2011;5(1):35. doi: 10.1186/1753-2000-5-35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 95.Clavenna A, Bonati M. Safety of medicines used for ADHD in children: a review of published prospective clinical trials. Archives of disease in childhood. 2014 Sep;99(9):866–872. doi: 10.1136/archdischild-2013-304170. [DOI] [PubMed] [Google Scholar]
  • 96.Poulton A, Cowell CT. Slowing of growth in height and weight on stimulants: a characteristic pattern. Journal of paediatrics and child health. 2003 Apr;39(3):180–185. doi: 10.1046/j.1440-1754.2003.00107.x. [DOI] [PubMed] [Google Scholar]
  • 97.Pidsosny IC, Virani A. Pediatric psychopharmacology update: psychostimulants and tics - past, present and future. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2006;15(2):84–86. [PMC free article] [PubMed] [Google Scholar]
  • 98. [Accessed March, 23 2015, 2015];L. V. Follow up review of AERS search identifying cases os sudden death occurring with drugs used for the treatment of attention deficit hyperactivity disorder (ADHD) 2006 http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4210b_07_01_safetyreview.pdf.
  • 99.Perrin JM, Friedman RA, Knilans TK Black Box Working G, Section on C, Cardiac S. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008 Aug;122(2):451–453. doi: 10.1542/peds.2008-1573. [DOI] [PubMed] [Google Scholar]
  • 100.Hammerness P, Wilens T, Mick E, et al. Cardiovascular effects of longer-term, high-dose OROS methylphenidate in adolescents with attention deficit hyperactivity disorder. The Journal of pediatrics. 2009 Jul;155(1):84–89. 89 e81. doi: 10.1016/j.jpeds.2009.02.008. [DOI] [PubMed] [Google Scholar]
  • 101.Findling RL, Biederman J, Wilens TE, et al. Short- and long-term cardiovascular effects of mixed amphetamine salts extended release in children. The Journal of pediatrics. 2005 Sep;147(3):348–354. doi: 10.1016/j.jpeds.2005.03.014. [DOI] [PubMed] [Google Scholar]
  • 102.Graham L. AHA Releases Recommendations on Cardiovascular Monitoring and the Use of ADHD Medications in Children with Heart Disease. Am Fam Physician. 2009 May 15;79(10):905. [Google Scholar]
  • 103.Durell TM, Adler LA, Williams DW, et al. Atomoxetine treatment of attention-deficit/hyperactivity disorder in young adults with assessment of functional outcomes: a randomized, double-blind, placebo-controlled clinical trial. J Clin Psychopharmacol. 2013 Feb;33(1):45–54. doi: 10.1097/JCP.0b013e31827d8a23. [DOI] [PubMed] [Google Scholar]
  • 104.Wilens TE, Robertson B, Sikirica V, et al. A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2015 Nov;54(11):916–925. e912. doi: 10.1016/j.jaac.2015.08.016. [DOI] [PubMed] [Google Scholar]
  • 105.Banaschewski T, Roessner V, Dittmann RW, Santosh PJ, Rothenberger A. Non-stimulant medications in the treatment of ADHD. European child & adolescent psychiatry. 2004;13(Suppl 1):I102–116. doi: 10.1007/s00787-004-1010-x. [DOI] [PubMed] [Google Scholar]
  • 106.Reid R, Hakendorf P, Prosser B. Use of psychostimulant medication for ADHD in South Australia. Journal of the American Academy of Child and Adolescent Psychiatry. 2002 Aug;41(8):906–913. doi: 10.1097/00004583-200208000-00008. [DOI] [PubMed] [Google Scholar]
  • 107.Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child and Adolescent Psychiatry. 2009 May;48(5):484–500. doi: 10.1097/CHI.0b013e31819c23d0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 108.Fabiano GA, Pelham WE, Gnagy EM. The single and combined effects of multiple intensities of behavior modification and methylpheniate for childrne with attention deficit hyperactivity disorder in a classroom setting. School Psychol Rev. 2007;36:195–216. [Google Scholar]
  • 109.Barkley RA, Robin AL. Defiant teens: A clinician's manual for assesment and family intervention. 2. New York: Guilford; 2014. [Google Scholar]
  • 110.Robin AL. Training Families of Adolescents with ADHD. In: Barkley RA, editor. Attention Deficit Hyperactivity Disorder: A Handbook of Diagnosis and Treatment. 4. New York: Guilford; 2015. [Google Scholar]
  • 111.Sibley MH, Kuriyan AB, Evans SW, Waxmonsky JG, Smith BH. Pharmacological and psychosocial treatments for adolescents with ADHD: an updated systematic review of the literature. Clinical psychology review. 2014 Apr;34(3):218–232. doi: 10.1016/j.cpr.2014.02.001. [DOI] [PubMed] [Google Scholar]
  • 112.Sibley MH, Pelham WE, Derefinko KD, Kuriyan AB, Sanchez F, Graziano PA. A Pilot Trial of Supporting Teens' Academic Needs Daily (STAND): A parent- adolescent collaborative intervention for ADHD. Journal of Psychopathology and Behavioral Assessment. 2013;35:436–449. [Google Scholar]
  • 113.Evans SW, Schultz BK, Demars CE, Davis H. Effectiveness of the Challenging Horizons After-School Program for young adolescents with ADHD. Behavior therapy. 2011 Sep;42(3):462–474. doi: 10.1016/j.beth.2010.11.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 114.Antshel KM, Olszewski AK. Cognitive behavioral therapy for adolescents with ADHD. Child and adolescent psychiatric clinics of North America. 2014 Oct;23(4):825–842. doi: 10.1016/j.chc.2014.05.001. [DOI] [PubMed] [Google Scholar]
  • 115.Antshel KM. Psychosocial interventions in attention-deficit/hyperactivity disorder: update. Child and adolescent psychiatric clinics of North America. 2015 Jan;24(1):79–97. doi: 10.1016/j.chc.2014.08.002. [DOI] [PubMed] [Google Scholar]
  • 116.Sonuga-Barke E, Brandeis D, Holtmann M, Cortese S. Computer-based cognitive training for ADHD: a review of current evidence. Child and adolescent psychiatric clinics of North America. 2014 Oct;23(4):807–824. doi: 10.1016/j.chc.2014.05.009. [DOI] [PubMed] [Google Scholar]
  • 117.Hilty DM, Ferrer DC, Parish MB, Johnston B, Callahan EJ, Yellowlees PM. The effectiveness of telemental health: a 2013 review. Telemedicine journal and e-health. 2013;19(6):444–454. doi: 10.1089/tmj.2013.0075. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES