Signs and Symptoms of Adolescent ADHD
Adolescents with ADHD present with less overt hyperactivity than younger children, making inattention symptoms more prominent, while impulsivity persists and manifests through risky behaviors including substance use, dangerous driving, and sexual risk-taking. 1
Core Symptom Presentation in Adolescents
Inattention Symptoms (Most Prominent)
- Difficulty sustaining attention across multiple classes with different teachers, making symptom observation more challenging than in elementary school 1
- Poor organizational skills affecting homework completion and long-term project management 1
- Forgetfulness in daily activities and losing materials needed for school 1
- Difficulty following through on instructions despite understanding them 1
Hyperactivity/Impulsivity Symptoms (Modified Presentation)
- Hyperactive behaviors become less obvious and overt compared to younger children, often manifesting as internal restlessness rather than physical overactivity 1
- Impulsivity persists and increases risk for substance experimentation, risky sexual behaviors, and motor vehicle violations 1
- Difficulty waiting turn in conversations, interrupting others 1
- Acting without considering consequences, particularly in social situations 1
Critical Diagnostic Requirements
Establishing Childhood Onset
- Adolescents must demonstrate documented manifestations of inattention or hyperactivity/impulsivity before age 12 to meet DSM-5 criteria 1
- Obtain collateral information from parents about elementary and middle school behaviors 1
- Review old report cards or school records when available to confirm early symptom presence 1
Multi-Informant Assessment Challenges
- Obtain information from at least 2 teachers or other sources (coaches, school guidance counselors, community activity leaders) despite the difficulty of coordinating multiple informants 1
- Expect variability in ratings between different classrooms and teachers, as adolescent behavior often varies by setting 1
- Adolescents tend to minimize their own problematic behaviors, making self-report alone insufficient for diagnosis 1
- Secure adolescent agreement and participation in the evaluation process for success 1
High-Priority Comorbid Conditions to Screen
Substance Use (Critical Assessment)
- Screen all adolescents with newly diagnosed ADHD for substance use symptoms before initiating treatment 1, 2
- Marijuana and other substances can produce symptoms that mimic ADHD 1
- Adolescents may feign symptoms to obtain stimulant medication for performance enhancement 1
Mental Health Comorbidities
- Depression and anxiety disorders increase significantly during adolescence and must be assessed, as they affect treatment sequencing 1
- Risk of intentional self-harm and suicidal behaviors increases in adolescents with ADHD 1
- Oppositional defiant disorder and conduct disorders commonly co-occur 1
Trauma and Stress-Related Conditions
- Assess for trauma experiences, posttraumatic stress disorder, and toxic stress as additional comorbidities 1
- These conditions can produce attention symptoms that mimic or complicate ADHD 1
Academic and Developmental Issues
- Learning disabilities and language disorders are common comorbid conditions requiring separate assessment 1
- Sleep disorders can worsen attention symptoms 1
- Tic disorders may be present 1
Functional Impairment Patterns
Academic Impact
- Declining grades despite adequate intelligence 1
- Incomplete assignments and poor long-term project completion 1
- Difficulty managing workload across multiple classes 1
Social and Behavioral Risks
- Increased risk for motor vehicle crashes and traffic violations, requiring special attention to medication coverage during driving hours 1
- Risky sexual behaviors with potential consequences 1
- Peer relationship difficulties 1
- Family conflict escalation during adolescence 1
Common Diagnostic Pitfalls
Mimicking Conditions to Rule Out
- Active substance use must be identified and addressed before or concurrent with ADHD treatment 1
- Depression causing concentration difficulties 1
- Anxiety interfering with focus and task completion 1
- Sleep deprivation from irregular adolescent sleep patterns 1
Assessment Errors to Avoid
- Relying solely on adolescent self-report without collateral information from parents and teachers 1
- Failing to document symptom onset before age 12 1
- Not accounting for normal developmental changes in activity level during adolescence 1
- Missing comorbid conditions that require treatment modification 1
Medication Diversion Risk
- Monitor for signs of medication misuse or diversion to peers, parents, or classmates through prescription refill patterns and symptom reports 1, 2
- Consider nonstimulant medications (atomoxetine, extended-release guanfacine, extended-release clonidine) when diversion risk is high 1
- Utilize state prescription drug monitoring programs as required 1, 2