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Paying attention to Teens


When she was an infant, they called her lively. During preschool they said she was precocious. By first grade, they had shifted from compliment to concern, saying she had hyperkinetic disorder of childhood. But within a few years, they had reclassified her symptoms as attention deficit hyperactivity disorder (ADHD).

Whatever you call it, her disorder manifested in an inability to focus her attention, coupled with various degrees of impulsiveness, excitability, and hyperactivity. And it had been sabotaging her chances at a quality educational experience, meaningful social development, and healthy self-esteem.

"The myth of ADHD," says Dr. Thomas Burchard, a psychiatrist and medical director of Adolescent Services for Community Hospital's Behavioral Health Services, "is that ADHD is merely a figment of somebody's imagination. It really does exist in up to 6 percent of the population. We have many studies to support its existence."

Medical practitioners have found that up to 75 percent of ADHD kids improve with stimulant medication, Burchard says. This response is called a paradoxical effect because a stimulant is normally used to increase energy and activity; but for those with ADHD, it actually seems to be calming. It is believed that the front part of the brain is underutilized or "not turned on" for those with ADHD, he says. Certain medications can stimulate that part of the brain, resulting in decreased impulsiveness and an increase in focus and concentration.

"Most kids can be hyperactive depending on their age," Burchard says, "so comparing a 6-year-old to a 12-year-old is not a fair test. Hyperactivity should be compared within peer groups. There is no physical test or brain scan. It is based on symptoms that are measures of inattention and impulsivity."

Six or more expressions of inattention that are age-inappropriate, persist for at least six months, began before age 7, and show a failure to adjust to the environment are required before ADHD can be diagnosed.

Some of the criteria are that the child fails to pay close attention to details or makes careless mistakes. She or he doesn't listen when spoken to and tends not to follow through on instructions. Maybe the child has difficulty organizing tasks and activities, is reluctant to engage in tasks that require sustained mental effort, or often loses things needed to complete a task. He or she is easily distracted by external stimuli.

The child with ADHD may also be impulsive, fidgety, and unable to stay seated at school. She or he runs about the class, has difficulty settling down to engage in quiet activities, blurts out answers before the questions have been completed, and interrupts others.

"To receive a diagnosis of ADHD, the child has to have the impairment before age 7," Burchard continues. "And it has to exist not just in school, but in another place, such as the home. So when we see it in a teenager, we expect him or her to have had it as a child. We don't see sudden onset in teenagers."

Sometimes the diagnosis may not have been considered because the child was a girl. ADHD was initially thought to be six times more common among boys than girls because girls traditionally don't get into as much trouble. But, says Burchard, a girl might just be sitting there quietly daydreaming, living in her fantasy world, a cue easily missed in her silence.

Conventional thought held that kids with ADHD grew out of it by the time they reached their teens. The "hyper" tends to disappear, but a number of teens still have attention deficits; they still can't concentrate or focus.

"I tell people who have a child with ADHD," he says, "that one-third get better by age 12 as they grow up and mature, but two-thirds seem to have problems that persist well into their teen years. Perhaps one-half of those improve by adulthood."

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The resolution, Burchard says, is usually a combination of non-drug treatments such as behavioral management, counseling, and nutrition, and possibly either stimulant or non-stimulant medication.

"The problem with treating teens with stimulants," he says, "is that stimulants are drugs of abuse. We have to be very careful that teens take them only as prescribed and that they don't sell or misuse them. Stimulants have street value; they can help a teen get a little high and stay up late to finish a term paper, and they are drugs of abuse for those predisposed to abusing them."

Despite that risk, Burchard is concerned about underdiagnosis and a teen's inability to concentrate, which may result in academic underachievement.

"The consequences of ADHD become more significant with age," he says. "Older kids with ADHD are often considered lazy because adults assume they should know better by now. We need to know that some of the symptoms may be beyond their control. Adults can do their part by giving their teen a more structured environment, decreasing distractions, simplifying instructions, and having their child appropriately evaluated. A first step is often consultation with a school official who can arrange a child-study team upon request.

"ADHD is often associated with learning disabilities, and they should be assessed. ADHD is a disorder that meets the requirement of a disabling condition and it is eligible for a 504 Plan, a federal mandate for special accommodation in school. That can foster success and turn what could be a disability into a more normalized school experience."

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Community Hospital of the Monterey Peninsula

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