Attention deficit is a common diagnosis with which many pediatricians are faced. In the more common scenario, the child presents anywhere from age 5 to 10 years with parental and teacher complaint of hyperactivity or academic underachievement. But, what do you do with the child who presents at age 11 years or high school age with no significant history of school failure or behavior issues? Is this a child whose symptoms were overlooked? New-onset inattention? Are they seeking medication to augment their intellectual ability to become more competitive? Or are they just drug seeking? Well, the truth is that any one of the above could be true, and only through careful analysis can you obtain the proper diagnosis.
For the adolescent that meets the DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD), it is possible that they have learned to compensate for their inattention and have been successful in maintaining a good grade-point average. Through detailed questioning about study habits and home environment, they likely required a lot of support from their parents to maintain organization and from tutors. Many children without comorbid conditions are very intelligent and are able to keep up with the course load until they reach high school. The demands for independence and the amount of class work required start to become overwhelming and grades start to decline. These children tend to do very well on stimulant medication.
Dr. Francine Pearce
Now for the child who presents with absolutely no past history of inattention, disorganization, hyperactivity, or impulsive behavior, it is important to do a detailed physical exam looking for symptoms that are consistent with Wilson’s disease, hyperthyroidism, or drug use. A careful social history will identify symptoms of depression, anxiety, and disruption within the home such as divorce, domestic violence, etc. Questions regarding school and social pressure such as bullying also are important to ask to identify a cause for the acute onset of inattention.
Red flags should be raised with a teen who has socially withdrawn, has defiant or high risk taking behaviors, and a history of illicit drug use. According to a study published in the British Journal of Psychiatry, stimulant used as prescribed actually lowers the risk of substance abuse (Br. J. Psychiatry 2013 [doi:10.1192/bjp.bp.112.124784]). But according to the National Institute of Drug Abuse, teens are using the stimulants to get a high by snorting or injecting the stimulant, making Adderall a hot commodity on college campuses. Stimulants are also used to "cram" for tests so teens are taking them to stay awake to study. Stimulants coupled with excessive caffeine lead to increased heart rates and blood pressure, as well as panic attacks. The DAWN Report (Drug Abuse Warning Network) published a warning on Jan. 24, 2013, stating that the number of emergency room visits increased threefold in young adults over the age of 18 years. Only a small increase was noted in teens aged 12-17 years, but they all were related to using stimulants improperly.
Choosing the right stimulant for the adolescent must take into consideration their social environment and their risk of drug abuse. Given that Adderall is an amphetamine, it should be used with caution and careful supervision, but since all stimulants can be abused, the same caution applies to them as well.
ADHD prevalence in adolescents aged 11-17 years is 10%-15% (CDC Weekly; Nov.12, 2010;59:1439-43). So evaluation and proper treatment can mean school success and continuing on to college. The diagnosis should not be excluded because it was not identified earlier, but other diagnoses must be considered.
Dr Pearce is a pediatrician in Frankfort, Ill.