The document discusses ADHD in adolescents, highlighting its symptoms, prevalence rates, and long-term consequences such as academic difficulties, emotional challenges, and increased risk of antisocial behavior and substance abuse. It emphasizes the importance of organized treatment protocols and effective transition services to improve outcomes for those affected. The current service landscape reveals significant gaps, particularly in transitioning from child to adult care, which needs addressing to meet the needs of patients and families.

1. ‘Mind the gap’
ADHD and Young People

2. ADHD AND ADOLESCENCE
• The disorder in adolescence
• Exploring consequences
• Defining needs
• Transition?
• Conclusions

3. PREVALENCE RATES OF ADHD
• Worldwide-pooled prevalence rate of 5.29% amongst children +
adolescents with ADHD1
• Symptom persistence into adolescence in as many as 85% of
patients2
• 5:1 ratio of males to females having the full syndrome in
adolescence3
• 15-65% symptomatic into adulthood4
• Male: Female in Adults ratio 1:15
1. Polanczyk G et al. 2007 Am J Psych; 164: 942–948
2. Biederman J et al, 1996 Arch Gen Psychiatry ;53: 437–46
3. Cuffe SP et al. 2001 J Am Acad Child Adolesc Psych; 40: 1037-44
4. Faraone S et al., 2006 Psych Med; 36: 159-65.
5 Levy, F. et al. Gender differences in ADHD subtype comorbidity. J Am Acad of Child and Adolesc Psych. 44, April 2005

4. SYMPTOMS INTO ADULTHOOD
DSM-V1
• Difficulty sustaining
attention in activity listen
• Can't organize
• Easily distractible
• Careless mistakes
• No follow-through
• Avoids/dislikes tasks
requiring sustained mental
effort
• Loses important items
• Forgetful in daily activities
• Does not listen
Common Adult Symptoms2
• Difficulty sustaining
attention
• Easily distracted
• Forgetful
• Poor concentration
• Poor time management
• Difficulty finishing tasks
• Loses/misplaces things
1. Adapted from DSM-V. APA 2014,
2. Weiss M et al. ADHD in Adulthood: a guide to current theory, diagnosis and treatment. 2001: 15-16
A
D
O
L
E
S
C
E
N
C
E

5. Symptoms into Adulthood
DSM-V1
Hyperactivity
• Talks excessively
• Squirms and fidgets
• Can't stay seated
• Runs/climbs excessively
• Can't play/work quietly
• On the go: ‘’Driven by a
motor’’
Impulsivity
• Blurts out answers
• Can't wait turn
• Intrudes/interrupts others
Common Adult symptoms2-4
• Restlessness
• Emotional: over reacts
• Impatience
• Easily provoked
• Irritable
• Impulsive job changes
• Drive too fast: traffic accidents
1.Adapted from DSM-V. American Psychiatric Association.2014
2. Weiss M, et al. ADHD in Adulthood: A guide to current theory, diagnosis and treatment.2001 pp15-16.
3.Barkley RA. J Clin Psych 2002;63(Suppl 12):10-15.
4.Barkley RA, et al. Pediatrics 1996:98:1089-95 .
A
D
O
L
E
S
C
E
N
C
E

6. PRESENTATION OF ADOLESCENTS WITH
ADHD
ADHD Clinical presentation: Adolescence (13-18 years)
May have a sense of inner restlessness(rather than hyperactivity)
Schoolwork disorganised and shows poor follow through; fails to
work independently
Poor peer relationships
Difficulty with authority figures
Engages in ‘risky’ behaviours (speeding and driving mishaps)
Poor self-esteem
1.Adapted from Wilens T 2004 J Clin Psych; 65/10: 1303-13

7. ADHD IN ADOLESCENCE- REALITY?
• Vulnerable age: Long term risks associated
with persisting ADHD 1
• Organised evidence based treatment protocols
-> improves outcomes 2
• Complete disengagement from services by
age 21 3
• Many remain untreated- as Adult ADHD is an
unrecognised entity & limited services 1
1.Wong et al Health technology assessment 2009, 13(50): 1-120
2. Swanson et al (MTA part II) 2008, J Atten Dis, 12: 15-43
3. McCarthy et al, 2009, B J Psych, 194: 273-77

8. WHAT ARE THE POSSIBLE
CONSEQUENCES?

9. CONSEQUENCES
• Social Difficulties
• Emotional difficulties
• Academic problems
• Antisocial behaviour
• Substance abuse
• Sexual behaviour: STIs & teenage pregnancy
• Reduced Compliance Harpin 2005 Arch Dis Child, 90, supppl 1)
Langley et al 2010 BJPsych, 196:235-40
Wong et al Health technology assessment 2009, 13(50): 1-120

10. SOCIAL DIFFICULTIES IN
ADOLESCENCE
• Impaired relationships 1
• Severe lack of friendship 1
• Less sharing, co-operation, turn-taking 2
• Reduced empathy and guilt 2
• In the presence of ODD/CD co-morbidity,
more bullying/being bullied 2
1. The mental health of children and adolescents in Great Britain. 2000 Office for National Statistics, London:
2. Wehmeier P et al 2010. J Adolesc Health; 46/3: 209-17

11. EMOTIONAL DIFFICULTIES
• Reduced self-esteem compared to control
adolescents 1
• Poor self-regulation of emotion 2
• Increased anger and aggression 2
• Anxiety/mood disorders may increase in
adolescence 3
1. Slomkowski C et al. 1995J Abnorm Clin Psychol; 23/3: 303-314
2. Barkley RA..2006 ADHD: A Handbook for diagnosis and Treatment. 3rd ed New York.
3. Biederman J et al. 1996 Arch Gen Psychiatry; 53:4 37–46

12. EDUCATIONAL IMPAIRMENT IN ADHD
• Lower grades in final year of schooling
• Ranked lower in the class
• Fewer graduate high school (68% vs 100%)
• Higher grade retention (42% vs 13%)
• Higher suspension or expulsion (73% vs 23%)
Barkley RA. 2006J Am Acad Child Adolesc Psych; 45/2: 192-202

13. ANTI-SOCIAL BEHAVIOUR
• Increased antisocial acts compared to control teenagers 1
• Theft
• Possession/Use of a weapon
• Vandalism
• Assault
• Young drivers with ADHD are 2,3
• Significantly more
• Driving Offences2
• Car crashes2
• More bodily injuries
• At fault more often for such accidents3
1.Barkley R et al. 1991 J Am acad Child Adolesc Psych; 30/5: 752-761
2.Nada-Raja S et al. 1997 J Am Acad Child Adolesc Psych; 36: 515–522
3. Barkley RA et al. 2003 Pediatrics; 92: 212-218

14. ANTI-SOCIAL BEHAVIOUR IN ADHD ADOLESCENTS
0
10
20
30
40
50
60
*
Subjects%
*P= 0.01
*
*
*
*
**
Adapted from Barkley R et al.1990 J Am Acad Child Adolesc Psych; 29/4: 546-557
Hyperactives (n=123)
Normal (n=66)

15. ADHD AND SUBSTANCE ABUSE
• Addicted to cigarette smoking twice the
rate of non-ADHD individuals 2
• Cigarette/marijuana use 2-5 times
higher with both ADHD and CD 1
• Increased risk of cigarette smoking and
substance abuse in adolescence 2
• Independent of co-morbidity, individuals
with ADHD maintain addictions longer 2
1.Barkley R et al. 1990 J Am Acad Child Adolesc Psych; 29/4: 546-556
2.Wilens T et al. 2002 Ann Review Med; 53:1 13-31

16. SEXUAL BEHAVIOUR OF ADOLESCENTS WITH ADHD
• Adolescents with ADHD :
• Earlier sexual activity
• More casual sex outside a relationship
• Less likely to use contraception
• There is an increased number of:
• Sexual partners
• Sexually transmitted diseases (4:1)
• Teenage pregnancies
• Births before the age of 20
Barkley RA. 2006 Attention-Deficit/Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd edition. New York, NY: Guilford Press

17. COMPLIANCE
• Adolescents are more likely to stop taking their medication:
• Exert more control on their life
• Try time off medication
• Want to know who they really are
• Don’t want to be different
• In 3-year, longitudinal study, 48% of children between 9 - 15 yrs
discontinued their medication1
1.Thiruchelvam D et al. 2001 J Am Acad Child Adolesc Psych; 40: 922–928,

18. TREATMENT DISCONTINUATION
McCarthy S et al. 2009 British J Psych; 194: 273–277

19. • Swedish study: 2006-09
• 25,656 ADHD young people
• Criminality rates on meds & off meds
• When on meds
• Reduction by 30% in males & 41 % in females
Lichenstein et al 2012, NEJMed, 367: 2006-14
MEDICATIONS FOR ADHD & CRIMINALITY

20. • Swedish study: 2006-09
• 17, 408 ADHD young people
• Road Traffic Accident rates on meds & off meds
• Increased risk of RTA (Hazard ratio: 1.45- 1.47)
• When on meds
• Reduction by 58% in males
• No reduction in females!
Chang et al JAMA Psychiatry, 2014; 71(3):
MEDICATIONS - ADHD & RTA

21. • Danish study: 2006-09
• 1.52 million population studied: 32,061 with ADHD
• Mortality rate (per 10,000 person years) was 5.85 in ADHD vs 2.21 in those without
• People diagnosed with ADHD in adulthood had a higher rate
• Higher in women with ADHD than men with ADHD
• Mainly due to unnatural deaths!
• Dalsgaard et al The Lancet Feb 2015
ADHD & MORTALITY

22. BURDEN ON SOCIETY
• Anti-social behaviour support
• Educational support
• Substance abuse related issues
• Pregnancy related issues
• STI related issues
• Involvement of multiple agencies
• Health
• Education
• Criminal Justice
• Social services
• Voluntary agencies
Birnbaun et al, 2000, Cur Med Res Opin, 21: 195-206
Leibson et al, 2003, Pharmaco-economics, 21: 1239-62

23. What is the current
reality?

24. WHAT IS THE CURRENT SCENARIO?
• Cost of ADHD tremendous- for the patient and society
• Children’s services stretched
• Adult services yet to awaken!
• No transition service set pathway
• No clear pathways in YP or adults
• Self referral - Via GP surgery
• No supportive adult services: post-diagnosis
• More self support groups than help from CCGs

25. What do you think
is lacking?

26. DIFFICULTIES WITH SERVICES
• Complexity of service structures
• Arbitrary service boundaries
• Variations in protocol & policy practice gap
• Lay & professional misunderstanding
Singh et al -TRACK survey / 2009 Cur Opin Psych 22: 386-90
• Adult services are ill prepared
• Lack of structured guidelines on transitioning (‘Mind the gap- Hall et al)
• Little published evidence of transition: No transition policies within most trusts
• Different commissioning arrangements
• Who pays to bridge this gap?

27. DIFFICULTIES RELATED TO THE PATIENT
• Moving homes, going to university
• Considered adults, less parental control
• Poor parental/ patient organizational skills
• Lost to follow up…….
• Offenders/ emerging personality disorders/ substance misuse/ Comorbid
mental disorder
• Present when faced with crisis: relationship breakdown/ occupational problems
Young et al 2011, BMC Psychiatry 11:174

28. What
do
patients/families
want?

29. WHAT DO PATIENTS/FAMILIES WANT- SERVICES?
• Full reassessment: Current ADHD severity & co-morbidity, ASD, Dyslexia, Dyspraxia
• Easy access to ADHD services via GPs
• Information pack (‘Colourful and attractive’)
• Other services
• Welfare rights, benefits, job interview training, careers advice
• Support groups & ADHD coaching
• Strategies for living,
• Business development support
• University grants
• Money management courses

30. WHAT DO PATIENTS/FAMILIES WANT- PATIENTS?
• Mentor & Life coach: To speak to when struggling
• Technology for contact - texts, email!
• Apps
• E-Forums
• Drop in sessions/ support sessions
• Anger management, time management
• Parents to take a lead with the consent of young person
• incapable/disinterested/unmotivated to come to appointments
• Book appointments & discuss medications etc

31. What should it look like?

32. A GOOD TRANSITION SERVICE
• Focus on CAMHS/Paediatric services
• Clear transition policy & pathway
• Planned in advance
• Before age 18
• Agreed between child & adult ADHD services
• Person-centered
• Reassessed: co-morbidities
• Participation of young person and families
• Ensuring consistency in service- Seamless transition
• Joint working/ multi agency involvement
• Information sharing between services
Young et al 2011, BMC Psychiatry 11:174
NICE Guidelines Clinical guideline 72, 2008

33. What are we doing locally?
• CAMHS- Agreed transition pathway to Adult ADHD services
• Pilot project
• North west surrey- Transition Paediatric ADHD clinics- 4/ year
• Attended by staff from Adult ADHD services.
• Agreed transition plan/documentation
• GP- Education: Manage simple ADHD
• Adult ADHD services: Manage complex ADHD
• Supporting UNIQUE

34. CONCLUSIONS
• ADHD impairments persist into adolescence AND adulthood
• Problems are multi-faceted; issues and impairments specific to adolescents
• Huge implications to person and society
• Many problems preventable by smooth transition
• Medication as effective in adolescence & adulthood as in childhood
• Very little supportive services to Young people/ young adults
• Transition services imperative to prevent societal burden

35. Acknowledgement: Dr Bhathika Pereira, AMHS, Epsom