Based on self-reported data, adolescents assumed increased responsibility for managing medication as they matured and developed insight into the functional impact of ADHD and medication on their lives. Insights were often formed by contrasting time spent on and off medication. Select domains of functioning were relevant for some adolescents but not others. Adolescents described different roles that they played in managing medication as well as strategies they employed to exert autonomy over medication use. Peer feedback influenced appraisals of medication for some teens. Some adolescents had begun to use medication selectively. Many expressed uncertainty about future use of medication.
ADHD puts adolescents at risk for impaired functioning in multiple domains (e.g. academics,21
). Our analysis of adolescent comments demonstrates that the key domains of functioning impacted by ADHD were: school, social interactions and relationships, creativity, and driving skills. Select domains were relevant for some teens but not others. This highlights the need to tailor target outcomes and management strategies for the individual teen as recommended by the AAP1
and other authors.24,25
Interventions are needed to help adolescents, parents, and clinicians to negotiate shared goals and treatment plans as well as to monitor progress toward those goals. Goals that are S.M.A.R.T. (i.e. specific, measureable, attainable, relevant, and time-bound) may be more likely to lead to improvement.26
While our study was not designed to determine the accuracy of teen appraisal of impairment, there is strong evidence that children with ADHD have unrealistically high self-views of skills and competence compared to children without ADHD.27
Differences of opinion on functional impairments may be a source of conflict between teens and their parents. Interventions that result in accurate self-appraisals may help teenagers to more effectively manage their ADHD.
Many adolescents described their involvement in discussions and decision-making with their parents and doctors as inadequate. Why might this be? Despite their lobbying efforts, medication is continued. Parents likely know their teen’s opinion but limit their share in decision-making due to worry that he/she lives in the moment and doesn’t prioritize outcomes that are important in the long run. Parents likely fear that their teen will ‘ruin their life’ by missing opportunities that he/she will come to value later (when it’s too late). Based on teen perceptions, some parents and doctors are more successful than others in involving them in a meaningful way in management decisions. Medication use becomes a battle of attrition for parents and teens unable find common ground.
Normal adolescent development is characterized by the pursuit of independence. For teens with a chronic health condition, efforts to exert control over daily life often include aspects of medication management.2
Selective use of ADHD medication described by adolescents in this study mirrors that reported by college students.11
Whether selective use of ADHD medication constitutes effective self-management or misuse of a prescr prescription medication is debatable, but awareness of selective use is important for physicians and parents so that medication can be a continued topic of discussion given the chronic nature of ADHD. Our previous work with parents of children/adolescents with ADHD revealed that trials on and off medication to determine the continued need for medication were common and rarely coordinated by a physician.28
In the current study, adolescents reported similar trials stopping medication. This phenomenon may represent a continuation of the medication usage pattern demonstrated by their parents, curiosity on the part of adolescent patients, or an act of rebellion from teens who feel their voice is not respected by their parents and/or doctor. Regardless, adolescents and their parents may benefit from trials that are more highly structured. The American Academy of Child and Adolescent Psychiatry,29
authors of the Multimodal Treatment Study of ADHD in Children,30
have recommended that physicians coordinate trials stopping medication as follows: 1) consider annually when stable and doing well, 2) best when there are few transitions or demands (e.g. mid-school year), 3) avoid at beginning of any school year, especially at the start of junior/senior high school, 4) try discontinuing medications for 2 to 4 weeks with close monitoring of target outcomes. Structured trials stopping medication have the potential to be a powerful tool to foster productive partnerships between adolescents, parents, and physicians. Such trials can empower teens by legitimizing their preferred option of discontinuing medication, giving them more of a voice in discussions with their parents and doctors. Well-structured trials can also reassure parents by operationalizing a measurement system to detect early struggles before they become crises (e.g. school failure, delinquency, etc.). Use of S.M.A.R.T. goals, discussed previously, may accelerate what adolescents, parents, and doctors learn from trials discontinuing medication. Future studies should test whether physician-directed trials of medication discontinuation can identify children/adolescents with ADHD who continue to suffer from functional impairments in a timely manner and avert undesirable outcomes.
Many adolescents in our study and previous studies dislike taking medication for ADHD due to side effects, lack of perceived need for or improvement from medication, and/or social stigma.3–11
It is striking that despite the advent of extended-release medications that eliminate the need for a daily visit to the school nurse’s office, these teenagers reported stigma in the school setting as a result of comments or actions of other students and/or their teachers. In addition, social networks and peer acceptance were influential. Positive and negative feedback from peers, some of which was directly solicited, weighed heavily with some adolescents as they appraised the utility of medication. This finding is in contrast to a study by Knipp et al. that reported teens with ADHD did not perceive that their friends noticed a difference when they were on or off medication.10
This may be due to the fact that the previous study included only adolescents currently taking medication whereas one-third of adolescents in our study were no longer using medication.
Very few of the adolescents ≥ 16 years old in our study were aware of driving risks associated with ADHD or that medication can improve driving performance in teens with ADHD.33
Moreover, many adolescents remained skeptical about their personal risk after being presented with this information. The AAP policy statement entitled “The Teen Driver” has highlighted the need for prevention through office-based counseling and other efforts.34
Future studies should examine how adolescents with ADHD process risk information when making decisions about medication use.
This study has several limitations. Information was elicited in focus groups comprised of adolescents who were mainly White or African-American, which was reflective of the region’s racial composition and therefore may not reflect the views of other racial/ethnic groups of teenagers in other regions. Also, the group setting may have inhibited some adolescents from electing to participate in the study. Adolescents who did participate may have been influenced by comments made by others in their group and biased our findings toward consensus view or opposite views.
The strength of qualitative research is that it allows us to gain a deeper understanding of a phenomenon in the words of those who are affected by an experience.15
In this case, what was not well understood was how adolescents with ADHD view the disorder and contribute to medication treatment decisions. Using focus groups and a semi-structured question guide, we probed, in-depth, the perspectives of a group of adolescents living with ADHD. Interpretations of the teens’ statements were made by consensus of a multi-disciplinary team of researchers with varying perspectives. Together, the authors describe how teens contribute to ADHD medication treatment decisions. While efforts were taken to generate a sample with variation in age, gender, race, and urban-suburban residence, this study was not meant to produce any conclusion about the phenomenon under study that could be generalized to all adolescents with ADHD. Opportunities exist for quantitative investigations to test the implied hypotheses about relationships between variables identified that influenced adolescents in our study.15