Does Your Teen Have ADHD? Or Is It Something Else?
Often, I get calls from parents asking me to evaluate their teen for ADHD. My first question is, “Did your child have attention problems and trouble completing work in elementary school? Typically, the answer is, “No. He had no problem with school work in elementary school. He’s begun to do poorly in high school and complains that he can’t pay attention. He wants an evaluation so he can take medication for ADHD.”
At this point in the phone call, I often say, “Well, it’s not ADHD. I understand he’s having trouble focusing on schoolwork, and I’d be glad to evaluate him, but the cause is likely to be something else.”
“How can you make that conclusion when you haven’t seen him?” the parent asks.
“Because one of the criteria for the diagnosis is that the problems with attention, impulse control, hyperactivity, disorganization, etc. are evident to the parent and teacher at a young age, typically before age 7. In some cases, such as ADHD, Inattentive subtype, the problems are milder and may not be evident till age 11, but ADHD does not begin in middle school or high school.” (or adulthood for that matter) (1)
As a clinician who has seen many teens with this presentation, I have some hypotheses about what the problem may be.
Excessive cell phone use. Teens will not volunteer this information—that they are constantly looking at their phones—but their parents will. I recall an adolescent girl who had been a straight A student in middle school complain, “It takes me an hour and a half to do an assignment that should take a half hour. I keep losing my train of thought. I have to keep re-reading the material.” The father chimed in, “I’ve been watching you. You respond to a notification on your phone every 5 or 10 minutes. Sometimes you stop and watch a video that someone sent you.” She had to admit that this was true.
Some teens insist they can “multitask,” but psychological research says otherwise. The better name for responding frequently to notifications is “divided attention.” (2)(3)(4) When we do this, we stop paying attention to the task at hand and shift our focus to another, unrelated, and unimportant task. When that is over, we have to shift our focus back to the task we were working on. Our attention is slowly revved up as the brain resets itself. This greatly slows down task completion and makes the task mentally exhausting.
Put the cell phone on silent and put it in the drawer? Some high school students, and even college students, have told me that they feel nervous if they are away from their phones for more than a few minutes. They are worried they will miss something important. They feel compelled to keep checking it, yet once they do, they find themselves “doom scrolling,” consuming a string of bad news items on social media.
Poor study skills. Many high school students are shocked and upset to see their grades down in ninth grade. They had always made A’s, and a few B’s in middle school without having to work hard. “I didn’t have to take notes in class,” they would tell me, “Or really study for a test. It was enough just to pay attention in class and look over the handout the morning of the test.” Now, in high school, they are expected to read all the assigned material, to take practice quizzes on Quizlet, even take a couple of hours to memorize the notes they took in class. A highly motivated student will see right away “I have to up my game.” Others will persist into 10th and 11th grades with the study habits that worked for them in middle school.
Poor sleep hygiene. It is widely known that adolescents like to stay up late at night and sleep late the next morning. But they aren’t just being defiant when they say, “I don’t want to go to bed at 9:30. I’m not sleepy.” The adolescent brain actually goes through a period of growth in which sleep onset is delayed. Wakefulness is delayed too. (5)(6)(7) Ideally, based on research in neuroscience, we know that adolescents should go to bed about 11, get up around 8 and start school about 9:30 a.m. However, the reality is that many teens start school as early as 7:15 a.m. Thus, they may struggle to stay awake in their first two classes of the day, feel tired through their next four classes, and complain that they can’t pay attention. They doze off on the bus, make it home, then take a nap. The two hour nap disrupts their circadian rhythm (our body’s natural day-night cycle of wakefulness), thus they may not be able to feel sleepy till 12 a.m., knowing they must get up at 5:30 a.m. and repeat the cycle.
Add to this the problem of cell phones and screens. Studies have shown that the light from screens mimics daylight and again disrupts our circadian rhythm. (8) Many teens refuse to be separated from their phones at bedtime, insisting the phone is in a charger on their nightstand. They are awakened multiple times through the night by notifications or texts from friends. They fail to get an adequate amount of “deep sleep” causing problems in class with paying attention and with short term memory.
Ongoing anxiety and emotional problems. Many teens have said to me, “I must have ADHD. My mind wanders in class. I zone out. I’m thinking about something else. I didn’t hear it when the teacher said what day the test was going to be and what chapters we had to review.” When asked, “What are you thinking about when you zone out,” they might answer with “stuff,” at first, but when you probe a bit, you find out what they are worried about. It might be family issues (i.e., “Mom and dad are arguing. I think they’re going to get a divorce), or it might be peer issues (“I wonder if my friends really like me or if they’re fake friends.”). Teen romance problems are at the top of the list (“I saw my girlfriend talking to this other guy and really smiling at him a lot”), but so are worries about the future (“What if I’m not smart enough to get into a good college.”)
Very successful social life. It is an essential part of adolescent development to begin to separate from parental authority and to focus on friendships as a higher priority. This prepares them to leave home in adulthood as whole individuals who can make lasting bonds with others. I’ve seen many teens blossom in high school from the awkward, shy twelve year old to the fifteen year old who is outgoing, funny, and confident. When I ask why they don’t do any classwork, don’t write down assignments, why they are constantly talking in class, they answer, “I sit in the back of the class with my friends and we crack jokes and swap stories. People like me now. I’ve never had this kind of attention.” After school they are focused on the friends they have made online during videogaming or social media.
Sources
DSM-5-TR. 2022. American Psychiatric Assn. (ADHD criteria, section B).
Talalay, I. 2004 (Jan. 26). The development of sustained, selective divided attention in school age children. Psychology in the Schools.
Levine, L., Mobile media use, multitasking, and distractibility. 2012. International Journal of Cyber Behavior, Psychology and Learning, 2 (3), 15-29.
Mrazek, A., et al. 2021. Teenagers’ smartphone use during homework: An analysis of beliefs and behaviors around digital multitasking. Education Sciences, 11 (11), 213.
Laberge, L., et al. 2001. Development of sleep patterns in early adolescence. Journal of Sleep Research, 10 (1), 59-678.
Colrain, I. & Baker, F. 2011. Changes in sleep as a function of adolescent development. Neuropsychology Review, 21, 5-11.
Carskadon, M. et al. 2006 (Jan. 12). Regulation of adolescent sleep: Implications for behavior. Annals of the N.Y. Acad. of Sciences.
Haghani, M.., et al. 2024 (June 1). Blue light and digital screens revisited: A new look at blue light from the vision quality, circadian rhythm and cognitive functions perspective. J. Biomed. Phys. Eng., 14 (3) 213-228.