Developing bodies, mood swings, new social dynamics, and increasing schoolwork make puberty a tough time for many young people. For the approximately 5% of children worldwide with the neurodevelopmental condition, Attention Deficit Hyperactivity Disorder (ADHD), these hurdles can feel even more overwhelming.
The significant hormonal changes of puberty can drastically affect the presentation and management of ADHD symptoms. This blog post explores the connection between ADHD and puberty. It offers support for parents and providers as they help teens during these challenging years.
“But Don’t Most Kids Outgrow ADHD?”
Until recently experts believed that about half of children with ADHD would 'outgrow' the disorder. In a 16-year study published in 2021, nearly 10% of young people with ADHD showed stable remission. Most participants experienced fluctuating periods of remission and then saw their symptoms return into young adulthood and beyond. (1)
The Hormonal Changes of Puberty
Puberty is a period of rapid growth and development. It typically occurs between ages 8 and 14 for females and 9 and 16 for males. During this time, the body goes through significant changes driven by increased production of sex hormones. In both males and females, testosterone levels rise, while females also experience changes in estrogen and progesterone levels as they start ovulating and menstruating in a monthly cycle.
Effects of Sex Hormones on the Brain
During puberty, the rise in sex hormones affects more than just secondary sex characteristics such as breasts and facial hair. These hormones also change the brain, both in how it's structured and how it functions. They influence the way brain circuits work and how neurotransmitters are processed. (2)
This process begins long before puberty. Experts believe that higher testosterone levels in boys before and shortly after birth can permanently affect brain development. This is especially true for dopaminergic circuits that control thinking, movement, and the brain's "pleasure and reward" signaling functions.
This early exposure to testosterone can increase the risk of developing inattention and behavioral disorders, making boys more likely to show hyperactive and impulsive behaviors. This leads to a higher rate of ADHD diagnoses and treatments for boys. (2)
As puberty begins, changes in sex hormones activate brain circuits that were affected earlier in development. For example, the effects of estradiol during puberty may change serotonergic pathways. This can put girls at a higher risk for internalizing and mood disorders. (2)
Symptoms of ADHD During Puberty
A recent 8-year study looked at how aging and puberty affect ADHD symptoms. It found the following:
- Hyperactivity and impulsivity appeared to decrease as young people got older
- Impairment from ADHD and depressive symptoms appeared to increase as puberty progressed
- Inattention did not change
These findings may help explain why ADHD in teens has often been overlooked. As they grow, symptoms become less obvious to others. (2)
Additionally, teens may start to assert their independence by refusing ADHD medications or treatments that they previously accepted during elementary school. Some may seek peer acceptance, sometimes with others who struggle socially or academically. They may also experiment with risky behaviors, which some researchers link to pubertal testosterone levels. (3, 4)
ADHD and the Menstrual Cycle
Research shows that hormonal changes during the menstrual cycle can make ADHD symptoms worse for girls. Estrogen tends to increase levels of dopamine and norepinephrine, two important brain chemicals that affect focus and attention. Estrogen does this partly by slowing down enzymes (MAO and COMT) that break down these chemicals.
When estrogen levels are higher, like during the late follicular phase and peak luteal phase of the cycle, girls may find it easier to focus and stay organized. However, when estrogen drops or is low, such as at the end of the luteal phase or during the period, ADHD symptoms often get worse. This can make emotional regulation and attention more difficult.
These hormonal shifts can affect school performance and relationships, which are especially important during adolescence. This highlights the need for strategies and interventions that support girls with ADHD during these challenging times. (5, 6)
Teens, ADHD and Mood Disorders
Puberty is a sensitive development period in general, with teens becoming particularly vulnerable to emotional and behavioral dysregulation and psychiatric conditions. Depressive disorder, which has typical onset during adolescence, impacts about 13% of the US population. (3)
Youth with ADHD may be especially susceptible to depression as hormonal changes affect brain networks that control thinking, decision-making, and feelings of reward. These changes can make it more difficult to stay organized, do well in school, and stay motivated. (3)
Implications for Treatment and Support
Understanding the relationship between ADHD and puberty is essential for developing effective treatment strategies. Healthcare providers should consider the impact of hormonal changes on ADHD symptoms and adjust treatment plans accordingly. For example, small preliminary studies suggest that increasing stimulant medication doses before a woman's period may help improve worsening ADHD and mood symptoms during that time. (7)
Many women with ADHD also report that "cycle synching" is helpful. This means tracking their menstrual cycles and planning demanding tasks for times when their energy, focus, and mood are at their best. (8)
Primary care providers and mental health professionals should work together to provide comprehensive care for children with ADHD, ensuring that both neurodevelopmental and hormonal factors are addressed.
For parents, this may be the time to:
- Seek out a therapist or peer support group to incorporate more behavioral therapies alongside medication adjustments.
- Enlist educational support such as tutors or an organizational/executive function coach.
- Be on the lookout for new, lasting or worsening mood changes.
- Use visual cues and reminders at home and on devices. These can help with routines such as self-care, hygiene, homework, activities, and chores.
- Discover and focus on your teen’s unique talents, interests and strengths. (9)
Conclusion
The relationship between ADHD and puberty is complex and influenced by normal hormonal changes, gender differences, and comorbid conditions such as depression. In addition to the suggestions above, utilizing convenient at-home hormone and neurotransmitter testing can help provide meaningful insights into the unique challenges faced by adolescents with ADHD during puberty. Armed with this information, healthcare providers can develop more effective, personalized treatment plans to support their teen patients through this critical developmental stage.
References:
1. Sibley, Margaret H., Ph.D., Arnold, L. Eugene, M.D., Swanson, James M., Ph.D., Hechtman, Lily T., Ph.D., Kennedy, Traci M., Ph.D., Owens, Elizabeth, Ph.D., Molina, Brooke S.G., Ph.D. (2021). Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD. The American Journal of Psychiatry, Vol 179, No. 2. https://psychiatryonline.org/doi/10.1176/appi.ajp.2021.21010032.
2. Eng, Ashley G., Phan, Jenny M., Shitcliff, Elizabeth A., Eisenlohr-Moul, Tory A., Goh, Patrick K., Martel, Michelle M. (2023). Aging and Pubertal Development Differentially Predict Symptoms of ADHD, Depression, and Impairment in Children and Adolescents: An Eight-Year Longitudinal Study. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC10198896/#R6.
3. Silvery, Larry, M.D. (2020). Boys 2 Men: When ADHD and Puberty Collide: What parents of boys with ADHD should watch for as their sons pass through adolescence. ADDitude Magazine. https://www.additudemag.com/boys-2-men-when-adhd-and-puberty-collide/#:~:text=Fortunately,%20boys%20with%20attention%20deficit%20disorder%20(ADHD%20or%20ADD)%20don%E2%80%99t.
4. Laube, Corinna, Lorenz, Robert, van de Bos, Wouter. (2019). Pubertal testosterone correlates with adolescent impatience and dorsal striatal activity. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC7242510/.
5. Roberts, Bethan, Esienlohr-Moul, Tory A., Martel, Michelle M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0306453017312635?via%3Dihub.
6. Eng, Ashley G., Nirjar, Urveesha, Elkins, Anjeli R., Sizemore, Yancey J., Monticello, Krystina N., Peterson, Madeline K., Miller, Sarah A., Barone, Jordan, Eisenlohr-Moal, Tory A., Martel, Michelle M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0018506X23001642#:~:text=Highlights%20%E2%80%A2%20Females%20with%20ADHD%20may%20experience%20both%20organizational%20and.
7. de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC10751335/#:~:text=Preliminary%20findings%20postulate%20that%20changes%20in%20sex%20hormones%20during%20the.
8. Pesantez, Nathaly. (2024). Menstrual Cycle Phases and ADHD: Why Cycle Syncing is Essential. ADDitude Magazine. https://www.additudemag.com/menstrual-cycle-phases-cycle-syncing-adhd/#:~:text=Here,%20we%E2%80%99ll%20break%20down%20the%20phases%20of%20the%20menstrual%20cycle.
9. (2024). ADHD across the lifespan: What is looks like in children and teens. NIH MedlinePlus Magazine. https://magazine.medlineplus.gov/article/adhd-across-the-lifespan-what-it-looks-like-in-children-and-teens#:~:text=Puberty%20can%20exacerbate%20ADHD%20symptoms%2C%20making%20it%20harder,and%20explore%20different%20activities%20to%20discover%20their%20strengths.
