HOW DOES TREATMENT FOR ADHD affect the risk of substance abuse among youth with ADHD? Insights from a leading researcher on ADHD can help parents with the sometimes tough decisions required while raising youth with ADHD.
Brooke Molina, PhD, researches the course and treatment of disruptive behavior disorders and substance abuse. She is professor of psychiatry and psychology at the University of Pittsburgh, director of its Youth and Family Research Program, and a licensed clinical psychologist. Her research has been federally funded since 1995, when she began longitudinal research on ADHD as a risk factor for alcohol use and abuse in adolescence in collaboration with William E. Pelham, PhD, of Florida International University.
Since demonstrating an association, that research has taken the form of a much larger study the Pittsburgh ADHD Longitudinal Study. The PALS study has followed 364 adolescents and young adults diagnosed with ADHD in childhood and an additional 240 peers who do not have a history of ADHD. These 604 participants and their parents are interviewed annually to track their development as they mature. The study is positioned to answer controversial questions about ADHD risks for substance use and abuse because of the extensive data collection, large number of carefully diagnosed children, and historical information available from childhood.
Dr. Molina is also an investigator on the Tween to Teen Study, a longitudinal study of family and social factors affecting the onset and course of early drinking among 450 children in Allegheny County, Pennsylvania. She has in addition been the lead investigator or co-investigator on other important studies of ADHD in children and adolescents, including the Pittsburgh site of the Multimodal Treatment Study of Children with ADHD (MTA) long-term follow-up and the Preschool ADHD Treatment Study (PATS). Dr. Molina has served on CHADD’s National Professional Advisory Board.
I understand the correlation between impulsivity with ADHD and substance abuse, especially with a teenager who is not medicated. But what do studies show the correlation to be with addiction and teens who have successfully been medicated for their ADHD and other co-occurring disorders?
This is currently a hot topic in the research field. Presently there are a number of studies that have been done. Some show protection from medication (medicated teens are less likely to become addicted to other drugs), some show more risk, and some show no association at all.
We are currently studying this question very closely. The answer may end up being different depending on the age of the child. The most important thing is probably to be vigilant about risk factors that we know affect drug use. These include good parental monitoring, involvement, and helping performance in school.
I’ve always heard that ADHD drugs can help lower the risk of later drug use, and that is a major reason why I'm willing to try them with my six-year-old. But are you saying that meds could actually increase her risk of later drug use?
There were a couple of studies that got a lot of attention in the media, and most professionals probably think of those studies. They showed protection. However, those studies were small, with complications, and need to be replicated.
At least one study showed higher substance use among treated children who were followed into adulthood. We need to see what happens when a large study of children with ADHD is conducted. We are doing that now and hope to publish the results in the next couple of years. The bottom line is that the jury is still out on this question.
Why is it easy for a child with ADHD to use drugs?
It may not be any "easier" for children with ADHD to use drugs per se. The research shows a lot of overlap between children who end up becoming addicted to drugs and alcohol and kids with ADHD.
The overlap is in things like impulsivity. Sometimes parents have a hard time keeping a close eye on their kids and their friends. Sometimes parents have more arguments with kids with ADHD, which makes it hard to have a good relationship that includes openness and honesty.
While this is not always the case, we also have found that ADHD and the addictions often run together in families, unfortunately. This may not be the case in your family, but it exists in some families, and that also increases risk.
Alcohol dependency runs in my family and in my husband’s family. Is our daughter, who has ADHD, at a greater risk of dependency?
Yes, sadly, I do have to say that children from families with alcoholics do have a greater—at least threefold—risk of developing alcohol problems themselves. There is no guarantee this will happen, but extra attention should be paid to this risk.
I understand that kids with ADHD can be self-medicating with street drugs. How do we help them before this occurs? Even using ADHD meds doesn't always seem to be the "right" thing to do. How do we justify to them one drug from another (street) drug?
As clinicians, we often compare medications for ADHD to medications for other chronic conditions, such as high blood pressure and cholesterol. Street drugs, in contrast to appropriate doses of ADHD medications, have an addiction potential that is typically different. Tolerance to street drugs is often developed more rapidly and intensively, and bad things can happen—such as being kicked out of school, grades dropping, and so forth.
My son has ADHD,and I suspect I have issues with it as well. My family has a long history of alcoholism and I had a drug and alcohol addiction problem from my teens to my mid-twenties. The doctors are advocating putting my son on ADHD meds. I am terrified that,given my family history, putting my boy on meds will teach him that drugs are the answer when things get hard. It was a lesson I learned as a child and it cost me a decade of my life. I want to do what's best for my son, but I am very concerned that ADHD meds will open the door to illegal drugs later on. What do I do here? I know you can't really answer that without seeing my son, but please guide in the best direction.
First, thank you for understanding the limitations of the chat mechanism. Within those constraints, I'll try to be helpful. We have not yet looked at the impact of addiction history in the family on the results of taking meds. That said, there is always a cost-benefit analysis that we recommend be done in every situation.
There are several ways to attack the problem of ADHD in teens, including working with the school, family therapy, or guidance provided directly to parents by a therapist or other professional, and then also medication.
Sometimes the need for medication can be decreased if good structure and communication in the home can be implemented and good work with the school can be put in place. However, often medication is still an important treatment option.
The issue is whether the medication makes a big enough difference to offset all of the other risk factors for the addictions. We know that poor school performance, problems in the family, hanging out with friends who use and abuse substances, are all risk factors. If medication can help with any of these, then you might consider it, with careful communication about what it's doing. It's not using drugs to cope—it's using medication to improve attention. That's different from the sensation-seeking social type of involvement that often drives teenage alcohol and drug abuse.
Keeping communication lines open with kids is key to avoid or be aware of your child's risky behavior. What is the best language and behavior to use with them to keep that door open when we still have to do a lot of reminding and controlling?
Adolescence brings a lot of challenges, including kids with ADHD pushing for independence that they may not be ready for. There will be tussles over these issues. Keeping calm is the key, if you can, when having these discussions. Then, I also highly recommend working hard at finding enjoyable activities or moments with your son or daughter. These go a long way toward keeping balance in the relationship.
Do you know why youth with ADHD are at a higher risk for drug abuse? Is it a lack of self-control, lack of foresight,an attempt to feel normal,a result of past hurts or struggles—or any or all of these things?
We are actually funded to work on this question. We have some preliminary findings, as do others, that a number of factors are important and it won't be just one or two.
We have one paper that shows poor coping skills and strained parent-child relationships are associated with cigarette smoking among teens with ADHD histories. We also have findings that persistence of ADHD symptoms, poor grades in school, behavior problems, and some social problems play a role.
The literature on drug abuse has not been terribly supportive of the idea that low self-esteem, depression, or anxiety causes it. However, those problems can result from use of drugs and alcohol. One very strong correlation that shows up all the time, including in our research with teens with ADHD: having friends who use or tolerate substance use is strongly associated with teen drug abuse. So, there is a lot to be said for paying attention to your child’s friends and doing your best to facilitate healthy peer relationships.
How should parents respond if they suspect their teenager of using drugs or alcohol?
My first suggestion in most situations would probably be to do some information gathering. Calm discussions with teens are usually the most productive, causing them to open up more and be willing to problem-solve. Once you discover what led up to the behavior, then you can discuss reasonable consequences as well as what actions to take to prevent it next time. Family therapy is one evidence-based method of helping parents deal with this. The idea is to treat the substance use as part of a larger situation in which expectations can be clarified, shared problem-solving can occur, and relationships can be strengthened.
The chat invitation mentioned a relationship of addiction patterns related to ADHD medications. What has been found in this area? Which meds have a greater effect on addictive behaviors?
Presently the medications that are causing the most questioning are the stimulant medications—methylphenidate, mixed amphetamine salts, etc. These are the ones being investigated for their association with drug abuse.
There have been studies showing results in different directions, and the jury is still out about what association exists between medication and later risk of addiction. We are working hard on that question now.
Does the research focus only on stimulant medication treatments for ADHD and addiction, or does it include studies on nonstimulant medications as well?
In terms of propensity for addiction, the research has focused mostly on the stimulants because that's what most kids are being treated with. Certainly atomoxetine was developed to avoid the addiction potential. I'm not a hundred percent sure, but I do not think we have good data on this yet. Not many people would have been taking this medication for a long enough time period yet.
What are the differences between the stimulant meds and nonstimulants? I was told that nonstimulants are less likely to lead to trying other drugs. Has this been studied?
Atomoxetine is the first nonstimulant drug that was approved for ADHD. It takes a few weeks to start working, and the effects appear not to be as strong as the stimulant medications. That said, doctors tend to move to that when there is a strong risk of addiction (such as a young adult with an addiction history). I'm sure you hear this all the time, but this is a great thing to discuss with the pediatrician.
I have read that extended-release stimulant medications cannot be abused, but that short-acting stimulant medications can. Why is this?
There is a timed-release mechanism in some of those medications that prevents the user from getting a big dose fast.
If a child is successfully medicated for their ADHD, can they still abuse their stimulant medication and get "high" from a higher dose?
Yes, but within limits. Certain medications have time-release mechanisms that will limit this.
Aren't there any good alternative, non-medicine treatments available?
Absolutely. Behavior therapy has a strong evidence base. The problem has been finding professionals to provide it. Research is solid with children: Both behavior therapy and medication show positive results, either alone or together. It's the teens where we are still lacking data.
With regard to teens, there are a few studies; just not a lot. Research has tended to look most at behaviorally oriented family therapy, school-based interventions where goals are set, and teachers and parents are involved to help facilitate. That's pretty much what exists out there right now for strong evidence-based therapies in this age range.
What elements do you think need to be included in an effective behavioral therapy program for young children (elementary school ages)?
We are fortunate that there is a lot of information available on this topic. We tend to recommend parent training and school-based interventions.
Parent training does not assume that the parent doesn't know anything about parenting; it is about parenting a child with ADHD. School-based intervention is about working with the teacher to identify specific academic and behavioral goals and setting up a daily report card for the teacher to report progress on those goals. These can be a little tricky but they are very effective, and when combined with good parent training, have been shown to decrease the amount of medication a child takes.
My twelve-year-old will be starting middle school. Do you recommend that we discuss substance abuse with her before she gets there? What is a good way to go about it without creating more stress for her?
There will be many stresses in the transition to middle school, and it is often healthy to talk about all of them. Start with, What are you looking forward to in middle school? followed by, What are you worried about in middle school? You might be surprised. She might bring these concerns up herself, creating a natural window of opportunity for a good discussion.
Perhaps the most important thing based on parenting literature is to avoid lecturing and instead to engage in a discussion about all the challenges. Problem solve together about how to manage them. See what ideas your daughter comes up with first. Lots of schools are also addressing these things. Ask her if the school talks about these things and what she thinks.
My teenage daughter has poor social skills and does not choose friends; rather,she accepts whichever girls choose to befriend her. How significant is this risk when it comes to peer pressure to take drugs?
It can be a little worrisome. It kind of depends on what group she falls into. In situations like this I like to encourage teens getting involved in activities that will insulate them somewhat from negative influences. One great thing about secondary school, high school in particular, is that activity options expand a lot. Kids with social-skill deficits can do okay in certain kinds of activities and clubs.
The trick is to keep experimenting with opportunities until the right one clicks. Also, do things to keep the lines of communication open. Always be on the lookout for opportunities to strengthen the relationship (of course, not when you are punishing her). Doing enjoyable things together—walks, movies, shopping, catalog shopping, games, whatever—strengthens these relationships and protects them when things become difficult, which they always do off and on.
I want to educate my thirteen-year-old son about the risk of drug use that comes with his ADHD. Can you recommend a book that he could read that would be on the level and appealing to a young teenager?
My suggestion at this age is not to focus on the ADHD, because lots of kids at one point or another will dismiss their ADHD. Instead, I think that all kids, whether low or high risk, need to have ongoing discussions, often short, about drug use and abuse. There are many opportunities for this when families find moments to share, such as reading the paper at the breakfast table.
For example, if there is a story in the newspaper about a kid who got busted for drugs, you might mention it and ponder together how that kid got mixed up in it. The trick is to start working on this early and stick with it. One big lecture or class won't do it. In my opinion it needs to be an ongoing process of the parenting. That gives you a lot of power.
Behavioral therapy was never recommended to us. Our daughter is twelve; is it too late to start this type of therapy so that we may be able to alleviate problems in the future?
No, it’s not too late at all. The trick is to find the right professionals to help you. Sometimes you can start with the school for school-related issues. They often have behavior specialists on staff; sometimes they are very good, but not always.
Joining a CHADD parent support group can help provide some ideas, but you might also look for a psychologist in the area who would be willing to work with you. The trick here: It's not about putting the child in one-on-one therapy for ADHD; it's about parents or the parents and child together working with the psychologist. This is because the most powerful force in the behavior therapy is ultimately the parents. They drive the train.
My daughter-in-law seems ready to give up on her two teenage boys, both of whom have ADHD. How do we help parents who are at their wit’s end? I am afraid drugs will become part of my grandchildren’s lives because she is giving up.
It's wonderful when grandparents want to be helpful. These situations are not easy. Perhaps the most helpful thing for a grandparent to do in a situation like this is to provide support to the parent. It's hard to pinpoint specific ideas in your situation, but in situations like this, making the offer to help in whatever way you can might mean a lot.
There may be ways that you can assist that you are not aware of, particularly because mom might feel like she's banging her head against the wall. Even offering to read up on ADHD and teens might be helpful. The trick is to ask first rather than to come off as the expert (not that you would).
For those of us who, unfortunately, are already dealing with a kid with ADHD and a drug problem, please comment on the effectiveness of traditional twelve-step programs in treating these kids. I have heard they are not very effective since kids with ADHD often do not have the patience to stick with them.
Twelve-step programs have generally been shown to be effective for adults, but the research with teens is mostly correlation; there have been no studies in which teens were randomly assigned to twelve-step programs versus other programs.
There is plenty of enthusiasm for twelve-step programs for teens, but a problem with them may be lack of social role-models their age in these groups. An important part of this may be finding a group that the teen likes (if you are talking about twelve-step groups in the community). Also, parents no doubt have to be involved to facilitate the attendance. If there is a good family therapy in your area, consider that option as well.
What are the top three suggestions you would give parents to help decrease the risk of substance abuse in their children with ADHD?
These suggestions are about parenting, which has been shown time and again to be correlated and predictive of teen drug abuse:
FOR MORE INFO
Visit the website of the National Resource Center on ADHD for bibliographies of some of Dr. Molina’s published studies and more research based information regarding substance abuse and ADHD. The NRC has also posted a series of Frequently Asked Questions, where you can learn more about the correlation between substance abuse and ADHD.
This Ask the Expert column is adapted from an online chat produced by the National Resource Center on ADHD: A Program of CHADD. The NRC’s Ask the Expert chats are supported by Cooperative Agreement 5U38DD000335 from CDC. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of CDC.
This article originally appeared in the October 2012 issue ofAttention magazine. Copyright © 2012 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). All rights reserved. No portion of this article may be reproduced without written permission from CHADD.