A chat with
Brooke Molina, PhD
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
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
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
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
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
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
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
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
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
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
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
What elements do you think need to be included in an effective
behavioral therapy program for young children (elementary school
We are fortunate that there is a lot of information available on
this topic. We tend to recommend parent training and school-based
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
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
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
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
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
These suggestions are about parenting, which has been shown
time and again to be correlated and predictive of teen drug
- Establish clear expectations for
behavior and follow-through.
- Remember to work on maintaining the
supportive warm part of the relationship in between those tough times.
Do fun things together, even if you’re just listening without
lecturing and a little joking around here and there.
- Keep your son or daughter involved in
healthy activities and stay involved, even if it is tiring. It will pay
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 of
Attention 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.