Attention Deficit Hyperactivity Disorder (ADHD) and substance use problems have been gaining more attention in the news and in research over the last 7 months. At times this attention has to led to controversy instead of clarity.
First, here is a summary of the most recent news about ADHD, which has implications for people we treat with substance abuse problems:
The New York Times reports that pediatrician Michael Anderson treats patients in a more impoverished Georgia county with the stimulant Adderall. “He calls [ADHD] ‘made up’ and ‘an excuse’ to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.” “I don’t have a whole lot of choice,” said Dr. Anderson. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”
The New York Times reports a study by the Federal Centers for Disease Control and Prevention (CDCP) showing “nearly one in five high school age boys in the United States and 11 percent of school-age children overall have received a medical diagnosis of attention deficit hyperactivity disorder.” You should note that the only question asked of households with children was whether or not a physician diagnosed the child with ADHD. The article then reports on other recent studies. For example, 6.4 million children ages four through 17 at one time were diagnosed with ADHD, which rose 16% since 2007 and 41% over the past decade. Two-thirds of these children were treated with a stimulant. Finally, the Times article printed a number of opinions, including those experts and administrators that either overstate the problem or are not backed by research evidence:
- The stimulant medications “can drastically improve the lives of those with ADHD but can also lead to addiction, anxiety and occasionally psychosis.”
- Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”
- Medication advertising plays off the fears of parents and may lead to the rise in stimulant use. On the other hand, some respected researchers think that this data is inflated and overstates the prevalence of ADHD.
The President-elect of the American Psychiatric Association denounces the March 2013 Times article. He states that current data suggests that physicians may be either under-diagnosing or over-diagnosing ADHD. He also points to a number of inaccuracies in the article, three of which were corrected in later versions.
May 18, 2013:
The DSM-V is released, culminating a 14-year process of discussion and revision. The definition of ADHD is updated to account for its continuation into adulthood. The DSM-IV-TR criteria did not essentially change, still emphasizing that ADHD symptoms must appear in multiple settings (home, school, work) and must result in performance problems, such as “failure to pay close attention to details, difficulty organizing tasks and activities, excessive talking, fidgeting, or an inability to remain seated in appropriate situations.”
So how should clinicians who treat patients with ADHD and substance use disorders react to this news?
Here are my answers to five basic questions:
Q: Is ADHD a real disorder, or just a way to control children who do not fit the norm?
A: Researchers and clinicians do not know yet how to answer this question. Here’s what I think, based upon my being a child and adolescent psychiatrist over 30 years. Keep in mind that based upon research-supported criteria, five to six percent of all children under age 18 have ADHD. This figure is more modest than the CDCP data cited in the Times article. It is still significant for a disorder, compared to major depression (2 percent of school-aged children and about 8 percent of adolescents). There is also convincing data showing that specific brain centers in ADHD patients are significantly distinct in terms of inattention, poorer executive control, and more impulsivity and hyperactivity.
So, these children have a real disorder with a biological origin, but ADHD only becomes a problem if they have a poor fit with their environment. They typically tend not to follow rules well, fail to achieve expectations, and get in more trouble than their peers with social institutions and families. Some of the best researchers in my profession, however, proposed back in 1997 that in earlier societies, ADHD once had an adaptive purpose. Tribes depended upon some individuals who were more distracted by sound, symbols, color and motion (see below). These kids living in the village took greater risks without thinking of the consequences. Wouldn’t you want these more impulsive, brave, hypersensitive souls hanging around to inform the tribe about approaching intruders and enemies and to take more chances without hesitation to protect the village? But with our more sophisticated and complicated societies that ensure greater community safety, such children can be viewed as an annoyance rather than as a gift. The problem with ADHD may be that “we” have not respected these children for what they can contribute, nor have we found lasting ways to make them feel more welcome and competent.
Q: Is Doctor Anderson doing more harm than good, or more good than harm?
A: Overall I think he defeats his purpose, despite making one good point: that our schools, communities and families let down these ”wild and wooly children” and families by failing to create necessary and effective accommodations in terms of teaching, community activities, and parenting. But he potentially puts at risk underachieving children with less ADHD criteria than required, by over treating them with powerful medications. This goes against a basic principle in medicine – “First, do no harm”. Dr. Anderson is also wrong in ignoring impeccable diagnostic and treatment research pointing to the validity of ADHD and the superior effectiveness of medication with adjunctive treatment (see below). Then he takes a big chance by treating in a vacuum those without the full definition of a disorder, and without stating that the clinician must work closely with the child’s school, community and family. The USA is a can-do country, but this doctor seems to be throwing up his hands, while handing out prescriptions. Note: “wild and wooly” is my non-professional description of kids with ADHD, whom I enjoy engaging and treating.
Q: Are we just diagnosing and treating to satisfy the pharmaceutical companies?
A: No, we are not. Both the American Association of Pediatrics and the American Academy of Child and Adolescent Psychiatry publish “practice parameters” about ADHD that emphasize a unified biological, psychological and social approach to evaluation and treatment. Physicians, nurses, social workers, counselors, and therapists should be the leaders in the community pushing for rigorousness in making diagnoses and advocating for the humane treatment of ADHD children.
Q: Are we simply drugging the next generation of children and turning them into addicts?
A: No. ADHD is a real phenomenon. Even though stimulants are a controlled substance, a meta-analysis of open-label long-term studies of stimulant treatment in ADHD concluded that stimulant treatment does not increase the risk of substance abuse, and may even have a protective effect. ADHD research indicates, however, that we need to do better about intervening with children and teens to prevent substance abuse problems. 15-19% of patients with ADHD will start to smoke or develop other substance abuse disorders.
One of the most important studies conducted over many years at many sites helped determine what treatment helps ADHD children. This was the MTA Study (Multimodal Treatment of Attention Deficit Hyperactivity Disorder). It demonstrated that ”combination treatment and medication management alone were both significantly superior to intensive behavioral treatment alone and to routine community care in reducing ADHD symptoms.” The study also showed that these benefits last for as long as 14 months. “In other areas of functioning (e.g., anxiety symptoms, academic performance, parent-child relations, and social skills), combination treatment was consistently superior to routine community care, whereas medication alone or behavioral treatment alone were not.” The children in the combination treatment also ended up taking lower doses of medication than the children in the medication-alone group. Finally, in an 8-year follow-up of ADHD children, the MTA study showed that “treatment with stimulants did not seem to have any affect whatsoever on substance use or the development of substance use disorders (SUDs). Children with ADHD, regardless of treatment, were at a greater risk for SUDs.
On the other hand, a 10-year follow up of children in Minnesota showed that 29% continued to have ADHD as adults. Both those with or without the disorder in adulthood were still at risk for other psychiatric diagnoses and for substance abuse dependence or abuse. In other words, it’s not the medication creating future problems, but the nature of ADHD, especially if untreated in childhood and adulthood.
Take home message #1
From the MTA Study: “The good news is that stimulants are not increasing the risk for substance use disorders as some have suggested. The bad news is that our treatment does not seem to be doing much of anything to address the elevated risk for SUDs in this vulnerable population, despite the fact that stimulants provide dramatic improvement in ADHD symptoms for 80% of the children to whom they are prescribed. While disappointing, these results will hopefully inspire us as clinicians and researchers to develop new ways, psychosocial or pharmacologic, to intervene with children with ADHD to try to decrease and prevent the onset of SUDs.”
Take home message #2
From the MTA Study: “It is concerning that only a minority of children with ADHD reaches adulthood without suffering serious adverse outcomes, suggesting that the care of childhood ADHD is far from optimal. Our results also indicate that clinicians, insurers, and health care systems must be prepared to provide appropriate care for adults with ADHD.”
Q: So what can we clinicians do?
Practice guidelines for ADHD suggest that we do the following:
- Always assess for substance use disorders
- Screen older adolescents with ADHD for substance abuse disorders, as they are at greater risk than teenagers without ADHD for smoking, alcohol and other illegal substance abuse disorders
- Consider non-potentially addicting agents for ADHD (such as atomoxetine, bupropion), if there is active addiction
- Address generalized family dysfunction (parental depression, substance abuse, marital problems), so that psychosocial or medication treatment is fully effective for the child with ADHD
In conclusion, I propose that we know how to diagnose ADHD and we know what treatment works, but we need to apply it in the context of the community and the family. This takes work, backed by a can-do spirit. Diagnosis and treatment with medication alone may help, but does not respect the talents, energy and the creativity of these unique children. As a prescribing psychiatrist who is also certified in addiction medicine, I will continue to chase my tail, trying ineffectively to medicate “wild and wooly” behavior, if I don’t utilize motivational therapy, family-focused and parent-focused interventions, school collaboration and consultation, and community reinforcement of pro-social behaviors. Therefore, prescribing a stimulant to an underachieving child is the last thing I think about doing.
1. Attention Disorder or Not, Pills to Help in School, New York Times, Alan Schwartz, October 9 2012
2. A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise, New York Times, Alan Schwartz & Sarah Cohen, March 31, 2013
3. APA President-Elect Denounces Times Article on ADHD, Psychiatric News Alert, April 1, 2013
4. Attention Deficit/Hyperactivity Disorder Fact Sheet, American Psychiatric Publishing 2013
5. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder, American Academy of Child and Adolescent Psychiatry, 2007
6. ADHD Practice Guidelines of the American Academy of Pediatrics, January 2013.
7. Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation, Peter Jensen, David Marazek et al, Journal of the American Academy of Child & Adolescent Psychiatry, 36:12,
December 1997, Pages 1672–1681
8. The MTA Study (Multimodal Treatment of Attention Deficit Hyperactivity Disorder), NIMH, 1999-today
9. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Pediatrics, Barbaresi WJ, Colligan RC, et al., 2013, 2012-2354 (thanks to Stuart Goldman MD, AACAP News, May/June 2013)
10. Adolescent substance use in the multimodal treatment study of attention deficit/hyperactivity disorder (ADHA) (MTA) as a function of childhood ADHD, randomassignment to childhood treatments, and subsequent medication. Molina BS, Hinshaw SP et al. J Am Acad Child Adolesc Psychiatry 52(3):250-63(2013). (thanks to Stuart Goldman MD, AACAP News, May/June 2013)
Peter R. Cohen MD is a board certified child and adolescent psychiatrist with additional certification in addiction medicine. He has written extensively about adolescent addiction and recovery, in addition to writing the Hazelden book, “Helping Your Chemically Dependent Teenager Recover.” He has also served as the behavioral health medical director for Montgomery County, Maryland and the medical director for Maryland’s Alcohol and Drug Abuse Administration. He is semi-retired, but serves as the psychiatrist for emotionally challenged senior high students at the Foundation School in Largo, Maryland.