The results of two long-term studies conducted by Massachusetts General Hospital researchers have shown that attention-deficit hyperactivity disorder (ADHD) significantly increases the risk of cigarette smoking and substance abuse in both boys and girls.
ADHD and Substance Abuse in Children, Adolescents
Q&A with Timothy Wilens, MD
The studies, led by Mass General child psychiatrist Timothy Wilens, MD, followed almost 500 participants over 10 years. In the study, boys and girls with ADHD had a one and a half times greater risk of developing substance abuse than participants without ADHD.
But the news isn’t all bad, Dr. Wilens says. He reminds parents: “You’ve got an active role in this, you can help your kid, you can talk to your kid, you’re part of the solution.” Dr. Wilens answers our questions here.
Q: What can parents do to lessen their child’s risk of substance abuse later?
A: Number one, we feel that discussion of cigarette smoking and also substance use is important. Given what we know about when things start, it’s not too early to start having this conversation when the child is in middle school, in the same way you talk to them about seat belts and other safety issues. The earliest risk is as early as fifth and sixth grade. Children with ADHD and delinquency, or a consistent pattern of less than desirable behavior, like bullying, stealing, shoplifting and fighting, typically start using cigarettes or marijuana around age 12, so parents really have to start monitoring these kids a year before then.
I tell children with ADHD in the same way that diabetics have to watch their sugar, you’re going to have to watch your use of cigarettes and substances because you have ADHD. They’re going to start thinking about that. It plants the seed. A lot of the kids are uncomfortable with the conversation, but at least having it opens the door to further discussion and monitoring by their parents.
Q: How can parents assess their child’s current risk of substance abuse?
A: First ask yourself, are the kids smoking cigarettes? Of kids with ADHD who smoke, half go onto become substance abusers. Second, are your kids hanging out with kids who smoke cigarettes or use substances? The values of the group create an inviting place to smoke cigarettes, the availability makes it easier to find the drugs and peer pressure can push children who usually might avoid using to use.
Delinquent children with ADHD have a higher risk of cigarette use or substance abuse. Adolescents with ADHD but without delinquent behavior are at a higher risk of substance abuse at 19 to 20 years, often when they leave home and lose the monitoring and structure provided by the parents. If your child grows out of the ADHD, they’re no longer at an increased risk of substance abuse. Twenty-five to 50 percent grow out of ADHD by the time they are adults.
Q: You talk about monitoring your kids. Is it okay for parents to go through their child’s room?
A: Absolutely. If you’re in a kid’s room, you’re in their world. If your kid is driving, you should definitely look through their car. What do you do if you find cigarettes? Throw them out, have a conversation about it. Keep your own prescription drugs accounted for and I strongly advise appropriately disposing of all old medication.
Q: Children with ADHD are often treated with stimulants. Does stimulant treatment increase the risk of substance abuse in children or adolescents with ADHD?
A: Unequivocally, no it doesn’t. Treating ADHD with stimulants reduces the risk for cigarette smoking and reduces the risk for substance abuse at least through adolescence. On the other hand, our team and others have studied this effect into adulthood and stimulant treatment doesn’t increase or decrease substance abuse in adulthood. I think that some of the loss of a protective effect may be related to the stopping of the medication as children age into young adulthood. If you stop your medication, your ADHD comes back and that appears to put you at risk for substance abuse. But at least through adolescence we can show that treatment is effective not only for ADHD but for reducing cigarette smoking and substance abuse.
There are a number of different medications that are available for ADHD: short-acting, intermediate-acting and long-acting stimulants. Stimulants have abuse liability, which means they increase the likelihood that someone will misuse or abuse the stimulants. It appears that the extended release (long-acting) are less likeable and less abused than the short-acting. If you have any concerns about misuse or diversion—giving away or selling the medication—we strongly recommend that the extended release medication be used and monitored carefully.
Q: When and how should parents intervene if they think their child is abusing substances?
A: They’re going to need some intervention for the cigarette smoking or the substance abuse—it may be a discussion, monitoring to ensure that they’re not using substances or a professional intervention for their smoking or substance use.
If you get a sense that there’s self medication, try to figure out what they’re self medicating. For two thirds of kids who use substances, if you ask why do you continue to use, they’ll answer to calm their mood, to treat underlying anxiety or to help them sleep.
The Addiction Recovery Management Services (ARMS) program at Mass General is an option for families with youth age 15 to 25 who have developed substance-related problems. The program is tuned into the needs of the families and their children; as well as the very frequent co-occurring problems that exist in these youth (e.g. ADHD and others).
Q: What is the next step in your research?
A: We are still trying to understand why some children with ADHD and/or delinquency develop substance issues while others are resilient and do not develop any cigarette or substance use. We’re also very interested in more mechanistically, why does ADHD drive substance abuse—is there something about their risk systems in the brain, is there something different? The real question is neurobiologically what is going on.