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. Here are the most recent highlights about ADHD:
October 2012: 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.?
March 2013: The New York Times reports a study by the Federal Centers for Disease Control and Prevention 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 a physician diagnosed the child with ADHD. The article then reports on findings from other studies.?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. The Times article then printed a number of opinions, including those experts and administrators that 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.
April 2013: The President-elect of the American Psychiatric Association denounces the Times article. He states that the current data may suggest that physicians may be either under diagnosing or over diagnosing ADHD. Furthermore, there were too many 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 take into account the fact that it can continue into adulthood. The criteria have not changed, still emphasizing that the 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.?
However, we clinicians know that?ADHD and substance use?can affect sobriety and recovery. We?call it ?double trouble.? So how should we react to this news?
Question & Answer format (a doctor interviewing himself):
Q: Is ADHD a real disease or just a way to control children who do not fit the norm?
A: We do not know how to answer this question, but here is what I think about it, 5-6% of children have ADHD, a more modest figure. They are called disordered, because they have a poor fit with their environment. They tend not to follow rules well, fail to achieve expectations, and get in more trouble with social institutions and families. ?This 5-6% is still a significant percentage for a disorder, higher than for schizophrenia. It could mean that?in earlier societies,?ADHD once had an adaptive purpose when tribes needed some individuals who were more distracted by sound, symbols, color and motion. These village kids 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? Now, with more sophisticated and complicated societies insuring greater safety, such children are seen as an annoyance rather than gifted. Some of the best researchers in my field first proposed this hypothesis back in 1997 (see below). The problem may be that ?we? have not respected these children for what they can contribute or 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: It depends on the case, but overall I think he defeats his purpose.?He makes a 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.? Then he potentially?puts underachieving children who have less?ADHD?criteria than required at risk by over treating them with powerful medications. This goes against one of basic principles in medicine ? ?First, do no harm?.? Dr. Anderson is also wrong in ignoring excellent diagnostic and treatment research that points to the validity of ADHD and the superior effectiveness of medication with adjunctive treatment (see below). ?He then takes a big chance, 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 and handing out prescriptions. Note: ?wild and wooly? is my non-professional depiction of kids with ADHD, most of 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 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.? The?ADHD?research indicates 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, and 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.
One study that is important in addressing ADHA is the MTA?Study (Multimodal Treatment of Attention Deficit Hyperactivity Disorder), which was long-term, multi-site research to figure out what helps ADHD children. It showed 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.The MTA study also showed in an 8-year follow-up of ADHD children 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.
The take home message
?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.?
A 10+ year follow-up of Minnesota children with ADHD (in school from 1976-82) showed that 29% continued to have the condition as adults. Those who no longer had the condition were still three times more likely to have a psychiatric diagnosis. 26.3% had?alcohol abuse or dependence and 16.4% had other substance abuse or dependence. The 29% who had ADHD into adulthood had almost six times the odds of having another psychiatric diagnosis.
The take home message
?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.?
The 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 only continue to chase my tail, trying to medicate ?wild and wooly? behavior, without including 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.
Peter R. Cohen MD
Dr. Cohen 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 Schools in Largo, Maryland.
References:
1.?Attention Disorder or Not, Pills to Help in School, New York Times, Alan Schwartz,?October 9 2012
http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=all&_r=1&
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
http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=1
3.?APA President-Elect Denounces Times Article on ADHD, Psychiatric News Alert, April 1, 2013
http://alert.psychiatricnews.org/2013/04/apa-president-elect-denounces-times.html
4. Attention Deficit/Hyperactivity Disorder Fact Sheet, American Psychiatric Publishing 2013
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf
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
http://download.journals.elsevierhealth.com/pdfs/journals/0890-8567/PIIS0890856709621821.pdf
6. ADHD Practice Guidelines of the American Academy of Pediatrics, January 2013.
http://www.cdc.gov/ncbddd/adhd/guidelines.html
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
http://www.nimh.nih.gov/health/trials/practical/mta/the-multimodal-treatment-of-attention-deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml
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)
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