The American Academy of Pediatrics has issued guidance on the care of children with ADHD to prevent substance abuse, because children with this disorder are at greater risk from alcohol, tobacco and other illicit substances, outlines the paper published in Pediatrics.
The clinical report also gives practical advice around the irony that while medications for attention-deficit hyperactivity disorder help to reduce the risk of substance misuse, the drug treatments themselves are open to abuse.
The pediatricians say: "Prescribers are cautioned that many school-aged children [with ADHD] - up to 23% - are approached to sell, buy or trade their medication."
This is a problem termed "diversion" and forms one of three elements of ADHD treatment abuse: "stimulant medications have the potential for misuse, diversion and addiction," the pediatricians add.
"Treatment of ADHD symptoms with stimulant medication may reduce the risk of developing substance use disorders," the report's authors conclude, but they call for safe stimulant-prescribing practices.
The American Academy of Pediatrics (AAP) outlines the following measures for specialists who treat ADHD with stimulants:
- Before prescribing, confirm a diagnosis of ADHD - many who are "depressed, anxious, neglected, or having academic difficulty because of a learning disorder may present as inattentive," and other conditions "that might be confused with ADHD" should be ruled out.
- Screen older children and adolescents for use of alcohol, marijuana, and other drugs - a brief intervention is recommended, simply by asking: "In the past year, have you: 1. Had a drink with alcohol in it?; 2. Used marijuana?; 3. Used any other substance to get high?"
- Provide anticipatory guidance - give instructions on proper use of ADHD medication, along with an explanation of the risks of misuse, and what this could involve, such as being approached to sell the prescription drugs.
- Document prescription records - good record-keeping is a requirement because stimulant medication is a Drug Enforcement Administration class II controlled substance.
Children at risk
The AAP was moved to issue its report on the overlap between ADHD and substance use disorders "because few clinical guidelines support physicians in managing the intersection of these disorders." The reasons for the overlap are yet to be fully understood, the report adds:
"To date, the mechanisms underlying the association between ADHD and substance use disorders are not completely understood, although several theories have been proposed.
Impulsivity is associated with an increased risk of substance use, a prerequisite for developing a substance use disorder."
The evidence cited by the Pediatrics was first reported by Medical News Today in February 2011 - see Children with ADHD much more likely to develop substance abuse problems as they age.
The APP cites that children with ADHD (compared with controls without the disorder) are more than 2.5 times more likely to develop a substance abuse disorder overall, as well as being:
- Twice as likely to have a lifetime history of nicotine use
- Nearly 3 times more likely to report nicotine dependence in adolescence/adulthood
- Almost 2 times more likely to meet diagnostic criteria for alcohol abuse or dependence
- About 1.5 times more likely to meet criteria for marijuana use disorder
- Twice as likely to develop cocaine abuse or dependence.
The authors make it clear that managing the risk of substance abuse in children with ADHD is complex. For example, it says, "depression, anxiety, and low self-esteem have each been noted to confer increased risk of substance use in individuals with ADHD." The report therefore recommends treatment of comorbid health conditions.
Effect of ADHD stimulant medications
While the present report is the first authoritative, wide-ranging statement on ADHD treatment and substance abuse, another recent paper published in Pediatrics offered specific findings that stimulant treatment for ADHD may also reduce smoking risk.
In research published in JAMA Psychiatry in 2013, it was found that a specific stimulant methylphenidate (Ritalin) may help in treating addiction.
The AAP report says stimulants are "highly effective for children and adolescents in reducing the core symptoms of ADHD," adding that the two most commonly prescribed are methylphenidate and amfetamine.
The full list of stimulants licensed in the US for ADHD treatment are: amfetamine (Adderall; also available as a combination of dexamfetamine and amfetamine), atomoxetine (Strattera), dexamfetamine (Dextroamp, Dexedrine), dexmethylphenidate (Focalin), lisdexamfetamine (Vyvanse), methylphenidate (Concerta, Daytrana, Metadate, Methylin, Ritalin), methamphetamine (Desoxyn). More information is available on these treatments from the National Institute of Mental Health.