Kids with ADHD may be more likely to drink and smoke

A study shows that kids who have ADHD may be more likely to drink and smoke as teenagers.

Teens are more likely to start smoking or drinking with each additional symptom they have of attention-deficit hyperactivity disorder (ADHD) or conduct disorder, new research suggests.

"Our findings underscore the need to counsel families about the risk of substance use as [these] children approach adolescence," said study author Dr. William Brinkman, research director at Cincinnati Pediatric Research Group, which is part of Cincinnati Children's Hospital. "This need is heightened among children with ADHD and/or conduct disorder diagnoses or symptoms."

Brinkman's team analyzed data on more than 2,500 teens, aged 12 to 15, in a national survey conducted with their parents between 2000 and 2004.

First, the researchers identified the teens with an ADHD and/or conduct disorder diagnosis, as well as those with the symptoms of either disorder, regardless of whether there was a diagnosis. Conduct disorder is characterized by aggressive, destructive or deceitful behavior. Children with ADHD tend to be hyperactive, impulsive and/or inattentive.

Then Brinkman's team compared use of tobacco and alcohol among the teens, to look for a link between symptoms of ADHD or conduct disorder and substance use.

Brinkman said that 45 percent of the children in the study had at least one ADHD symptom, and nearly 15 percent had at least one conduct disorder symptom.

For each additional ADHD symptom related to inattention -- but not hyperactivity or impulsivity -- the risk that a teen would use tobacco or alcohol increased by 8 percent to 10 percent. Similarly, each additional conduct disorder symptom was linked to a 31 percent increase in the likelihood of using tobacco, according to the study.

A very small percentage of teens in the study -- about 1.5 percent -- were diagnosed with both ADHD and conduct disorder. These teens were more than three times more likely to use tobacco or alcohol, even after accounting for differences in age, race/ethnicity, sex, household income and having a household member who smoked.

The findings were published recently in the journal Drug and Alcohol Dependence.

Brinkman said more research may provide clues as to why the link exists between these disorders and substance use.

"Because nicotine can improve attention and arousal, some have speculated that the association between inattention symptoms and higher rates of tobacco use suggests a form of self-medication for ADHD," Brinkman said. "Certainly higher rates of risk taking and novelty seeking has been documented among children with a diagnosis of ADHD, as well as those with ADHD symptoms [but too few for a diagnosis]."

Social pressures may be involved as well, suggested Dr. Glen Elliott, chief psychiatrist and medical director of Children's Health Council in Palo Alto, Calif.

"It is important to emphasize that not all teens with ADHD follow this path, just a higher percentage than those without ADHD," Elliott said. "We believe it is a combination of impulsive decision-making and perhaps the social strain that ADHD can place on the individual, who may feel unable to connect with peers in socially acceptable ways and therefore more vulnerable to trying other methods such as doing things peers dare them to do or that they view as 'cool' or 'adult.' "

Elliott said the study provides new insights into the interplay between ADHD and conduct disorder. But it sheds little light on whether treating ADHD, either earlier in childhood or during adolescence, might change the risk of starting to smoke or drink, he said.

"We believe medication can make a difference, but the evidence is not nearly as compelling as we wish it were -- partly because teens often go through a phase of refusing to take medications just when it might do them the most good," Elliott said. "Just as with parents of any teenager, there is no guaranteed way to prevent a son or daughter from experimenting if they are determined to do so."

The best tools parents have, Elliott said, are setting consistent and clear expectations for their children, closely monitoring them, praising them for good choices and administering appropriate, meaningful consequences for poor choices -- while also showing children early on what behavior is acceptable.

"Adolescence is hard," Elliott said. "And having ADHD can make it harder. So parents need to be vigilant, caring, consistent and involved."

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Treating ADHD lowers the chance that a child will smoke

A study shows that treating ADHD lowers the chances that children with ADHD will smoke.

Children taking medications to treat attention-deficit/hyperactivity disorder (ADHD) -- such as Adderall, Ritalin and Vyvanse -- are less likely to smoke, according to a new analysis.

Kids with ADHD who were treated with these so-called stimulant medications were about half as likely to smoke as children with this disorder who weren't treated with these medications, researchers found.

"We found an association between getting treated with stimulant medications and having a lower risk of smoking in adolescence and adulthood," said study researcher Erin Schoenfelder, clinical psychologist at Duke University School of Medicine in Durham, N.C.

The study, which was funded by the U.S. National Institute on Drug Abuse, is published online May 12 and in the June print issue of the journalPediatrics.

About 11 percent of American children aged 4 to 17 have a diagnosis of ADHD, according to the U.S. Centers for Disease Control and Prevention (CDC). Children with ADHD can be impulsive, have trouble concentrating and may have other behavior problems. About 70 percent to 80 percent of children respond to stimulant medicine, according to the CDC. Behavior therapy can also help.

Experts have long known that children with ADHD have a higher risk of starting to smoke cigarettes. Teens with ADHD are two to three times more likely to smoke cigarettes than their friends who don't have the diagnosis, according to Schoenfelder, citing previous research.

But, research on the effects of ADHD stimulant medicine on the risk of smoking has been conflicting.

To try to better answer the question of whether or not these medications could help prevent kids from smoking, the Duke researchers re-analyzed the results of 14 studies of cigarette smoking and ADHD treatments. The studies included more than 2,300 children with ADHD. About 1,400 of the kids were being treated with stimulant medications, according to the new analysis.

The studies were published between 1980 and 2013. The average follow-up time was about seven years. The researchers compared the teens treated with stimulants to those who weren't to see which group was more likely to smoke.

Overall, those on medications were about half as likely to smoke as those not on the medications, Schoenfelder said.

"Those who took their medication consistently and for a longer period of time had an even lower risk of smoking," she added.

The data she analyzed overwhelmingly showed that medications appear to decrease the risk of smoking, according to Schoenfelder.

Like all medications, ADHD medicines have side effects. This analysis showed a "slight effect" on growth, she said. However, that finding must be weighed against the many positive long-term benefits, she explained.

Schoenfelder pointed out that the researchers "can't say based on this study that the treatment caused the lower rate of smoking, but there is an association we found."

However, association does not prove a cause-and-effect relationship.

One potential reason medication might have an effect is that both nicotine and the stimulant medications used to treat ADHD operate on the same pathways in the brain. They both improve the same processes that are disrupted in ADHD, according to Schoenfelder.

"Kids who have ADHD know that something is not quite right," said Dr. Trevor Resnick, chief of the department of neurology at Miami Children's Hospital, who commented on the study.

"They try to self-medicate," he explained, and "cigarettes would be an example of self-medication." As a result, children with ADHD have a much higher risk in general of turning to cigarettes, pot or illicit drugs, he said.

"What this study shows, similar to previous research, is that successful treatment of ADHD with stimulant medication decreases the risk of self-medication in these children," Resnick noted.

While stimulant medications do have several possible side effects, Resnick said, "most kids are able to tolerate" the medication.

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Smoking rates lower with ADHD treatment

A study found that treating ADHD is associated with a lower rate of smoking.

Treating attention deficit hyperactivity disorder (ADHD) with stimulant medication may reduce smoking risk, especially when medication is taken consistently, according to an analysis led by researchers at Duke Medicine.

The findings appear online May 12, 2014, in the journal Pediatrics.

"Given that individuals with ADHD are more likely to smoke, our study supports the use of stimulant treatment to reduce the likelihood of smoking in youth with ADHD," said senior author Scott Kollins, Ph.D., professor of psychiatry and behavioral sciences and director of the Duke ADHD Program. "The risk is further lowered when adherence to medication treatment is consistent, presumably since this increases the chances that symptoms are managed effectively."

ADHD is a common childhood disorder that can continue through adolescence and adulthood, and is characterized by hyperactivity, difficulty paying attention and impulsivity. It is most commonly treated with stimulant medication (such as Vyvanse or Concerta), as well as with behavior therapy or a combination of the two.

Individuals with ADHD smoke at rates significantly higher than the general population, and they often start earlier. Studies have shown that youth with ADHD are two to three times more likely to smoke cigarettes than their peers, and 40 percent of adults with ADHD smoke regularly, more than twice the rate among adults without ADHD.

Research on how stimulant medications influence smoking behaviors in individuals with ADHD has led to mixed results. Some studies suggest an increase in smoking among those treated with stimulant medications, while others showed no effect or a decrease in smoking.

"Nicotine operates on the same pathways in the brain as stimulant medications, and the relationship between stimulants and smoking has been controversial," said lead author Erin Schoenfelder, Ph.D., clinical associate and a psychologist in the Duke ADHD Program.

"It has been suggested that some people with ADHD 'self-medicate' their attention deficits using nicotine," Schoenfelder said. "Our findings show that treating ADHD effectively with medication may prevent young people from picking up the habit."

The researchers examined 14 longitudinal studies of cigarette smoking and ADHD treatment, including a total of 2,360 individuals with ADHD, making this the largest meta-analysis on the issue to date.

Some of the studies used nicotine dependence to measure smoking behaviors, although nicotine dependence may not be found in adolescents who recently started smoking. In order to capture an accurate picture of smoking behaviors, the researchers expanded their criteria beyond nicotine dependence to include smoking frequency and whether participants currently smoked.

The analysis revealed a significant association between stimulant treatment and lower smoking rates. The effect was larger in those with more severe ADHD and when participants took stimulant medications continuously.

The researchers noted that based on the design of the study, they were able to identify an association but not a causal relationship between reduced smoking risk and stimulant treatment. Additional studies are needed to determine the recommended timing and duration of stimulant treatment to help lower smoking risk.

"This study may debunk the perception that stimulants will increase one's risk for smoking," Kollins said. "It gives us more confidence when we talk with parents to reassure them that consistent ADHD treatment won't increase their children's risk of smoking, and in fact, may actually do the opposite."

"My hope is that this research can help inform our efforts to prevent negative outcomes for kids with ADHD, including cigarette smoking," Schoenfelder said. "This population hasn't been targeted for smoking prevention efforts, despite the well-known connection between ADHD and smoking."

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