AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE & DENTISTRY
ADHD and Substance Use Disorder
BY H. BARRY WALDMAN, DDS, MPH, PHD, RICK RADER, MD, DHL (HON), STEVEN P. PERLMAN, DDS, MSCD, DHL (HON) AND ALLEN WONG, DDS, EDD
Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts throughout adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.1
Note: Children with Attention-Deficit-Disorder (ADD) – also known as ADHD with inattention – are not hyperactive. They do not have high energy levels like other children with ADHD and may seem shy or as if they are often daydreaming. Children with ADD are harder to diagnose because their symptoms may be mistaken for daydreaming, shyness, or timidness.2
According to the 2016 National Survey of Children's Health report, the estimated number of children who were diagnosed with ADHD was 7.4 million (9.4%).
• 388,000 children aged 2–5 years
• 4 million children aged 6–11 years
• 3 million children aged 12–17 years
Boys are more likely to be diagnosed with ADHD than girls (12.9% compared to 5.6%).3 In 2016-2018, for the first time, a U.S. survey found that black children appear to be more likely than white youngsters to have been diagnosed with ADHD and learning disabilities; 17% of black, 15% of white and 12% of Hispanic children. 4 In 2016:
• Almost two thirds (62.0%) of children with current ADHD, were taking medication and slightly less than half (46.7%) had received behavioral treatment for ADHD in the past year.
• 6 in 10 children with ADHD had at least one other mental, emotional, or behavioral disorder.
• Other conditions affecting children with ADHD include: depression, autism spectrum disorder, and Tourette syndrome.5
Among children 2-17 years in 2011, in states with the highest prevalence of ADHD, the proportion ranged from 12.2% in Rhode Island (including [Alphabetically] Alabama, Arkansas, Indiana, Louisiana, Mississippi, North Carolina, Ohio, South Carolina, Tennessee) to 16.6% in Kentucky. 6
AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE AND DENTISTRY
The American Academy of Developmental Medicine and Dentistry (AADMD) was organized in 2002 to provide a forum for healthcare professionals who provide clinical care to people with neurodevelopmental disorders and intellectual disabilities (ND/ID). The mission of the organization is to improve the quality and assure the parity of healthcare for individuals with neurodevelopmental disorders and intellectual disabilities throughout the lifespan.
WHY ARE PEOPLE WITH ADHD MORE LIKELY TO USE DRUGS AND ALCOHOL?
"People with ADHD tend to be more impulsive and likely to have behavior problems, both of which can contribute to drug and alcohol abuse, researchers say. Also, both ADHD and alcoholism tend to run in families. A child with ADHD who has a parent with alcoholism is more likely to also develop an alcohol abuse problem. Researchers have pointed to common genes shared between ADHD and alcoholism." 7
It is more common for children with ADHD to start using alcohol during their teenage years. Studies have found that at a mean age of 14.9 years, 40% of children with ADHD began using alcohol, compared to 22% of children without an ADHD diagnosis. ADHD is five to 10 times more common among adult alcoholics than it is in people without the condition. Among adults being treated for alcohol and substance use disorder, the rate of ADHD is about 25%. 7
"Researchers have also found links between ADHD and the use of marijuana and other recreational drugs, particularly in people who also have other psychological disorders (such as obsessive-compulsive disorder). What's more, people with ADHD typically start having problems with drugs and alcohol at an earlier age than people without the condition."7
However, contrary to characteristics of the use of recreational drugs, many with ADHD who also have substance use disorder, do not illicitly use substances in an attempt to "get high" or achieve a euphoric state, rather, they are using drugs or alcohol as a means to self-medicate symptoms associated with their disorder. "Only 30 percent of young adults surveyed used substances for the pleasurable effect, in comparison to the 70 percent who used them to improve their mood, to sleep better, or for other reasons. They need something to calm their brain enough to be productive." 8
"Stimulant medications work differently on the brain of an individual with ADHD versus that of a non-ADHD individual. The latter individual experiences a pleasurable effect, whereas the former–those in need–experience an adjustment to their thought process by becoming more balanced and focused, while not experiencing the euphoria illicit drug users seek. Administration of stimulant medications may actually help to prevent the occurrence of a SUD, (substance use disorder) especially in youth."8
SCHOOL DAZE: To find the best treatment options, it is recommended that parents work closely with others involved in their child's life. Schools must be part of the treatment as well; recommendations also include adding behavioral classroom intervention and school supports.
TREATMENT FOR ADHD
When a child is diagnosed with ADHD, parents often have concerns about which treatment is right for their child. ADHD can be effectively managed with the right treatment. There are many available options and what works best can depend on the individual child and their family. To find the best options, it is recommended that parents work closely with others involved in their child's life – healthcare providers, therapists, teachers, coaches, and other family members.
Children with ADHD younger than 6 years of age: The American Academy of Pediatrics (AAP) recommends parent training in behavior management as the first line of treatment, before medication is tried.
Children 6 years of age and older: The recommendations include medication and behavior therapy together – parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents. Schools must be part of the treatment as well; recommendations also include adding behavioral classroom intervention and school supports. 9
Young (and older) adults: Approximately 10 million adults have ADHD. Adults with ADHD often cope with difficulties at work and in their personal and family lives related to ADHD symptoms. Many have inconsistent performances at work or in their careers and may have chronic feelings of frustration, guilt or blame. 10
Parents sometimes worry whether the stimulant drugs their children are taking to treat ADHD (such as Ritalin and Adderall) are themselves addictive. Stimulant medications work by raising levels of a chemical messenger called dopamine in the brain, which helps improve focus and attention – skills that people with ADHD often find difficult to master.
"Dopamine also affects emotion and the feeling of pleasure, creating a 'high' that makes people want more. Because cocaine and other street drugs also raise dopamine levels, there has been concern that ADHD stimulants might be similarly addictive. Ritalin's ability to increase energy and focus has even led some people to refer to it as the 'poor man's cocaine.'" 11 "In large doses – greater than what is typically prescribed for ADHD – Ritalin does have effects similar to those of cocaine. However, researchers have found marked differences between the two drugs" 10 (emphasis added).
Most important, to avoid the risk of substance use disorder accelerating into an addiction, appropriate treatment, including ADHD medications, is essential both for youth and adults. In many instances, this may be best supported when used within the context of medication-assisted treatment, either during instances of abuse or addiction. As ADHD is, in part, a behavioral disorder, certain behavioral therapies that impart behavioral modifications may be particularly beneficial.11 For example:
Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to improve mental health. CBT focuses on challenging and changing thoughts, beliefs and attitudes. It emphasizes behaviors, improving emotional regulation and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its uses have been expanded to include treatment of a number of mental health conditions. CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. 12
If you think there is substance abuse, Shatterproof, a national nonprofit organization dedicated to reversing the addiction crisis in America, created "National Principles of Care", standard of care for addiction treatment to provide guidance to those and their loved ones as they seek addiction treatment. Additionally, individuals or their loved ones, can visit treatmentATLAS.org where they can take an assessment to understand the type of care that may be needed and can search for high-quality services.
YOUR CHILD'S FUTURE
"I think everybody in the field agrees, if you can get a toehold on the addiction, you should think about treating the ADHD relatively quickly. If you treat ADHD aggressively and you monitor for substance abuse, you're going to reduce delinquency." 13 •
ABOUT THE AUTHORS:
H. Barry Waldman, DDS, MPH, PhD is a SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. E-mail: h.waldman@stonybrook.edu. Rick Rader, MD, DHL (Hon) is the Director of the Morton J. Kent Habilitation Center, Orange Groove, Chattanooga, TN; Senior VP Public Policy, American Academy of Developmental Medicine and Dentistry; Adjunct Professor, Human Development, University of Tennessee-Chattanooga. He is Exceptional Parent Magazine's Editor in Chief. Steven P. Perlman, DDS, MScD, DHL (Hon) is the Global Clinical Director and founder, Special Olympics, Special Smiles; and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine. Allen Wong is Professor at University of the Pacific, Arthur A. Dugoni, School of Dentistry, San Francisco CA, and Global Clinical Advisor, Special Olympics.
References
1. Centers for Disease Control and Prevention (CDC). Attention-Deficit/Hyperactivity Disorder (ADHD) ADHD Available from: cdc.gov/ncbddd/adhd/facts.html Accessed November 1, 2020.
2. Janes R. ADHD Vs. ADD: Understanding the difference. Available from: healthprep.com/adhd/difference-between-adhd-and-add/?utmsource=bing&utm_medium=search&utm_campaign=376073530&utm_content=1140194196654307&utm_term=what%20is%20attention%20deficit%20hyperactivity%20disorder&msclkid=ae67 a52d3acd1c80363ffab26f746082 Accessed October 31, 2020.
3. CDC. Data and statistics about ADHD. Available from: cdc.gov/ncbddd/adhd/data.html Accessed September 29, 2020.
4. Stobbe M. ADHD diagnoses increasing in black children report suggests. A Available from: timesfreepress.com/news/national/science/story/2020/mar/04/adhd-diagnoses-increasing-black-children-report-suggest/517302 Accessed November 1, 2020
5. Danielson ML, Bitsko RH, et al. Parent-Reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Clinical Child Adolescent Psychology. 2018, 47(2): 199–212.
6. CDC. State-based Prevalence of ADHD diagnosis and treatment 2011 Available from: cdc.gov/ncbddd/adhd/data/diagnosis-treatment-data.html Accessed October 29, 2020.
7. WebMD. ADHD and substance abuse. Available from: webmd.com/add-adhd/adhd-and-substance-abuse-is-there-a-link#:~:text=People%20with%20ADHD%20tend%20to%20be%20more%2 0impulsive,likely%20to%20also%20develop%20an%20alcohol%20abuse%20problem. Accessed October 30, 2020.
8. Turning Point. ADHD and substance abuse: Why does ADHD increase person's risk of substance abuse? Available from: turningpointtreatment.org/blog/adhd-and-substance-abuse Accessed November 1, 2020.
9. CDC. Treatment of ADHD. Available from: cdc.gov/ncbddd/adhd/treatment.html Accessed November 1, 2020.
10. CHADD Overview Adults with ADHD. Available from: chadd.org/for-adults/overview Accessed November 1, 2020.
11. WebMD. ADHD and substance abuse. Are stimulant drugs for ADHD addictive? Available from: webmd.com Accessed October 31, 2020.
12. Cognitive behavioral therapy (CBT). Available from: en.wikipedia.org/wiki/Cognitive_behavioral_therapy Accessed November 1, 2020.
13. ADHD and addiction. Available from: addictioncenter.com/addiction/adhd Accessed November 1, 2020.