SAN DIEGO – Adolescents with attention-deficit/hyperactivity disorder are at increased risk of substance abuse disorders, especially if their parents smoke or abuse alcohol or drugs, said Dr. Iliyan S. Ivanov. Interventions that target schools, communities, and families can help, especially if these programs last more than 10 weeks and include training for children and parents, he said.
Several psychosocial modalities can aid teens with attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), but the evidence to date particularly supports family therapy, Dr. Ivanov said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
Parents with SUDs often don’t realize that their children know about their substance abuse, he emphasized. For this and other reasons, these children might harbor positive feelings about “light” (or soft) drugs, such as cannabis, which further increases their risk of using drugs, alcohol, or tobacco, said Dr. Ivanov, of the division of child and adolescent psychiatry at Mount Sinai Hospital, New York.
In addition to family therapy, adolescents with ADHD and SUD can benefit from “contingency management,” in which they earn rewards if they achieve positive outcomes, he said. “For example, look for the first negative urine test, and use that for positive reinforcement instead of using negative punishment for positive urine screens,” he said. “You really have to be on top of educating the parent or whoever is implementing the rewards that it is a moving target. The rules will change as the adolescent’s feelings change or improve.”
Medications are often key to treating adolescent ADHD; however, evidence is limited on whether they improve or control comorbid SUD in most cases, Dr. Ivanov said. “Stimulants are effective in controlling ADHD symptoms but have limited efficacy in controlling SUD,” he added. “Stimulant treatment is most effective when used concurrently with SUD treatment, and that is best done in a clinic with some kind of behavioral therapy.”
In longitudinal studies, stimulants such as methylphenidate usually have a neutral effect on substance abuse in children and adults, Dr. Ivanov said. An exception is smoking, he noted. Patients with ADHD have an especially hard time quitting tobacco use, but are less likely to start if they receive consistent treatment with stimulants (Pediatrics 2014;133:1070-80), he said. Osmotic-release oral system methylphenidate (OROS-MPH) also has been found to improve substance abuse treatment outcomes in patients who have ADHD with comorbid conduct disorder (J. Subst. Abuse Treat. 2013;44:224-30), Dr. Ivanov said.
Clinicians should carefully monitor adolescents on stimulants who have SUDs because of the potential for abuse, Dr. Ivanov emphasized. “Given the pharmacokinetics of the long-term stimulants, they might be the better choice,” he said. Also consider drugs with different mechanisms of action, such as lisdexamfetamine, a prodrug stimulant that the brain takes up relatively slowly; atomoxetine, which has distinct neurophysiological effects; extended-release guanfacine; omega fatty acids; buproprion; serotonin norepinephrine reuptake inhibitors; and glutamatergic agents, he said.
Clinicians also should educate patients about proper medication use and should closely follow them, use random urine toxicology screens to look for substance use, and check to see whether the patient has sought scripts from other clinicians, Dr. Ivanov said. New York State has passed legislation requiring prescribers to carry out these checks through prescription monitoring registries, he noted.
Because severe substance abuse predicts worse treatment outcomes for both ADHD and SUD (J. Subst. Abuse Treat. 2013;44:224-30), early detection and prevention of SUDs are key, and several screening tools can help, Dr. Ivanov said. The most comprehensive, the POSIT (Problem-Oriented Screening Assessment for Teenagers) tool, assesses patients for SUDs and also for unrelated problems, he added. The tool is self-administered, as is AUDIT (the Alcohol Use Disorders Identification Test), while CRAFFT (which stands for Car Relax Alone Forget Friends Trouble) is intended for interviews, he said.The CRAFFT tool asks about key signals of worsening substance use, such as riding in a car driven by someone who is intoxicated, using substances to relax or while alone, forgetting incidents that occurred while intoxicated, having friends or family express concern about substance use, and getting into trouble while using alcohol or drugs.
Why are teens with ADHD at particular risk of developing SUDs? In part, they might have greater neural reward processing than other children, as well as deficits in conflict resolution, Dr. Ivanov said. These combined factors lead to a cumulative risk effect for SUD compared with either ADHD alone or parental SUD alone.
The brain’s tendency to seek sensation also peaks in early to middle adolescence, making this age particularly vulnerable to substance abuse, whether or not children have ADHD, Dr. Ivanov noted. But ADHD exacerbates this risk. In one study individuals with ADHD were significantly more likely to abuse alcohol (adjusted odds ratio, 14.28; 95% confidence interval, 1.49-138.88) and drugs (aOR, 3.48; 95% CI, 1.38-8.79), compared with controls (PLoS One 2014;9:e105640). These individuals also were more likely to develop drug dependencies as adults, even if they did not abuse substances during adolescence.