One of the top worries for parents of kids with attention-deficit hyperactivity disorder (ADHD) is the long-term consequences of this condition. "Families want to know, 'So what does this mean?'" says Alice Charach, head of the neuropsychiatry team at The Hospital for Sick Children in Toronto.

Two recent, large reviews of previous studies reveal one disquieting answer: Getting an ADHD diagnosis in childhood is associated with nicotine and alcohol dependence in adulthood.

The two studies' results on marijuana and other drugs, however, were more mixed. One review—a meta-analysis published in the April issue of Clinical Psychology Review by a team of researchers at the University of California, Los Angeles, (U.C.L.A.) and the University of South Carolina, Columbia—concluded that children with ADHD also have a strong risk of abusing marijuana, cocaine and other unspecified drugs.

In contrast, Charach's team—which published its review in the January issue of the Journal of the American Academy of Child & Adolescent Psychiatry—also found an increased risk for marijuana and other drugs, but decided the results of the individual studies examined were too varied to reach a strong conclusion. Overall, however, "the similarities outweigh the differences" between the two meta-analyses, Charach says. Steve Lee, lead researcher on the U.C.L.A. review, agrees, "I think both studies are collectively persuasive."

Charach's study included 2,000 participants in a nicotine use analysis and 3,200 participants an alcohol abuse review. And 5,400 subjects were involved in the U.C.L.A. team's nicotine dependence analysis, whereas more than 2,500 participants were the focus in their alcohol abuse analysis. Ten of the studies appeared in both reviews, resulting in an overlap of 2,000 patients.

Knowing the connections among substance abuse problems and ADHD—a disorder in which patients are unable to focus on tasks and fail to control their impulses as well as others of their age groups do—means doctors and parents can get an early start on preventing abuse. Parents can carefully monitor where their kids are, what they're doing, and who they're friends with, experts say. Of course, that's standard advice for all parents, but Lee emphasizes that parents of ADHD children need to be more consistent in their monitoring and in providing rewards and consequences. "You have a lot less wiggle room," he says. That can be difficult, and parents may need support from a mental health professional, he adds.

Charach agrees that children with ADHD need extra support and guidance. She suggests plenty of supervised activities outside of school. "Find something they excel in," she says. Children with ADHD often have trouble making friends and structured activities give them more chances to meet other kids.

Parents can also start talking to their kids early about making good choices. Whereas most children do not start experimenting with drugs until adolescence, parents should initiate discussions about substance abuse when their children are in fifth or sixth grade, says Timothy Wilens, a Harvard Medical School psychiatrist who was not involved in the studies. Doctors can even show older children with the disorder the research on their higher risk for addiction. Wilens says he tells his college-age patients, "Look, you've got ADHD, you've got to be careful." He adds, "Kids hear that."

Experts are optimistic about the impact parents and doctors can have. "I think we've got a very, very good chance at interrupting" the "chain of events" that lead from childhood ADHD to later substance abuse, Lee says.

Scientists think ADHD and substance abuse may arise from a common pathway in the brain because both disorders are associated with dopamine, a chemical messenger that controls movement, emotions and feelings of pleasure and pain. "How efficiently [dopamine is] transported in the brain seems to be disrupted in ADHD as well as in drug abuse," Lee says. But scientists still don't know the exact mechanism of this relationship. "They're still trying to parcel out the neurobiology," Wilens notes.

Lacking the details of this biology, researchers cannot say if ADHD and substance abuse are directly linked. The actual link may be another syndrome, called conduct disorder, some researchers say. Psychiatrists characterize this condition as chronic problems with criminal activity and defiant, or antisocial, behavior. ADHD and conduct disorder are often found together—27 percent of ADHD children also have conduct disorder, according to a study in the February issue of Pediatrics.

Along these lines David Brook, a psychiatrist at New York University Langone Medical Center, has published two studies that found conduct disorder is the direct predictor of substance abuse. David Fergusson, a psychologist at the University of Otago, Christchurch, in New Zealand, has found that kids who have ADHD but not conduct disorder do not go on to develop substance abuse problems. "Conduct disorder is a mediator between earlier ADHD and later substance use disorder," Brook says.

Charach and Lee agree that conduct disorder may be a mediating factor, but they say that they could not provide a statistical analysis of the relationship because few studies have differentiated between subjects having only ADHD and those with both disorders.

But maybe it does not matter exactly how ADHD appears to lead to substance abuse in later life. "The arguments are becoming theoretical," says Fergusson, who thinks substance abuse in people with ADHD is "likely" due to conduct disorder. "Really, our major concerns now need to be with developing treatments."

Although doctors and researchers think close monitoring can prevent drug abuse in ADHD kids, treating sufferers who already have substance use problems is more challenging. So far, scientists have not found an effective treatment. One small study treated amphetamine-dependent, ADHD adults with sustained-release methylphenidate, a mild stimulant commercially sold as Ritalin-SR. The 12 study participants who took Ritalin-SR did not reduce their ADHD symptoms nor their drug dependence more than the 12 participants who took a placebo, according to results published in the April 2010 issue of Drug and Alcohol Dependence. A larger study administered osmotic-release oral-system methylphenidate, commercially sold as Concerta, to adult smokers with ADHD. The drug helped the 204 study participants control their ADHD symptoms but not their smoking, according to a paper published in the December 2010 issue of the Journal of Clinical Psychology.

It may turn out that seeing a therapist is more effective than drug treatment. Cognitive behavioral therapy, a particular type of talk therapy, works for both ADHD and substance abuse in adolescents and adults, Harvard's Wilens says. It has not, however, been studied as a treatment for people with both disorders.

So, what is the best treatment for adult addicts with ADHD? How should clinicians respond to ADHD kids who are just starting to experiment with drugs? Says Wilens, "This affects a lot of kids, and we really don't have answers to these important questions."

9 Comments

1. 1. pointvector 02:58 PM 4/4/11

   I guess the teams didn't correlate drug use and the fact that kids with ADHD are pumped full of drugs their whole life. Maybe that prescription drug use desentizes the kids and they are a lot less worried about future drug use. But I'm sure the teams at UCLA and Columbia didn't want to implicated the pharmicutical companies!

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2. 2. h4x354x0r 03:06 PM 4/4/11

   Let's see... How have we, as a society, decided to deal with AD disorders? Drugs. Ritalin affects the brain almost exactly like cocaine does. Then we're concerned when, as adults, these people continue to use drugs to cope?
   
   I'm not sure exactly where the thought process stopped, but the thought process has, most definitely, stopped.

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3. 3. ArjanD 05:10 PM 4/4/11

   Indeed, the insinuations made in this article is typical psychiatric stigmatisation that I have seen in The Netherlands also. For a disease that justifies these claims lacks any objective evidence.
   
   The children get powerful drugs that work simular to cocaine on the brain.
   
   In The Netherlands a recent study that was published in The Lanced (5 feb. 2011) showed that 2 out of 3 ADHD diagnosed children can be freed from the diagnosis by a special diet.
   
   Isn't it a terrible shame that questionable doctors are allowed to teach young children that they have a genetic brain disease that will cause them to be criminal, substance abuser or likely to cause other societal problems when they are adult, while in fact a diet or good nurture can solve the problems and enable them to prosper in life with their unique abilities and potential?

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4. 4. supermom890 06:09 PM 4/4/11

   A similar article cited ADD/ADHD medications such as Ritalyn affecting the part of the brain related to addictive behavior.

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5. 5. Knuckleheddd 11:03 AM 4/21/11

   It is extremely important to understand true cause and effect. Consider the fact that the drugs considered most effective (Adderall, for example) in treating ADHD are amphetamines, possibly the most abusable of all drugs. So we give kids potent drugs for a condition and them somehow postulate that the CONDITION is related to, or foreshadows, substance abuse?
   
   We don't truly understand brain chemistry and addiction yet: Averring that ADHD and substance abuse "may arise from a common pathway in the brain because both disorders are associated with dopamine" is the moral equivalent of stating that porn addiction and cataracts are related because both involve the eyes. My bet is that more specific, and different, chemicals are involved in these disorders. The dopamine "link" among virtually all pleasurable activities does not suffice. More will be revealed.

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6. 6. Ghostwheel00 12:17 AM 5/1/11

   So let me see. First we slap a label on the kids which tells them they are defective or "not the norm". Then, most of these children get put on drugs, whether THEY want to or not. They never learn to deal with the ADHD in any other manner. In our neighborhood, for every ADHD child on a prescription, there is a parent with a prescription (usually for Valium), so they get an addicted parent as a model. Many of these parents also drink a considerable amount, some are alcoholics. Most of them are put out that THEIR child has a problem, which "we just won't talk about". Did any of these studies measure what the family life of the child was like, or just the fact that they were ADHD? What about the ADHD children who were not substance abusers? Where is that information?
   
   I'd be wondering why they WOULDN'T be substance abusers.

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7. 7. Beatrix 10:46 AM 6/1/11

   Wow. I am kind of blown away at the ignorance displayed in these comments. Where exactly, in the article does it say these "ADHD kids" are on drugs? I certainly didn't see it. These could very well be the kids who aren't taking the drugs and are following some special diet or doing nothing to deal with it.
   
   I would say, in this case, if drugs help a kid control himself and he gets along better with his peers and learns to function better in society he is LESS likely to abuse drugs later on. Because what are illegal drugs anyway? They are self-medicating substances.
   
   I know a lot of kids with ADHD and not a single drug addicted, loutish parent. That is a gross generalization. Children definitely learn by example, but they also can learn a lot from therapy in conjunction with pharma.
   
   You're probably the same people who poo-pah (I love using that word) talk therapy too. Do you call these kids just overly-rambunctious? They'll grow out of it? Tell that to the parent pulling their hair out, and the child distraught at not being able to control themselves.
   
   Stop talking until you walk in someone's shoes who's been there.

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8. 8. kandrea in reply to ArjanD 10:34 PM 1/9/12

   I read the report you are referring to. This study focused its effort on the behavioral "symptoms" of ADHD.
   
   A strictly supervised and highly restricted elimination diet is a valuable instrument to help reduce the symptoms of ADHD.
   
   However, simply addressing the symptoms is very different from actually finding a cure for ADHD. Just because the symptoms are diminished or gone doesn't mean the person does not have ADHD. There is no cure for ADHD, yet.
   
   And since there is no cure, doctors support and we families to treat people with ADHD by helping them to manage ONLY the symptoms. Whether through medication, special diet, behavioral coaching etc..., its all for the same outcome; to reduce the symptoms. That's all we've got and must do for the sake of this children and struggling adults.
   
   If this report is confirming that a strictly supervised restricted elimination diet is a valuable instrument to attack the symptoms, then the question becomes, does a person with ADHD have the capacity to independently follow a "highly strict and restricted diet" "independently" for the rest of his/her life? If he/she can, great! That should be the next logical study.
   
   And what do you propose we say to those with ADHD who can not follow a strict structured diet because their organizational skills/impulse control behaviors/conduct disorders/levels hyperactivity function on a severe level?
   
   In my opinion, you adults who are making these strong and highly questionable anti-medication claims/arguments are fighting the wrong battle.
   
   For the sake of those children suffering from ADHD, if you feel like picking a fight, then focus your fight and energy on putting pressure on our government/researches to find a cure! similar to they way families with Autism are fighting and putting pressure the public to find a cure for autism. We never see a "help find a cure for ADHD ad on TV."

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9. 9. Researcherofallthings 01:23 PM 4/25/12

   I think those of you before me need to reread the article..... The thought process for you has obviously stopped! The ADHD kids self medicate NOT REALIZING THEY HAVE ADHD!!!! I read somewhere that a child that is treated for ADHD is LESS LIKELY TO DO DRUGS....

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