Results
- |
Industry leaders in improving attention. |
|
For more information call (800) 788 - 6786 or request
a |
Does ADHD Predict Early Drug Use?
A widespread concern among parents of children with ADHD, as well as among clinicians who work with such children, concerns the degree to which it increases a child's risk of drug use. For some, these concerns focus on whether treatment with medication - by itself - will lead children with ADHD to be more likely to use illicit substances later in life. No evidence for this concern has been reported in several relevant studies, however.
Other parents and clinicians have concerns about the role of ADHD in eventuating later drug use irrespective of whether a child is being treated with stimulant medication. Evidence for an association between ADHD and later substance abuse has been mixed. Some studies have reported increased rates of substance use and abuse among adolescents with ADHD while others have found no such association. It is also not clear whether any association between ADHD and adolescent substance use or abuse that have been found can be attributed specifically to a child's ADHD symptoms, or whether the association between ADHD and substance use is explained by the other kinds of behavior disorders (i.e. Conduct Disorder - CD) that often go along with ADHD. Finally, little research has been conducted on the specific factors in the environment of children with ADHD that will act to protect them from becoming involved in substance use, or increase their risk for doing so.
A study published recent in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) was designed to answer these important questions (Chilcoat, H., & Breslau, N. (1999). Pathways from ADHD to early drug use. JAACP, 38, 1347-1354). In this study, a representative community sample of 717 children were followed from ages 6 to 11. At age 6, children's mothers were interviewed to determine whether or not their child had ADHD. In addition, mothers completed ratings of aggressive, delinquent, and oppositional behavior problems in addition to the information they provided about specific ADHD symptoms. (An important strength of this study is that the children were all from a community context rather than being selected from a clinic population. This allows one to have more confidence that the results are representative of children with ADHD in general, rather than to the relatively small subset who are treated in mental health settings. It would have been preferable, however, if diagnosis was based on information from teachers as well as mothers).
When children were 11, their own use of drugs, the drug use by their peers, and their perceptions of how closely parents monitored their behavior were all assessed in individual interviews with each child. During these interviews, children were asked about their use of tobacco, alcohol, marijuana, and inhalants. They were counted as drug users if they had ever used any of these substances (in the case of alcohol, they were not counted if the use had occurred with parental permission - e.g. a small glass of wine at a family celebration). Peer drug use items measured friend's use of these same substances, as well as friends' attitudes towards drugs, as reproted by the children with ADHD who were the subjects in the study. Items on the parent monitoring questionnaire concerned parents'practices for supervising their child, and their knowledge/surveillance of their child's whereabouts and behaviors outside their home.
It is important to note that the definition for "drug use" in this study is a lenient one. This is because the authors were specifically interested in whether or not ADHD is associated with the earlier use of any type of drug. They did not address whether ADHD might also increased the risk of substance abuse rather than just substance use. In part, this is because children in their study were only 11 years old at follow up, an age before substance abuse problems would be expected to develop in very many children. It should be noted, however, that early drug use is an extremely important predictor of subsequent substance abuse problems.
Results
Of the 711 children with complete data, 137 (19.1%) had used drugs at least once. Incidence was highest for tobacco and alcohol (10.6% and 10.1% respectively). Of the 117 children who had used tobacco or alcohol, 31 had used both. A small number - 3.8% - had used inhalants and only 7 children reported having used marijuana. Interestingly, most of the children reporting inhalant use had not previously used tobacco or alcohol according to their self-reports.
Did ADHD Increase The Risk Of Early Drug Use?
Simply stated, the answer to this question is yes. The authors found that children with ADHD were about 1.7 times more likely than others to have been an early drug user. In addition, the risk of early drug use seemed to vary in relation to the number of ADHD symptoms that mothers had reported when their child was 6. There was a sharp increase in drug use in the 8+ symptom range that peaked at around 10 symptoms (Note: This study was done when the prior version of DSM was in effect and a total of 14 symptoms for ADHD were listed in the diagnostic criteria). At this level of symptoms, more than one in three children reported early drug use.
The authors also examined whether treatment with stimulant medication was associated with different rates of early drug use in children with ADHD. No such association was found. The rates of early substance use in children with ADHD who had and had not received stimulants was equivalent.
What Role Do Other Behavior Problems Play In The Early Onset Of Drug Use For Children With And Without ADHD?
The answer to this question is that other kinds of behavior problems (e.g. aggression, defiance, argumentativeness, etc.) play a substantial role in predicting early drug use for children, regardless of whether they have ADHD. These findings are important to examine in some detail.
As expected, children with ADHD also had higher scores on maternal ratings of these other externalizing behavior problems than children without ADHD. In relation to early drug use, however, what is VERY IMPORTANT to emphasize is that when these behavior problems were low, a child with ADHD was quite unlikely to be an early drug user. Thus, by itself, ADHD did not appear to increase children's risk for early onset substance use.
In a child with ADHD, however, even moderate levels of externalizing behavior problems were associated with a substantially increased risk for early drug use. In fact, children with ADHD with externalizing problems just slightly above average were more than twice as likely as children without ADHD, but with similar scores for other behavior problems, to be early substance users. At the highest levels of these behavior problems, risk of early drug use was high for children, regardless of whether they also had ADHD.
The message here is an important one: children with ADHD but without even modest levels of other behavior problems are no more likely to become early substance users than anyone else. When even modest levels of other behavior problems occur in a child with ADHD, however, there is an increased risk for early substance use.
Environmental Risk/protective Influences On Drug Use
How closely children reported they were monitored by their parents was a significant predictor of early drug use. Children whose parents were reported to engage in a high level of monitoring of their whereabouts and behaviors were about half as likely to report early drug use than children who reported low monitoring by parents. This relationship held for children both with and without ADHD.
Increasing levels of drug use by peers was also found to be a risk factor for early drug use. Children who reported high levels of drug use by peers (i.e. in the top 33% of the scores) were SIX times more likely to be early drug users than children reporting low drug use by their peers. Once again, this relationship held for both children with and without ADHD.
Summary And Implications
I think there are several very important messages in this study.
First, ADHD in the absence of other behavior problems does not increase a child's risk for early substance use.
Second, even when accompanied by modest levels of associated behavior problems, however, a child with ADHD is at greater risk to be an early substance user. The types of behavior problems assessed by the authors included such things as defiance, verbal and physical aggression, irritability, blaming others for mistakes, argumentativeness, etc.
Finally - and this is especially important - how carefully parents monitor their child's whereabouts and the kids their child spends time with - has enormous implications for whether or not their child is likely to be an early substance user. Thus, for children with ADHD who are also showing other types of externalizing difficulties, careful parental monitoring is essential.
What I think is noteworthy about this is that parental monitoring was shown to be so important in regards to substance use even though the children in this study were not even teenagers when the follow up data was collected.
Most parents would recognize the importance of careful monitoring for their adolescents sons and daughters, being careful to make sure their child is not hanging around with peers who are likely to get in trouble.
What these data indicate, however, is that such monitoring is just as important when children are still in elementary school, as it can be a key factor in reducing a child's risk for beginning to experiment with illicit substances at a very early age.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.