July 19, 2004: Does the treatment of ADHD with stimulants contribute to subsequent Drug Use/Abuse?

Treatment of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) with stimulants has been and is a hot bed of controversy.  Stimulant administration for this disorder has markedly increased in the last 10 years. Children with ADD or ADHD are at risk for learning disabilities and educational failure, impaired social relationships and various psychiatric disorders. PET scans have demonstrated abnormalities in children with this disorder.   Treatment with stimulants reduces hyperactive, impulsive, and inattentive behavior while increasing task persistence, work productivity, working memory, handwriting and other parameters in 74-97 % of school age children with this disorder. (1)

The incidence of the disorder is increased in boys.  Common beliefs include: “boys will be boys”; the disorder is diagnosed as a way of explaining the natural inclination males, and some females, have to fidget; and recommending medication is an attempt to make these kids behave.

Part of the problem comes from the parameters (or lack of) that have been used to make the diagnosis.  Many times formal neuropsychological testing is not done.  Neuropsych testing is a standardized battery of tests (usually takes hours) that essentially maps the brain. There are no other short cuts to getting this information.  It determines standard deviations from a mean for each age group. Many physicians are not familiar with this testing.  It contains essential information that may confirm/rule-out the diagnosis of ADD.  (Toxicologists become familiar with it as it is used to make a diagnosis in toxin exposure (i.e., CO) that may cause specific NP abnormalities.).  

One of the concerns is that stimulant use will lead to later drug use/abuse.  There are a number of studies that have demonstrated that this is not the case. (1)

An editorial on page 2 of The City Paper (July 12th) is entitled “School rules should avoid pharmacy”.  This editorial discusses the Child Safety Medication Act which would ban schools from making medication a requirement for some children attending school.  The author of this editorial states that: school systems are pressing parents to seek medical treatment for children with behavioral problems: we expect too much from schools as far as disciplining children: and medication is an attempt to push unruly children into pharmacy rather than discipline them in more traditional ways.  Editorials such as this reinforce misconceptions about a disorder in which there are already multiple misconceptions.

As physicians, it is our responsibility to educate parents and the public about this disorder as well as the use of stimulants. Stimulants can be used as a drug of abuse. All drugs have the potential for toxicity if used inappropriately. Treating children with this disorder with stimulants does not increase their chances of later using the stimulant as a drug of abuse.  Not treating the disorder puts children at risk for failure in school and social settings, as well as later drug abuse.  Not every child with a behavior problem has ADD/ADHD and appropriate testing must be done so that kids with the disorder are helped.  We need to educate the public so parents understand the disorder and realize there is a standard approach to making the diagnosis, and a treatment that helps the disorder.  
(1) Barkley R, Fischer M, Smallish M, Fletcher, K.  Does the Treatment of ADHD with Stimulants Contribute to Drug Use/Abuse?  A 13-Year Prospective Study.  Pediatrics (1) 2003; 97-107

An Added note:  The Last Question of the Week discussed DEET.  I received an email stating that the AAP is issuing a statement that concentrations up to 30% should be safe in kids and should be allowed due to presumed increase in efficacy in higher concentrations. Preventing West Nile virus is the reason for this recommendation.  Policy Statement will be published next month in Pediatrics.   I suspect the committee felt that the risk of West Nile was greater than the potential adverse effects of higher concentrations of DEET.  This is a tough decision when there is not a lot of data.  It will be interesting to see if there is an increased incidence of seizures.  (Thanks for the info, Dr. Smith)

I am interested in any questions that you would like answered in “Question of the Week.”  Please e-mail me with any suggestions at donna.seger@Vanderbilt.edu

Donna Seger, M.D.
Medical Director, Tennessee Poison Center