ADHD Medication in Childhood Does Not Increase Addiction Risk

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Taking medication for attention deficit/hyperactivity disorder (ADHD) as a child does not increase — or decrease — the risk for later addiction or alcoholism, according to a new review of the research.

The research may help reassure parents who are concerned about the controversy over the use of medications to treat the disorder, which is now diagnosed in 11% of all schoolchildren.  The condition is widely seen as being over-diagnosed, with a rate that has increased 3% to 6% every year between 2000 and 2010 — accompanied by a worrying rise in medication use.

The review, which was published in JAMA Psychiatry, included over 2,500 participants in 15 different studies.  Whether the drug in question was alcohol, cocaine, marijuana or nicotine and whether the study looked at experimentation or addiction, researchers found no overall difference in risk related to ADHD medication.  The most commonly used ADHD medications are stimulants, typically Ritalin (methylphenidate) or Adderall (a mixture of amphetamines).

“The best evidence to date seems to suggest that treatment with stimulant medication has no substantial role in increasing or decreasing risk for the development of alcohol and drug problems,” says Steve Lee, a co-author of the study and associate professor of psychology at the University of California in Los Angeles.

“Stimulants did not contribute to substance abuse, which is one of the major concerns of parents whenever you are starting a child on medication,” says Dr. Joe Austerman, a psychiatrist at the Cleveland Clinic’s Children’s Hospital, who was not connected with the study.

MORE: Understanding the Rise of ADHD Diagnoses

The question of whether stimulants, which can be addictive themselves, affect addiction risk in ADHD has long been a difficult one.  For one, ADHD itself is linked with a greatly increased risk for all types of addictions.  Secondly, there are compelling reasons to predict either positive or negative effects.

On the concerning side, some animal research suggests that early exposure to such medications could reduce the capacity to experience pleasure, by affecting the development of the brain’s dopamine systems. Alternatively, it could increase a capacity for desire for the drug, which could be re-awakened in adolescent experimentation.  “Early in development, we know that brain structure is changing in immense ways and it could be that at one point in development or in certain brains, [children] are more or less reactive [to the brain effects of the drug],” says Lee. “That could be one mechanism for evidence of a ‘sensitization’ effect, where they would [later] enjoy it more.”

On the other hand, there are reasons to believe that medication would lower addiction risk by reducing stress:  a child who does better in school and with peers while on medication seems far less likely to turn to illicit drugs for relief.  “As far as being protective, that’s a bit more intuitive,” says Lee. “It might improve attention and functioning and may improve relationships with peers, parents and academics.”

One study did show that the earlier children started taking medication, the lower their risk for drug problems — suggesting that the social explanation may be more powerful, but there is not yet enough data on timing and especially on use in the youngest children.

And the only previous meta-analysis of the data, published in 2003, pointed in that direction as well. It suggested that medication reduced addiction risk by at least 40% in participants followed into adulthood.  But studies published since then have had conflicting results, with some even suggesting that children who take medication are at increased risk.  Moreover, two of the authors of that review were later disciplined by Harvard for taking millions of dollars in pharmaceutical industry funding without disclosing it.

“The [new review] was funded by the National Institute on Mental Health and [the authors] didn’t have pharmaceutical company involvement,” says Austerman, “It was more comprehensive and done with much higher fidelity so I feel more confident in citing it as a resource.”

The review was also limited by the fact that the children who take medication are not randomly assigned to do so. “The most common reason parents seek help is not because of the symptoms of ADHD,” Lee says. “It’s all of the problems that are consequences of these [symptoms] like academic failure or, My child can’t get a playdate.”  Consequently, the children who take medication are likely to have the most severe cases. This would actually mean that the research underestimates any protective effects of the medication.

For girls, the review did suggest that medication could protect against addiction — but because this was based largely on one study and most of the others included far more boys, the authors do not see it as conclusive. “I do believe there’s going to be a gender difference,” Lee says, based on the fact that such differences are seen in virtually all psychiatric disorders.

MORE: Early ADHD Treatment May Improve Girls’ Math Scores

Because of the possibility of misdiagnosis, Austerman suggests that parents who think that their children may have ADHD get comprehensive testing from an expert specialist, not their regular pediatrician.  This is especially true for children who are among the youngest in their class:  research shows they are far more likely to be diagnosed when they really are simply acting their age. Frequent monitoring to ensure the right dose and continued need for medication is also recommended. “For the majority, symptoms are reduced to the point that almost two-thirds of patients don’t need medication into adulthood,” he says.

But he notes that the research is far from definitive. As data across addiction shows, simply being exposed to a drug does not determine whether people will develop substance misuse problems.

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I was always told its as simple as, if the kid takes ADHD meds and gets a buzz then he doesn't have ADHD.  If it works and the kid doesn't get a buzz then he has ADHD.


@jmad789 Actually, there's been some evidence (I think the study was quoted by both The Seattle Times and Scientific American Mind, but I lost track of the link) that Americans may be simply genetically stacked for ADHD in a way that Europeans aren't.

The theory is that we know ADHD and novelty-seeking behavior is very closely linked, and if you take a close look at what it would take to convince someone to leave everything they know behind to start a new life in a new, sparsly populated country full of angry natives and completely new flora and fauna (the term "The Land of Everything Trying to Kill You" comes to mind), you start to notice an interesting pattern.  It's not enough for an individual to have a reason to leave their home country; there were plenty of people who had more than enough reason to leave, but never did.  You also have to be impulsive enough to snatch up the opportunity the second it becomes available, you have to be willing to accept a risk with no promise of a reward, and you have to be able adapt to sudden change.  All of those are traits that run very strongly with ADHD, and back in the early days of America, the environment may have been a much better fit for children with that type of brain that it is now.

Summary of the studies involved:  There's a higher rate of ADHD at least partially because most of the folks with the genes for it were more likely to leave Europe and take a risk in immigrating elsewhere than the ones who didn't have those genes.  So Americans have a much higher rate of ADHD genes than Europeans.

There's also mounting evidence that ADHD is a throwback to our hunter-gatherer ancestors, since a lot of the "negative" traits of ADHD would've been actually very helpful in that environment; there's a running theme that the jobs ADHD adults tend to excel in all involve tasks that mimic and encourage a sort of Prey Drive (seek out prey, chase prey, catch prey, eat prey).  They're all jobs where you have to sort of soak in all the details of your environment until something catches your eye (i.e., lack of focus, easily distracted), then you have to throw all of your energy into the chase until you reach the goal (hyperfocus on interesting things, focusing on the goal at the expense of procedure, etc.).  Then rinse and repeat.  

Take kids who are bred for one environment or type of work and stick them in the complete opposite environment, combine it was a higher genetic risk, and yes, you're going to see much higher rates of it than you would've at an earlier time where such traits may have been more beneficial.

Thom Hartman wrote an excellent book on these theories, and I really wish I hadn't lost my copy of it when I moved...


@BorisIII That's a big part of it.  The stimulant medication works by stimulating a part of the ADD brain that normally doesn't get activated until something interesting enough manages to catch the child's attention.  A child without ADD wouldn't need that extra stimulation.

It helps to think of ADD people as having a slightly more developed prey drive than most people.  Speaking from experience here, as an adult with ADD, it's less a lack of focus and more an issue of not being able to resist the urge to constantly scan my environment for anything interesting (which, instinctively, tends to be whatever seems like a reward, especially if there might be food involved), then being unable to resist the urge to hyperfocus on that interesting thing to the expense of all else until I reach some sort of goal. 

The medication actually LOWERS the risk of addiction, because a lot of people with any sort of untreated issue like ADD will start "self-medicating."  In my father's words (PTSD and strong hints of both ADD and Aspergers), he got addicted to alcohol in high school because it was "the only thing that made my racing thoughts slow down."  Proper treatment, sometimes including medication, eliminates the need to self-medicate with more harmful substances.