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ADHD RESEARCH UPDATE - Vol. 1
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* Are children with ADHD at risk for bipolar disorder?

* Is there a predictive relation between ADHD and substance abuse?

* Similarities and differences in adolescent substance abusers with and without ADHD

* Cigarette smoking and ADHD
 

** ARE CHILDREN WITH ADHD AT RISK FOR BIPOLAR DISORDER? **

It has long been known that children with ADHD are at increased risk for developing other problems including oppositional defiant disorder (ODD), conduct disorder (CD), anxiety disorders, and depression. Now, new research conducted by Dr. Joseph Biederman (Dr. Biederman is one of the worlds most prolific ADHD researchers and you will see his name in here frequently), and his colleagues at Harvard University Medical School suggest they are more likely to have bipolar disorder (BPD) as well. The study described below appeared in the January 1997 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

A good place to start is with a brief overview of BPD. The essential feature of BPD is a history of at least one manic episode or the simultaneous occurrence of both a manic episode and depression. In many, but not all cases, individuals with BPD have also had one or more bouts of depression.

What is a manic episode? A manic episode is defined as a distinct period of at least a week when there is an abnormally and persistently elevated, expansive, or irritable mood. This mood is quite different from what is typical for the person and causes marked impairment in functioning. During this unusual mood state, the individual must also display at least 3 (4 if the mood is irritable) additional symptoms including:

* inflated self esteem or grandiosity;
* decreased need for sleep;
* racing thoughts;
* being much more talkative than usual;
* distractibility;
* excessive involvement in pleasurable activities that can cause painful consequences (e.g. unrestrained shopping sprees, foolish business decisions, etc.);
* extreme restlessness and agitation or excessive focus on a specific goal or activity (e.g. working excessively on some sort of project to the exclusion of virtually everything else);

Although there is some controversy about whether BPD actually occurs in pre-pubertal children, a consensus is emerging that it does. BPD tends to look different in children than in adults, however. Manic children are seldom characterized by euphoric mood. Instead, their mood is much more likely to be characterized by severe irritability with 'affective storms' or prolonged and aggressive temper outbursts. This irritability and tantruming go well beyond what is common in children and is often associated with violence. In addition, the manic episode is likely to be accompanied by depression, making it a 'mixed episode'.

In the study by Dr. Biederman, 140 children and adolescents with ADHD and 120 children and adolescents without ADHD (i.e. control subjects) were evaluated at the start of the study and again 4 years later. The age range at the beginning of the study was 6 to 17 years. Using rigorous diagnostic procedures, 11% of the ADHD subjects were found to have BPD at the initial evaluation. Among the control subjects, in contrast, not a single instance of BPD was identified. At the 4 year follow-up, an additional 12 % of ADHD subjects were found to have developed BPD compared to less than 2% of control subjects. Children with ADHD who had developed BPD at follow-up were more impaired at the initial evaluation than those who did not, and came from families with a greater incidence of BPD and other types of mood disorders.

Although any single study has limitations, and these results need to be replicated, the clinical implications are extremely important. Available data suggest that children with ADHD and BPD account for a substantial number of child psychiatric hospitalizations and that their social and behavioral functioning is much more impaired. These children will thus be likely to require much more intensive treatment. Of special significance is the fact that medical treatment for a child with BPD and ADHD would be very different than for children with ADHD alone. Thus, if the BPD diagnosis is missed, a child's treatment is likely to be inadequate.

This study again highlights the importance of clearly distinguishing between symptoms that reflect ADHD and those which reflect a separate condition. Once a child has been diagnosed with ADHD, there can be a tendency to attribute almost any type of behavioral or emotional problem to the ADHD. Unfortunately, in many cases these difficulties often reflect a related problem that needs to be addressed by different means.

The message from this study is that children with ADHD may be at increased risk for BPD, and that displays of severe irritability, moodiness, agitation, and impulsive aggression should raise this as a question. Should you have these concerns about your child, discussing them with an experienced child mental health professional would be very important.
 

** ADHD and SUBSTANCE ABUSE  **

I would next like to review three studies from the January 1997 issue of the Journal of the American Academy of Child and Adolescent Psychiatry that deal with the relation between ADHD and substance abuse. The first is another study by Dr. Biederman and his colleagues using the same sample of children described above.

As described previously, 140 children and teens with ADHD and 120 control subjects were examined at baseline and then 4 years later. At follow up approximately 15% of the children in each group were found to be abusing either drugs or alcohol. Thus, subjects with ADHD were not more likely to have developed a problem with substance abuse during this period than non-ADHD subjects. For children with ADHD, however, there was a significantly shorter gap between initial abuse and subsequent dependence. This suggests that children with ADHD may be at higher risk for developing addictions at an earlier age.

Within both groups, children diagnosed with conduct disorder - a significant behavioral disturbance in which the basic rights of others or major age-appropriate social norms or rules are consistently violated - were significantly more likely to have developed substance abuse problems. The two groups were also similar in the preferred drug of abuse (i.e. marijuana), and there was no indication that children with ADHD were prone to abuse stimulant medication. (The fear that children who receive stimulants for ADHD will abuse this medication is common, but available data do not support this.)

How do these findings compare with prior studies on the association between ADHD and substance abuse and what are the implications for parents?

Prior studies have also found that children with conduct disorder are at significant risk for becoming substance abusers. This again underscores the importance of co morbid conditions (i.e. difficulties that occur along with ADHD) in the long term outcomes for children with ADHD. When clinically significant behavior disorders develop in addition to ADHD, the child's prognosis is much worse.

Promoting the healthy long term development of children with ADHD is thus critically dependent on preventing the development of these associated problems. If your child is being treated with medication but continues to display significant behavioral problems, it is critical that additional forms of treatment be implemented. The study also indicates that children who are diagnosed with both ADHD and conduct disorder are at elevated risk for becoming substance abusers in adolescence and it may be important to monitor them carefully for drug use.
 

** Adolescent Substance Abusers With and Without ADHD **

The second study in this series looked at similarities and differences between adolescent substance abusers with and without ADHD. Compared to non-ADHD substance abusers, the ADHD subjects began drug use at an earlier age, used drugs or alcohol more frequently, and were more likely to abuse multiple substances. Interestingly, there were few differences between the groups in their drug of choice, and ADHD subjects were NOT more likely to abuse stimulants.

A very important finding was that ADHD subjects reported a more negative self-image than control subjects prior to their drug use and a more improved self-image after drug use. In addition, two thirds of ADHD subjects reported that they continued to use drugs in an attempt to alter their mood. This suggests that their drug and alcohol use may have represented a type 'self-medication'. Although these results also require replication, they appear to have immediate relevance. Many children with ADHD develop secondary emotional problems and diminished self-esteem in response to the struggles that ADHD can cause. The data from this study suggest that these secondary emotional problems may be an important factor in the substance abuse difficulties that some adolescents with ADHD develop. Attending to these important emotional issues - which again are not primary symptoms of ADHD itself - can thus be essential in promoting the healthy development of your child.
 

** ADHD and CIGARETTE SMOKING **

The final study in this series examined the association between ADHD and cigarette smoking. Regardless of whether one considers cigarette smoking to be a form of substance abuse, it is certainly a dangerous habit with potentially lethal consequences.

Subjects in this study were the same as those reported above for the other two studies by Dr. Biederman and colleagues. (Because it is time consuming and expensive to follow large numbers of children over several years, conducting multiple studies on the same sample is common practice.)

At the 4 year follow-up assessment, ADHD subjects were more likely to be smokers (19% vs. 10%), and they became smokers at an earlier age. Among ADHD subjects, those with any other disorder at the initial evaluation (e.g. conduct disorder, mood disorder, or anxiety disorder) were much more likely than ADHD subjects without an additional disorder to become smokers. In addition, becoming a cigarette smoker was also associated with drug abuse. The odds of abusing drugs were 5 times greater in subjects who smoked - regardless of ADHD status - than in those who did not. Finally, there was some indication that children with ADHD who had received treatment were less likely to be smokers at follow-up than those who had not.

What are the implications of these results? Once again, the importance of difficulties that go along with ADHD (i.e. the term used in the mental health professions is 'comorbid') is clear, as ADHD children with additional behavioral and/or emotional problems were at greatest risk for becoming smokers.

I CAN NOT EMPHASIZE HOW IMPORTANT IT IS TO MAKE SURE THESE OTHER TYPES OF PROBLEMS ARE CLEARLY IDENTIFIED WHEN PRESENT AND TREATED APPROPRIATELY. THERE ARE STILL WAY TOO MANY INSTANCES - AS WAS SHOWN IN THE FIRST STUDY REVIEWED ABOVE - WHERE CHILDREN WITH ADHD WHO HAVE ADDITIONAL DIFFICULTIES ARE RECEIVING MEDICATION AS THEIR SOLE TREATMENT.

These results also suggest that special efforts to prevent children with ADHD from becoming smokers may be necessary, particularly among those children where co-occurring problems are also evident. This is especially important because it appears that cigarette smoking may often predate the development of drug abuse.

copyright 1997 ADHD RESEARCH UPDATE.

Please feel free to share this information with others who may benefit from it. If they would like to receive this newsletter on a regular basis, however, please suggest that they contact me about subscribing at addhelp@mindspring.com. Thank you.
 

David Rabiner, PhD
Licensed Psychologist