A new report in this month's American Journal of Psychiatry adds to the ongoing debate about the risks and rewards of using stimulant drugs like Ritalin and Adderall to treat kids with attention deficit hyperactivity disorder. Previous research has suggested that the stimulant medications offer a protective effect against drug abuse during adolescence. The new study, by Harvard researchers, shows that when those adolescents reach early adulthood, any protective effect is gone—though there doesn't seem to be an increased risk of substance abuse. U.S. News spoke with Brian Doyle, a clinical professor of psychiatry at Georgetown University Medical Center and fellow of the American College of Psychiatrists, to help put these and other recent findings about the stimulants into perspective. Excerpts:
What is the current thinking regarding the connection between stimulant therapy for ADHD in young children and future substance abuse with drugs, alcohol, and nicotine?
The current consensus is that treating ADHD in childhood with stimulant medication significantly lessens the likelihood that the child will have substance abuse problems as an adolescent.
How does this new study change that consensus, if at all?
What is remarkable about this study is that no one had yet done a 10-year follow-up. The prior study, a four-year follow-up of the same group of children done by the same author, found that stimulant therapy for ADHD actually protected the kids from drug abuse. But once they reach adulthood, we can't say that anymore. After 10 years, researchers found no association between being treated with stimulants for ADHD as children and a risk of alcohol or substance abuse in early adulthood. It's a less optimistic statement than the earlier pronouncement.
Are there other reasons parents should be concerned about putting their kids on stimulant therapy for ADHD?
There are some important side effects. Real weight loss can be a problem. In a few children, there's a problem with a delay in the onset of sleeping, though many of these kids already have problems sleeping before treatment. Another concern about stimulants in children is the effect on their growth rate. But while children's growth maturation may take longer, they will eventually get to where they should have gone anyway.
And the consequences of not treating ADHD are huge. Children and adults are two to three times more likely to have depression than those without ADHD and two to three times more likely to have anxiety disorders as well. Substance and alcohol abuse is a much bigger problem when ADHD is not treated than when it is.
What about becoming addicted to the stimulant drugs themselves?
Many parents are concerned that their children will end up abusing their ADHD medication—what's called a medically induced addiction. The good news is there's very little rational basis that this will happen. The vast majority of children and adults with ADHD are not using these drugs to get high but rather to feel normal. And if they're not chasing that high, they're unlikely to get addicted. There's a very small proportion of ADHD patients that develop a tolerance to the stimulants and chase their doses higher and higher.
Isn't there a trend of stimulant abuse among college students?
It's like the psychological equivalent of using steroids to enhance physical performance. These students seem to be doing it with relative impunity, and it doesn't seem to be causing too much trouble since most use the drugs not to get high but to function better. So when exams are over, they go back to normal and stop abusing the drugs.
Children with ADHD are more likely to have behavioral or conduct disorders. Will that increase their risk for substance abuse?
Children with ADHD manifest the condition in three forms: ADHD with hyperactivity alone; ADHD with inattention alone—the most common type; and a combined form of ADHD with hyperactivity and inattention. Kids with hyperactivity often have poor impulse control, which, if it persists into adolescence, can lead to experimenting with drugs and marijuana, having more sexual partners, and driving accidents. Stimulant therapy has the effect of decreasing that hyperactivity and controlling the impulses so they will be less likely to have conduct disorders in adulthood.
Are there alternatives to stimulants that parents should know about?
Absolutely. One drug in a totally different class of medications is Strattera. It's not a stimulant, but we know it influences the neurotransmitters involved in ADHD—dopamine and norepinephrin. The drug is slightly less effective than stimulants, but around 70 to 80 percent of children respond positively.
Nondrug treatments with cognitive behavioral therapy—helping kids to learn how to organize their life and thoughts—and parent effectiveness training can be very helpful in addition to medications. But it's quite clear that ADHD medication, and particularly stimulants, is still an important aspect of treatment, though I wish it were otherwise.