As a clinical psychologist with a private practice in Woodland Hills, CA, for several decades, I have enjoyed developing several areas of specialization. A few of these are the treatment of adolescents and children, and I’ve always had a special interest in the treatment of ADHD. Also, many teenagers consult me for substance abuse issues that most frequently involve alcohol, marijuana and tobacco. A certain percentage of these teenagers also suffer with ADHD. Their parents want to know: “How do I know if my child has ADHD?” “Why is my son or daughter with ADHD self-medicating?” “How does ADHD develop?” The research I reference here may be disturbing to the loved ones of individuals with ADHD, but I hasten to explain that timely interventions and skillful treatment can significantly reduce the detrimental impact of ADHD.
Definition of ADHD
ADHD is a biogenetic disorder and one of the most concise definition is given by Russell Barkley, Ph.D. (1991): “ADHD consists of three primary problems in a person’s ability to control behaviors: difficulty with sustained attention, increased distractibility, impulse control or inhibition, and excessive activity. In addition, there are two additional problems: difficulty following rules and instructions and excessive variability in response to situations, particularly during work.”
Twin studies reveal that the majority of hyperactivity and impulsive behaviors seen in children (55% to 97%) is explained by heredity. The identical twin studies reveal that if one twin has ADHD, there is an approximately 80% chance that the other twin will have it. Other studies confirm that at least two genes may be related to ADHD, and that individuals with ADHD have reduced amounts of one or more brain chemicals such as dopamine.
ADHD is the most commonly treated behavioral disorder in childhood. However, ADHD is often misdiagnosed and therefore may be treated inappropriately or missed entirely. It affects about 3-5% of young people. The good news is that 25% to 50% of children grow out of ADHD by the time they are adults. Up to one-half of children with ADHD also suffer from other disorders such as depression, anxiety, oppositional defiant disorder and conduct disorder.
Association with Adolescents with ADHD and Substance Abuse
Given the painful aspects of ADHD, it is not surprising that across the literature it is shown that children with ADHD have an increased risk of substance abuse. In a largely cited study, the Multimodal Treatment of ADHD study (MTA) reported that alcohol, tobacco and marijuana use were more likely to be initiated by early adolescence in youngsters with ADHD than for youngsters in that study that did not have ADHD (Molina, et al., 2007).
There is also a strong association between childhood ADHD and cigarette smoking. For example, in one study, 40% of children with ADHD became more daily smokers by the age of 17 versus 27% of those without ADHD (Lambert & Hartsough, 1958). A high percentage of children with ADHD who smoke will also go on to become substance abusers.
Also, one study revealed that children with ADHD are more likely to report heavy drinking in their teen years than non-ADHD teens. The study stated that 14% of teens with ADHD reported a drinking problem. ADHD children with conduct disorder or bipolar disorder are more likely to have a substance abuse problem, usually associated with drinking, beginning at age 12. Symptoms associated with conduct disorder include aggression toward people, destruction of property, stealing and serious violations of rules, which can lead to anti-social personality disorder.
Children who begin drinking earlier than age 15 are at a high risk for becoming alcohol dependent and marijuana users. According to Biederman, et al. (1995), marijuana is the most commonly abused agent.
Family data indicate that abusers with parents with substance abuse disorder, anti-social personality disorder, and ADHD are at particular risk for developing substance abuse disorders.
The Influence of Self-Medication
Adolescents who suffer from ADHD often seek relief from feelings of restlessness, impulsivity, low self-esteem and difficulties focusing. They often have associated symptoms with anxiety and depression. These adolescents often view themselves as “stupid” and see themselves as undesirable with peers. They feel isolated. They do not understand why they struggle academically and compare themselves with their peer group. They become easily frustrated and irritable and often have great difficulties remaining motivated to perform in school.
One 15-year-old high school student with ADHD comes to mind. He had used marijuana every day in order to relax and sleep, and he did not have friends nor was able to complete his assignments. He only felt relaxed when he was smoking or drinking. Another 15-year-old girl who had ADHD was ready to drop out of school because she could not sit still in class or complete her lessons, and found solace in her peer group that served as a surrogate family for her. She used drugs and alcohol. She displayed a concurrent conduct disorder and had been arrested. Her parents had a history of substance abuse and were emotionally abusive to her. These adolescents have attempted to compensate for their low self-esteem and emotional torment through self-medication. When adolescents realize that they suffer from ADHD and have a serious problem with substance abuse and are willing to engage in treatment, they can often ameliorate their maladaptive behavior patterns and enjoy positive results.
Both substance abuse and ADHD should be treated concurrently and early, and parental participation is essential in all programs to facilitate progress. Substance abuse is the more dangerous condition, and depending on the severity of the substance abuse, such measures as inpatient hospitalization, residential treatment, day treatment, a 12-step program, meetings, individual and group therapy and intermittent urine testing can be effective interventions. Both adolescent and parental groups can be very useful. Many parents realize that their own substance abuse issues had been overlooked and that their adolescent may be modeling their own behaviors.
Teenagers often respond well with an intervention from a teen who has a history of substance abuse and can serve as a peer group sponsor and participation in a 12- step program such as Alateen can be essential.
Individual and family therapies are essential interventions. In my practice, I typically have family sessions at least once a month or perhaps every two weeks, as healthy family functioning is vital to therapeutic progress for the adolescent. These young people do not function in a vacuum, and there are always difficulties in the family system as well.
Exploration of feelings is needed to build self-esteem and to help the adolescent become assertive. Many of the teenagers I’ve treated with substance abuse and ADHD have benefited greatly from counseling, so family members have reason to remain hopeful.
In middle school, adolescent support groups led by peers, the school psychologist or the school mental health practitioner can be a powerful adjunct to treatment. I strongly recommend them for high-risk teenagers who have ADHD and substance abuse difficulties. The parents can participate as needed. These groups are most useful when they occur on a weekly basis and as part of the counseling program.
Contrary to popular belief, psycho-stimulant medication for ADHD does not increase the risk for further substance abuse in most cases. A small percentage of substance abusers with severe conduct disorder/impulse control problems will attempt to abuse these drugs. Medication can be a valuable adjunct to psychotherapy as prescribed by a pediatrician and/or psychiatrist who are involved in the treatment plan. Collaboration is the name of the game. The more professionals that are involved in the treatment program, the greater the chance for success. Often parents come in to my office in a state of confusion and feeling overwhelmed because they believe there is no one professional who is “up to” organizing the treatment. I have found it gratifying to be able to function as a manager for the treatment team to avoid lapses in communication and to offer the young person the best treatment possible.
Parents often need to provide strict contracts with their adolescents including pay-offs and consequences for all behaviors. This provides the necessary structure that these adolescents desperately need and had previously lacked. The teenager should have input about which rewards would motivate them the most. I prefer a home/school reinforcement program, in which the school sends home a daily report so the parent and I can be aware of the progress that the adolescent is making. The adolescent understands that rewards and consequences will be determined on a daily basis based on this progress report. Intermittent urine testing, as already stated, is often useful as well. To sum up, ADHD and substance abuse can wreak havoc in the lives of youth and their families. However, treatment can break the grip of these disorders, especially when all parties contribute to a collaborative approach (i.e., the adolescent, parents, therapist, school, medical doctor and community organization offering a 12- step program). Early intervention enhances the likelihood of success.
The two adolescents previously mentioned were able to turn their lives around as a result of intensive counseling, medication, family therapy, structured contracts, random urine testing and help from the school. I have often been inspired by the courage, commitment and accomplishments of these young people.
Donn Warshow, PhD is a Licensed Clinical Psychologist with a private practice in Woodland Hills, California. He has over 30 years experience treating adolescents, children and adults with ADHD who also have substance abuse issues, depression or anxiety.
Phone: 818-703-5953 • www.drdonnwarshow.com