Attention Deficit Hyperactivity Disorder (ADHD) and substance use problems have been gaining more attention in the news and in research over the last 7 months. Here are the most recent highlights about ADHD:

October 2012: The New York Times reports that pediatrician Michael Anderson treats patients in a more impoverished Georgia county with the stimulant Adderall. “He calls [ADHD] ‘made up’ and ‘an excuse’ to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.” “I don’t have a whole lot of choice,” said Dr. Anderson. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

March 2013: The New York Times reports a study by the Federal Centers for Disease Control and Prevention showing “nearly one in five high school age boys in the United States and 11 percent of school-age children overall have received a medical diagnosis of attention deficit hyperactivity disorder.” You should note that the only question asked of households with children was whether a physician diagnosed the child with ADHD. The article then reports on findings from other studies. 6.4 million children ages four through 17 at one time were  diagnosed with ADHD,  which rose 16% since 2007 and 41 % over the past decade. Two-thirds of these children were treated with a stimulant. The Times article then printed a number of opinions, including those experts and administrators that overstate the problem or are not backed by research evidence:

1. The stimulant medications “can drastically improve the lives of those with ADHD but can also lead to addiction, anxiety and occasionally psychosis.”
2. Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”
3. Medication advertising plays off the fears of parents and may lead to the rise in stimulant use. On the other hand, some respected researchers think that this data is inflated and overstates the prevalence of ADHD.

April 2013: The President-elect of the American Psychiatric Association denounces the Times article. He states that the current data may suggest that physicians may be either under diagnosing or over diagnosing ADHD. Furthermore, there were too many inaccuracies in the article, three of which were corrected in later versions.

May 18, 2013: The DSM-V is released, culminating a 14-year process of discussion and revision. The definition of ADHD is updated to take into account the fact that it can continue into adulthood. The criteria have not changed, still emphasizing that the symptoms must appear in multiple settings (home, school, work) and must result in performance problems, such as “failure to pay close attention to details, difficulty organizing tasks and activities, excessive talking, fidgeting, or an inability to remain seated in appropriate situations.”

However, we clinicians know that ADHD and substance use can affect sobriety and recovery. We call it “double trouble.” So how should we react to this news?

Question & Answer format (a doctor interviewing himself):

Q: Is ADHD a real disease or just a way to control children who do not fit the norm?

A: We do not know how to answer this question, but here is what I think about it, 5-6% of children have ADHD, a more modest figure. They are called disordered, because they have a poor fit with their environment. They tend not to follow rules well, fail to achieve expectations, and get in more trouble with social institutions and families.  This 5-6% is still a significant percentage for a disorder, higher than for schizophrenia. It could mean that in earlier societies, ADHD once had an adaptive purpose when tribes needed some individuals who were more distracted by sound, symbols, color and motion. These village kids took greater risks without thinking of the consequences.  Wouldn’t you want these more impulsive, brave, hypersensitive souls hanging around to inform the tribe about approaching intruders and enemies? Now, with more sophisticated and complicated societies insuring greater safety, such children are seen as an annoyance rather than gifted. Some of the best researchers in my field first proposed this hypothesis back in 1997 (see below). The problem may be that “we” have not respected these children for what they can contribute or found lasting ways to make them feel more welcome and competent.

Q: Is Doctor Anderson doing more harm than good or more good than harm?

A: It depends on the case, but overall I think he defeats his purpose. He makes a good point, that our schools, communities and families let down these ”wild and wooly children” and families by failing to create necessary and effective accommodations in terms of teaching, community activities, and parenting.  Then he potentially puts underachieving children who have less ADHD criteria than required at risk by over treating them with powerful medications. This goes against one of basic principles in medicine – “First, do no harm”.  Dr. Anderson is also wrong in ignoring excellent diagnostic and treatment research that points to the validity of ADHD and the superior effectiveness of medication with adjunctive treatment (see below).  He then takes a big chance, treating in a vacuum those without the full definition of a disorder, and without stating that the clinician must work closely with the child’s school, community and family.  The USA is a can-do country, but this doctor seems to be throwing up his hands and handing out prescriptions. Note: “wild and wooly” is my non-professional depiction of kids with ADHD, most of whom I enjoy engaging and treating.

Q: Are we just diagnosing and treating to satisfy the pharmaceutical companies?

A: No, “we” are not.  Both the American Association of Pediatrics and the American Academy of Child and Adolescent Psychiatry publish “practice parameters” about ADHD that emphasize a biological, psychological and social approach to evaluation and treatment. Physicians, nurses, social workers, counselors, and therapists should be the leaders in the community pushing for rigorousness in making diagnoses and advocating for the humane treatment of ADHD children.

Q: Are we simply drugging the next generation of children and turning them into addicts?

A: No. ADHD is a real phenomenon.  The ADHD research indicates that we need to do better about intervening with children and teens to prevent substance abuse problems. 15-19% of patients with ADHD will start to smoke or develop other substance abuse disorders, and even though stimulants are a controlled substance, a meta-analysis of open-label long-term studies of stimulant treatment in ADHD concluded that stimulant treatment does not increase the risk of substance abuse and may even have a protective effect.

One study that is important in addressing ADHA is the MTA Study (Multimodal Treatment of Attention Deficit Hyperactivity Disorder), which was long-term, multi-site research to figure out what helps ADHD children. It showed that ”combination treatment and medication management alone were both significantly superior to intensive behavioral treatment alone and to routine community care in reducing ADHD symptoms. The study also showed that these benefits last for as long as 14 months…In other areas of functioning (e.g., anxiety  symptoms, academic performance, parent-child relations, and social skills), combination treatment was consistently superior to routine community care, whereas medication alone or behavioral treatment alone were not. The children in the combination treatment also ended up taking lower doses of medication than the children in the medication-alone group.The MTA study also showed in an 8-year follow-up of ADHD children that “treatment with stimulants did not seem to have any affect whatsoever on substance use or the development of substance use disorders (SUDs). Children with ADHD, regardless of treatment, were at a greater risk for SUDs.

The take home message

“The good news is that stimulants are not increasing the risk for substance use disorders as some have suggested. The bad news is that our treatment does not seem to be doing much of anything to address the elevated risk for SUDs in this vulnerable population, despite the fact that stimulants provide dramatic improvement in ADHD symptoms for 80% of the children to whom they are prescribed. While disappointing, these results will hopefully inspire us as clinicians and researchers to develop new ways, psychosocial or pharmacologic, to intervene with children with ADHD to try to decrease and prevent the onset of SUDs.”

A 10+ year follow-up of Minnesota children with ADHD (in school from 1976-82) showed that 29% continued to have the condition as adults. Those who no longer had the condition were still three times more likely to have a psychiatric diagnosis. 26.3% had alcohol abuse or dependence and 16.4% had other substance abuse or dependence. The 29% who had ADHD into adulthood had almost six times the odds of having another psychiatric diagnosis.

The take home message

“It is concerning that only a minority of children with ADHD reaches adulthood without suffering serious adverse outcomes, suggesting that the care of childhood ADHD is far from optimal. Our results also indicate that clinicians, insurers, and health care systems must be prepared to provide appropriate care for adults with ADHD.”

The practice guidelines for ADHD suggest that we do the following:

1. always assess for substance use disorders
2. screen older adolescents with ADHD for substance abuse disorders, as they are at greater risk than teenagers without ADHD for smoking, alcohol and other illegal substance abuse disorders
3. consider non-potentially addicting agents for ADHD (such as atomoxetine, bupropion), if there is active addiction
4. address generalized family dysfunction (parental depression, substance abuse, marital problems), so that psychosocial or medication treatment is fully effective for the child with ADHD

In conclusion, I propose that we know how to diagnose ADHD and we know what treatment works, but we need to apply it in the context of the community and the family. This takes work, backed by a can-do spirit. Diagnosis and treatment with medication alone may help, but does not respect the talents, energy and the creativity of these unique children. As a prescribing psychiatrist who is also certified in addiction medicine, I will only continue to chase my tail, trying to medicate “wild and wooly” behavior, without including motivational therapy, family-focused and parent-focused interventions, school collaboration and consultation, and community reinforcement of pro-social behaviors. Therefore, prescribing a stimulant to an underachieving child is the last thing I think about doing.

Peter R. Cohen MD

Dr. Cohen is a board certified child and adolescent psychiatrist with additional certification in addiction medicine. He has written extensively about adolescent addiction and recovery, in addition to writing the Hazelden book, “Helping Your Chemically Dependent Teenager Recover.” He has also served as the behavioral health medical director for Montgomery County, Maryland and the medical director for Maryland’s Alcohol and Drug Abuse Administration. He is semi-retired, but serves as the psychiatrist for emotionally challenged senior high students at the Foundation Schools in Largo, Maryland.

References:

1. Attention Disorder or Not, Pills to Help in School, New York Times, Alan Schwartz, October 9 2012

http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=all&_r=1&

2. A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise, New York Times, Alan Schwartz & Sarah Cohen, March 31, 2013

http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=1

3. APA President-Elect Denounces Times Article on ADHD, Psychiatric News Alert, April 1, 2013

http://alert.psychiatricnews.org/2013/04/apa-president-elect-denounces-times.html

4. Attention Deficit/Hyperactivity Disorder Fact Sheet, American Psychiatric Publishing 2013

http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf

5. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder, American Academy of Child and Adolescent Psychiatry, 2007

http://download.journals.elsevierhealth.com/pdfs/journals/0890-8567/PIIS0890856709621821.pdf

6. ADHD Practice Guidelines of the American Academy of Pediatrics, January 2013.

http://www.cdc.gov/ncbddd/adhd/guidelines.html

7. Evolution and Revolution in Child Psychiatry: ADHD as a Disorder of Adaptation, Peter Jensen, David Marazek et al, Journal of the American Academy of Child & Adolescent Psychiatry, 36:12,

December 1997, Pages 1672–1681

8. The MTA Study (Multimodal Treatment of Attention Deficit Hyperactivity Disorder), NIMH, 1999-today

http://www.nimh.nih.gov/health/trials/practical/mta/the-multimodal-treatment-of-attention-deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml

9. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Pediatrics, Barbaresi WJ, Colligan RC, et al., 2013, 2012-2354 (thanks to Stuart Goldman MD, AACAP News, May/June 2013)

10. Adolescent substance use in the multimodal treatment study of attention deficit/hyperactivity disorder (ADHA) (MTA) as a function of childhood ADHD, randomassignment to childhood treatments, and subsequent medication. Molina BS, Hinshaw SP et al. J Am Acad Child Adolesc Psychiatry 52(3):250-63(2013). (thanks to Stuart Goldman MD, AACAP News, May/June 2013)

At the Keeping It Real 2011 Conference, Phillip McCabe, CSW, CAS, spoke to healthcare professionals on behalf of LGBT youth. He explained that LGBT youth are more likely to have lower self-esteem, greater rates of depression and substance abuse, are at higher risk for HIV/AIDs and suicide, and are more likely to be targets of bullying than their heterosexual peers (Kosciw et al., 2012). He urged the audience to help prevent such issues in the context of a heterosexist and transphobic society; one in which heterosexuality is assumed and the LGBT minority is often discriminated against.

McCabe begins with a discussion about cyberbullying which includes violent videos posted online and websites that encourage suicide that have drawn the attention of lawmakers. McCabe uses the example of his home state of New Jersey which has “very comprehensive laws around bullying” to protect cyberbullying victims.

Another form of bullying that McCabe refers to as “institutional bullying” is not forbidden by the law. Institutional bullying is particularly entrenched and is accepted as part of the culture (Adams, Bell, & Griffin, 2007). One example of this is on the internet where we see certain organizations who oppose homosexuality providing anti-gay messages that could be harmful to LGBT youth and their families if they happen to “type the keyword ‘gay’ into a Google search” while seeking information, McCabe explains.

McCabe mentions the controversial Bishop Eddie Long of the New Birth Missionary Baptist Church who preached vehemently against “the sin” of homosexuality only to later settle in court on four accusations of sexual abuse against young boys (A Du, 2010). McCabe is particularly concerned about those, like Long, who promote reparative and conversion therapies that function under the assumption that homosexuality is a mental disorder and that persons should be helped to change their sexual orientation. Such therapies have been deemed unethical by mental health and medical associations (Just the Facts Coalition, 2008). McCabe warns that professionals should be aware of this so that they are prepared to help LGBT youth and their families navigate truth from fiction on the internet.

This is especially important given that LGBT youths’ feelings of nonconformity are what McCabe cites as a major risk factor for suicide. McCabe explains that we can encourage youths’ resilience to suicide by “engagement with the family, the community, and the school.” He explains that the more the family can accept the individual’s sexuality, the less likely the individual is to commit suicide.

“If they’re not getting it from the family then maybe we can help the family to become better understanding about the emerging sexual identity but, if not, we can still provide support in our community through our programs” McCabe continues.

Two resources that McCabe suggests professionals should access for programs to prevent bullying and increase resiliency among LGBT youth include; Stop Bullying Now (Davis, n.d.) and the Trevor Project (The Trevor Project, 2010).

McCabe also urges healthcare professionals to become comfortable asking questions about sexuality. He warns against making assumptions about patients’ sexual orientation—even in the case where the patient may speak of an opposite-sex partner—which risks missing opportunities to educate and screen patients properly.

McCabe offers HEADSS as an acronym for those assessing LGBT youth in healthcare: Home, Education, Activities, Drugs, Depression, Diet, Suicidality and Sex (Katzenellenbogen, 2005). Of these different factors he goes on to illuminate the importance of education, asserting that “Many kids survive if they keep their educational goals focused.”

McCabe stresses in a final call to arms that “One single agency will not be successful” and that all professionals must work to make sure their treatment is safe and sensitive, help youth develop positive coping mechanisms, and encourage positive LGBT media representation.

The Keeping it Real 2011 Conference: Street Level Intervention Strategies for Addiction, HIV/AIDS, and Hepatitis was held in Silver Spring, Maryland and was conducted by the Central East Addiction Technology Transfer Center, a program of the Danya Institute.

You can access many of the resources from McCabes presentation below:

Adams, M., Bell, L.A., & Griffin, P. (2007). Examples of institutional heterosexism. In Teaching for diversity and social justice (2^nd ed.) (Appendix 9H). New York, NY: Routledge. Retrieved from: http://www.life.arizona.edu/docs/ra-section/heterosexism.pdf

A Du (2010, September). Bishop Eddie Long preaching on gays/homosexuals. Retrieved from: http://www.youtube.com/watch?v=UItGijdsCf8

Davis, S. (n.d.). Building resiliency. Stop Bullying Now. Retrieved from: http://www.stopbullyingnow.com/resiliency.htm

Just the Facts Coalition. (2008). Just the facts about sexual orientation and youth: A primer for principals, educators, and school personnel. Washington, DC: American Psychological Association. Retrieved from www.apa.org/pi/lgbc/publications/justthefacts.html

Katzenellenbogen, R. (2005). HEADSS: The “review of systems” for adolescents. Virtual Mentor, 7(3).

Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN.

The Trevor Project (2010). Programs: The Trevor project programs. Retrieved from: http://www.thetrevorproject.org/Programs

     Catie Greene, MS, is a pre-doctoral student of Counselor Education at the College of William & Mary. 

Thank you in advance for your input. The instrument is available in
English and Spanish and will take no more than 5 minutes of your time.
Please help us building training priorities around culturally relevant
topics for Hispanic and Latino populations in need of substance abuse
treatment and recovery support services.

To access the survey please click here:

Carmen Andújar Cántres, BA
Logistic & External Affairs Specialist
National Hispanic and Latino ATTC
Universidad Central del Caribe
PO Box 60327
Bayamon, PR 00960-6032
Tel. (787) 798-3001 Ext. 2114
carmen.andujar@uccaribe.edu
hispanic@attcnetwork.org

In this session Kimberly McClellan, MSN, CRNP, WHNP-BC discussed Pre-conception Counseling and Contraception.

Click here to download a pdf of Ms. McClellan’s presentation

In this session Dace S. Svikis, PhD discussed What’s New in Addictions and Mental Health including prescription drug abuse and bath salts.

Click here to download a pdf of Dr. Svikis’ presentation slides

In this session Henry Fraimow, MD, Associate Professor of Medicine at UMDNJ-Robert Wood Johnson Medical School of Camden, NJ discussed how to best diagnosis and treat TB, and its relationship to HIV infection.

Click here to download a pdf of Dr. Fraimow’s presentation

In this session Dr. Luciano Kapelusnik, Assistant Professor, Institute of Human Virology, University of Maryland gives an update on Hepatitis C and STIs.

Click here to download a pdf of Dr. Kapelusznik’s presentation

Learner objectives for the whole conference were:
1. State current treatment practices for hepatitis C
and multi-drug resistant bacterial STDs
2. Identify interactions between HIV and TB
3. Explain how to screen clients for substance
abuse, including the identification of cooccurring mental health issues
4. Describe current methods of effective
contraception and pre-conception counseling

Conference presenters:

Baltimore City Health Department
National Hepatitis Technical Assistance Center
New Jersey Medical School Global Tuberculosis
Institute
Central East Addiction Technology Transfer Center
Pennsylvania/MidAtlantic AIDS Education and
Training Center
STD/HIV Prevention Training Centers
TRAINING 3, Family Planning Council

 REGISTER HERE

The enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care are issued by the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health (OMH) to advance health equity, improve quality, and eliminate health care disparities by establishing a blueprint to implement culturally and linguistically appropriate services.

NAADAC, NBCC, and IC&RC CEU’s available for a small fee.

When: Wednesday, May 29th, 2013

Time: 3:30PM EDT

Presenter: Víctor Flores, MC, LAC

National Hispanic & Latino ATTC

Universidad Central del Caribe

PO Box 60327

Bayamón, PR 00960-6032

787-785-5220

hispanic@attcnetwork.org

hispaniclatinoattc@uccaribe.edu

For more information, visit our website at:  National Hispanic & Latino ATTC

On March 8, 2013, Fiona McTavish, MS, shared the encouraging results of her team’s innovative research using smartphones to prevent substance abuse relapse to conference attendees at the “Brave New World: Using Technology to Enhance Behavioral Health” Symposium in Baltimore, Maryland.

McTavish and her colleagues have made use of laptops and mobile phones for those facing a wide variety of health issues for years. The new mobile phone app created to support individuals recovering from addictions (A-CHESS) includes assessments, education and training, social support, location tracking, alerts and reminders that combine to contribute to successful recovery (NIATxNPO, 2010). McTavish emphasizes that the goal is to treat the person “wholly.”

McTavish provides an example of A-CHESS in action through a short clip of a man during a weak moment in recovery; being confronted by feelings of loneliness and triggers to relapse when he is interrupted with A-CHESS recovery reminders on his smartphone that has detected his location (NIATxNPO, 2012). After ignoring an invitation to a virtual counseling session, he is sent a powerful video of himself describing the negative impact of addiction on his life. This moves him, and he boldly declares “I cannot afford to be that guy again,” and accepts the virtual counseling session.

“What motivates me is seeing that people’s lives have changed,” notes McTavish after reciting a heartening conversation between recovering veterans on one of their message boards which demonstrated the well-known benefit of having social support during recovery.

 “This is just an example of how giving people a smart phone like this can really make a difference in their lives,” she explains. She goes on to argue that the social support gained through A-CHESS message boards are much less invasive than a phone call at, say, 2 a.m.

 In 2012 her team received a $3.5 million grant from the National Institute on Drug Abuse (NIDA) to provide A-CHESS enhanced mobile devices to a randomized sample of individuals leaving addictions treatment centers in Boston, Massachusetts, and Peoria, Illinois (Board of Regents for the University of Wisconsin System, 2012).

 Individuals that were provided with A-CHESS enhanced mobile devices reported significantly less risky drinking days and were more likely to report having been completely abstinent within the last 30 days than a control group.  Participants also continued extended use of A-CHESS which, as McTavish explains, is atypical for free health mobile app downloads.

 The researchers are hopeful that the next step will be to disseminate A-CHESS as an app that could be downloaded by clinicians and individuals in recovery at reduced cost.

 McTavish is the Deputy Director of the Center for Enhancement Systems Studies at the University of Wisconsin-Madison.

 The Symposium was conducted through the collaboration of the Mid-Atlantic Node Clinical Trails Network, Maryland Alcohol and Drug Abuse Administration, Maryland Mental Hygiene Administration, and the Central East Addiction Technology Transfer Center, a program of The Danya Institute.

 You can access the clip shown by McTavish, a tutorial on how to use A-CHESS, and an article on UW-Madison’s research here:

Board of Regents for the University of Wisconsin System (2012, September 21). UW team to test mobile apps to prevent substance abuse relapses. University of Wisconsin-Madison News. Retrieved from http://www.news.wisc.edu/21082

NIATxNPO (2010, June 8). Addiction CHESS- Smart phone tutorial (part 1). YouTube. Retrieved from http://youtu.be/LEqY59bBwCo

NIATxNPO (2012, September 20). Innovations for recovery: Video chat. YouTube. Retrieved from http://youtu.be/WJXbC-hEQns

Catie Greene, MS, is a pre-doctoral student of Counselor Education at the College of William & Mary

Learn more here:

http://k2zombiedc.com/

Click here to download  the Happy, Joyous & Free mini-pamphlet