A strong link exists between ADHD, cigarette smoking, and substance use disorders (SUDs). Both research and clinical evidence have shown that a person who has one disorder may have the other. Understanding the nature of the ADHD/SUD overlap, how substance abuse develops, and which youngsters are at greatest risk are important in avoiding the situation and effectively managing those with problems.

According to Timothy Wilens, professor at Harvard Medical School and director of the substance abuse program at Massachusetts General Hospital, ADHD is often a precursor to the full spectrum of substance use disorder, and to help patients avoid the hazardous combination, it is important to provide cautionary guidance throughout childhood, screen all adolescents for substance abuse, and treat ADHD. Wilens et al. (2003) believes that the risk of SUD in individuals with ADHD extends across the timeline of life. When a pregnant mother first visits a physician, this is an opportunity to make it clear that addressing substance abuse is part of well-child care. Here the physician can show how using any dangerous substances increases the risk of spontaneous abortion or miscarriage, placental abruption disorders, postnatal withdrawal symptoms, neurobehavioral abnormalities, and sudden infant death syndrome (SIDS). Estimated exposure of the fetus while the mother is pregnant is 11 percent for tobacco, 10-13 percent for alcohol, and 3 percent for illicit drugs. Every year 40,000 babies are born with fetal alcohol syndrome; 40 to 50 percent of confirmed child abuse cases involve a parent with substance abuse.

Guidance on the importance of avoiding substance abuse should continue during middle childhood. Programs in school like DARE are important to assist children in framing appropriate attitudes about drugs, cigarettes, and alcohol. When peer influence becomes stronger during adolescence, teenagers are more directly exposed to substance abuse and may start to experiment with drugs. Monitoring the Future (Johnston 2006), an annual nationwide survey of behaviors, attitude, and values among 50,000 8th, 10th, and 12th graders in the United States, showed in the 2005 survey that more teens drank alcohol than used tobacco. For example, 47 percent of high school seniors said they had consumed alcohol within the previous month and 23 percent reporting use of tobacco. The survey showed that 10 percent of 8th graders and 25 percent of 12th graders had used some illicit drugs within the previous month. Although substance abuse and dependence are defined in DSM-IV, all children do not fit the descriptions of the diagnosis; therefore Wilens et al. (2003) believes that all teens should be tested for substance abuse.

About 20 percent of adults who abuse substances have ADHD. Several studies have shown that 35 to 71 percent of adult alcoholics had childhood-onset ADHD that had persisted into their adult years. In this ADHD/SUD overlapping population, several characteristics are common:

1. Other psychiatric comorbidities are common. About one-third of adolescents with ADHD and a diagnosis of substance abuse have other psychiatric disorders such as major depressive disorder, generalized anxiety disorder, and traumatic stress disorder. Girls with ADHD and substance abuse are more likely than their male counterparts to have psychiatric problems, and they begin abusing substances about a year and a half earlier than boys do. For example, studies in cocaine abusers who sought treatment showed a high proportion with ADHD and a history of conduct disorder or antisocial personality conduct disorder and persistent ADHD beginning in adolescence.

2. People with ADHD may seek to self-medicate. Upadhyaya et al. (2005) found in a study of 334 college students of whom 84 had been diagnosed with ADHD a relationship between the use of substances for relief and ADHD. Smoking has been associated with improvement in executive functions such as planning ahead, setting priorities, and controlling impulses, which are often impaired in ADHD. This study suggested the presence of self-medication and self-treatment.

Bibliography:

1) Biederman, J. et al. 2006. Is cigarette smoking a gateway to alcohol and illicit drug use disorders? A study of youths with and without attention deficit hyperactive disorder. Biology Psychiatry 59:258-64.

2) Johnston, L. D. et al. ''Monitoring the Future: National Results on Adolescent Drug Use.'' 2006. Bethesda, MD: National Institute on Drug Abuse.

3) Lang, Susan. ''Study Suggests Link between Maternal Cocaine Use, Attention Dysfunction in Kids.'' June 15, 2000.

4) Knight, J. R. et al. 2002. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatric Adolescent Medicine 156:607-14.

5) Knight, J. R. et al. 2005. Barriers to Screening Teens for Substance Abuse in Primary Care. Poster presentation, Pediatric Academic Societies 2005 Annual Meeting, May 14, 2005, Washington, D.C

6) Kollins, S. H. et al. 2005. ADHD and smoking: From genes to behavior. Archives of General Psychiatry 62:1142-47.

7) Molina, B. S. et al. 2003. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. Journal of Abnormal Psychology 112:497-507.

8) Upadhyaya, H. P. et al. 2005. Attention deficit/hyperactive disorder, medication treatment, and substance use among adolescents and young adults. Journal of Child Adolescent Psychopharmacology 15:799-809.

9) Wilens, T. 2004. Attention-deficit/hyperactive disorder and the substance abuse disorders: The nature of the relationship, subtypes at risk, and treatment issues. Psychiatric Clinic North America 27:283-301.

10) Wilens, T. E. et al. 2003. Does stimulant therapy of attention deficit/hyperactive disorder beget later substance abuse? A meta-analytic view of the literature. Pediatrics 111:179-85.

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