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Attention-Deficit/Hyperactivity Disorder and Substance Abuse

Attention-Deficit/Hyperactivity Disorder and Substance Abuse

FROM THE AMERICAN ACADEMY OF PEDIATRICS

Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Attention-Deficit/Hyperactivity Disorder and Substance

Elizabeth Harstad, MD, MPH, FAAP, Sharon Levy, MD, MPH, FAAP, and COMMITTEE ON SUBSTANCE ABUSE abstract KEY WORDS Attention-deficit/hyperactivity disorder (ADHD) and substance use dis- fi ADHD, attention-de cit/hyperactivity disorder, nonstimulant orders are inextricably intertwined. Children with ADHD are more medication, safe prescribing, medication, substance abuse likely than peers to develop substance use disorders. Treatment with may reduce the risk of substance use disorders, but ABBREVIATIONS stimulants are a class of medication with significant abuse and di- AAP—American Academy of Pediatrics ADHD—attention-deficit/hyperactivity disorder version potential. The objectives of this clinical report were to present DSM-5—Diagnostic and Statistical Manual of Mental Disorders, practical strategies for reducing the risk of substance use disorders Fifth Edition in patients with ADHD and suggestions for safe stimulant prescribing. OR—odds ratio SUD— Pediatrics 2014;134:e293–e301 This document is copyrighted and is the property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the INTRODUCTION American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. Attention-deficit/hyperactivity disorder (ADHD) is the most common The American Academy of Pediatrics has neither solicited nor neurobehavioral disorder of childhood and occurs in approximately 8% accepted any commercial involvement in the development of the content of this publication. of children and .1,2 It is characterized by deficits in attention in The guidance in this report does not indicate an exclusive addition to hyperactivity and that cause functional im- course of treatment or serve as a standard of medical care. pairment in at least 2 settings.3 ADHD is considered a chronic con- Variations, taking into account individual circumstances, may be dition.4 Stimulant medication is recommended as first-line therapy for appropriate. school-aged children with ADHD, with implementation of behavioral therapy also recommended. Children with ADHD are at high risk of having co-occurring and behavioral problems, including substance use disorders (SUDs).5,6 It is not clear whether stimulant treatment reduces the risk of SUDs in adolescents with ADHD. Some epidemiologic studies have found an inverse association between stimulant treatment and SUDs,7,8 although this association was not found in a study that examined the relationship between ADHD, stimulant medication, and .9,10 Stimulant medication can also have significant potential for misuse,11 abuse, and di- www.pediatrics.org/cgi/doi/10.1542/peds.2014-0992 version12,13 (ie, giving away, trading, or selling of prescription medi- doi:10.1542/peds.2014-0992 cation), which complicates care. Although the potential for misuse All clinical reports from the American Academy of Pediatrics and diversion of stimulants has been studied,11,12 there is a paucity of automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. recent research on the abuse potential of stimulants among children PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). and adolescents. The objectives of the present clinical report were to review the literature and provide practical suggestions for optimizing Copyright © 2014 by the American Academy of Pediatrics ADHD care while minimizing misuse, abuse, and diversion of stimulant medication.

PEDIATRICS Volume 134, Number 1, July 2014 e293 Downloaded from www.aappublications.org/news by guest on September 28, 2021 EPIDEMIOLOGY OF SUDS AMONG meeting criteria for a diagnosis of ADHD Stimulant medications manage ADHD INDIVIDUALS WITH ADHD in is associated with de- symptoms by increasing synaptic do- veloping SUDs in a subject’s 20s and 30s. pamine concentrations in the striatum Children and adolescents with ADHD Among individuals with ADHD, the num- (which includes the nucleus accumbens) are more likely to misuse , to- ber of inattention and hyperactivity/ via presynaptic transporters.35 Theo- bacco, and other illicit substances com- impulsivity symptoms exhibited is posi- retically, some individuals with ADHD pared with children without ADHD.14,15 tively correlated with risk of substance may use substances to increase syn- In a 2011 meta-analytic review of the use.21 Debate exists regarding whether aptic dopamine concentrations as prospective association of childhood the inattentive versus hyperactive/ a form of self-medication.36 Another 14 ADHD and substance use, Lee et al impulsive subtypes of ADHD confer theory proposes a common genetic included 27 longitudinal studies that different risk.22–26 factor underlying both ADHD and followedupchildrenwithandwithout risk of SUDs, although more studies ADHD into adolescence or adulthood. EXPLORING THE BIOLOGICAL AND are needed to further evaluate this The following demographic/methodologic association.37,38 factors did not significantly moderate ENVIRONMENTAL BASIS OF THE Children and adolescents with ADHD the associations between childhood RELATIONSHIP BETWEEN ADHD AND SUD have higher rates of grade retention ADHD and substance outcomes: gen- and school dropout than those without der, age, race, publication year, sample To date, the mechanisms underlying ADHD.39,40 These academic failures the association between ADHD and source, version of the Diagnostic and may increase an individual’s likelihood SUDs are not completely understood, Statistical Manual of Mental Disorders to use as a means to escape although several theories have been used to diagnose ADHD, family history anxiety about school.41 Academic fail- proposed. Impulsivity is associated of SUD, cognitive impairment, executive ures may also cause changes in peer 16 with an increased risk of substance dysfunction, and family environment. groups, placing the individual with use,27 a prerequisite for developing an Lee et al reported that, compared with ADHD in social settings with others SUD. It is also possible that impulsivity control subjects without ADHD, chil- who have experienced school prob- and poor judgment associated with dren with ADHD were: lems and are at a higher risk of al- ADHD contribute to the development  twice as likely to have a lifetime cohol and use.42,43 of SUDs.28 However, executive func- history of use (odds ratio tioning deficits and increased sub- [OR]: 2.08, P < .001); stance use seem to be only one piece TREATING ADHD AND CO-OCCURRING MENTAL HEALTH  nearly 3 times more likely to report of the puzzle.29 In addition to difficulty in adolescence/ with executive functioning and poor DISORDERS TO REDUCE THE RISK adulthood (OR: 2.82, P < .001); judgment, which may lead to trying OF SUDS  almost 2 times more likely to meet substances, individuals with ADHD Treatment of ADHD May Reduce the diagnostic criteria for may also be biologically more vul- Risk of SUDs or dependence (OR: 1.74, P < .001); nerable to developing addiction than Treatment of ADHD symptoms with  approximately 1.5 times more likely their peers without ADHD. stimulant medication may reduce the to meet criteria for marijuana use Dopamine transmission is central to risk of developing SUDs.7,44 Biederman disorder (OR: 1.58, P =.003); current models of both ADHD and et al45 determined that pharmaco- 30–32  twice as likely to develop SUDs. Compared with unaffected therapy was associated with an 85% abuse or dependence (OR: 2.05, control subjects, individuals with reduction in risk of SUDs in youth with P < .001); and ADHD have greater dopamine trans- ADHD. Timing of treatment matters:  porter density, which may result in children with ADHD who are treated more than 2.5 times more likely to rapid clearance and low levels of with stimulant medication at a youn- develop an SUD overall. synaptic dopamine.33 Drugs of abuse, ger age are less likely to use sub- ADHD is associated with an earlier age including cocaine, , stances than those who have delayed at onset of substance use and a higher , Ecstasy, nicotine, onset of treatment.46 Behavioral ther- likelihood of use of a variety of sub- alcohol, , and marijuana, all apy may also confer some protection stances.17–19 Brook et al20 reported increase synaptic dopamine concen- against substance use. Findings from that the diagnosis of ADHD poses an trations, most notably in the brain’sre- the Multimodal Treatment Study of increased risk of SUD into adulthood; ward center, the nucleus accumbens.34 Children with ADHD revealed that

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behavioral interventions afforded pro- risk. Brook at el20 determined that used medications for ADHD and their tection from SUDs at 24 months’ post- conduct disorder mediated the associ- suspected relative abuse potential. intervention but not at 36 months.47 The ation of ADHD and SUDs. Other studies The terms “misuse,”“diversion,” and optimal age at which to begin treatment have revealed that, even after control- “abuse” are all associated with im- of ADHD to decrease the risk of sub- ling for conduct disorder, ADHD symp- proper use of medication, but they stance use has not been established. toms are associated with increased risk are different phenomena with dif- The American Academy of Pediatrics of both substance use and development ferent definitions. The term misuse (AAP), in its clinical practice guidelines of SUDs.18,25 Comorbid conditions, in- includes the use of medications not for ADHD,4 recommends treating ADHD cluding , anxiety, and low symptoms in children 6 years and older self-esteem, have each been noted to prescribed to the individual and using by using both behavioral interventions confer increased risk of substance use medications in ways other than pre- and medications approved by the US in individuals with ADHD.5,17,25,50,51 These scribed. Examples of misuse include Food and Drug Administration. The AAP findings suggest that diagnosing and taking larger or more frequent doses recommends that ADHD symptoms in treating co-occurring conditions in than prescribed or using someone children as young as 4 years be treated individuals with ADHD may help to re- else’s medication to enhance perfor- with behavioral interventions and duce the risk of developing SUDs. mance.13 The most common reasons possibly medications. In this context, reported for stimulant misuse are to treatment of ADHD symptoms is rec- STIMULANT MEDICATIONS concentrate, study, and improve ommended as soon as the diagnosis grades; “to party” and “get high”;and Stimulant medications are highly effec- of ADHD is made. Symptoms of ADHD to experiment.54–57 Most individuals who 48,49 tive for children and adolescents in re- often persist into adulthood, al- misuse stimulant medications do so via ducing the core symptoms of ADHD.52 though optimal duration of medication oral administration, with intranasal in- treatment has not been established. The most commonly used preparations sufflation (“snorting”) less common.43,46 Maintaining children on medication of stimulant medication are methyl- Adolescents who report snorting medi- while symptoms persist and monitor- phenidate and amphetamine. Atom- cations or using stimulants to “get high” ing for adverse effects seems to be oxetine, a selective norepinephrine may be at highest risk of stimulant a reasonable approach. reuptake inhibitor, and long-acting guanfacine and clonidine, which abuse and dependence.58 The term di- AsnotedintheAAPclinicalpractice are selective α -adrenergic ago- version means the transfer of medica- guidelines for ADHD,4 at any point at 2 nists, are also recommended for tion from the person to whom it is which a clinician believes that he or she the management of some ADHD is not adequately trained or is uncertain prescribed to a person for whom it is symptoms.4 However, the effect sizes 13 about making a diagnosis or continuing not prescribed. The term substance (meaning likelihood of reducing ADHD with treatment, a referral to a pediatric abuse was used in the Diagnostic and symptoms compared with placebo) are or mental health subspecialist should be Statistical Manual of Mental Dis- lower for atomoxetine and long-acting made. If a diagnosis of ADHD or other orders, Fourth Edition, to refer to use guanfacine and clonidine than they are condition is made by a subspecialist, the associated with problems or risk that for the stimulant medications. primary care clinician should develop interfere with functioning. The term a management strategy with the sub- Stimulant medications are both more refers to loss of control or 53 specialist which ensures that the child effective at treating ADHD symptoms compulsive use of a substance. In the will continue to receive appropriate care and much more commonly misused Diagnostic and Statistical Manual of than nonstimulant medications. Pedia- consistent with a medical home Mental Disorders, Fifth Edition (DSM- tricians are thus in a position to pre- wherein the primary care clinician part- 5), diagnostic terms were changed to scribe a medication that can reduce ners with parents so that both health and SUD, mild/moderate/severe, depend- mental health needs are integrated. both ADHD symptoms and the risk of developing an SUD and simulta- ing on the number of positive crite- neously pose a risk for abuse and ria.3 Even though they are not formal Treating Co-occurring Mental diversion. An understanding of the diagnoses, the terms substance abuse Health Disorders factors associated with misuse, and addiction will likely remain in the Co-occurring mental health conditions abuse, and diversion of stimulant lexicon and retain their meaning for are common in individuals with ADHD medication may help to guide safe some time, particularly in reference and are associated with increased SUD use. Table 1 lists the most commonly to prescription medications.

PEDIATRICS Volume 134, Number 1, July 2014 e295 Downloaded from www.aappublications.org/news by guest on September 28, 2021 TABLE 1 List of Most Commonly Used Medications for ADHD With Suspected Relative Abuse disorders are more likely to both Potential misuse and divert their stimulant a Stimulant Status Medication Type US Trade Name Suspected Relative medication,64 as are white individuals, Abuse Potentialb members of fraternities and sorori- Stimulants Short-acting/immediate Ritalina High ties, and students with lower grade- release Methylina High point averages.54,65 Focalina High a Amphetamine- High Abuse of Stimulant Medications Dextroamphetamine Dexedrine High Methylphenidate and amphetamine a DextroStat High both have known abuse potential, al- ProCentra High LA/ER Methylphenidate Metadate CD Medium though there is little evidence that Metadate ERa Medium these drugs are widely abused by the a Ritalin LA Medium patients to whom they are pre- Ritalin SRa Medium 59 Methylin ER Medium scribed, and evidence for abuse po- Daytrana patch Low tential among children and adolescents a Concerta Low is limited. “Subjective effect” (ie, how Quillivant XR Low Dexmethylphenidate Focalin XR Low much a person likes a drug, achieves Dextroamphetamine Dexedrine Spansulea Medium , experiences reinforcement a Amphetamine- Adderall XR Medium with use) is an important factor con- dextroamphetamine Vyvanse Low sidered in determining abuse potential Nonstimulants of a substance. Among individuals with- α 2-adrenergic agonists Guanfacine Intuniv Low out ADHD, both methylphenidate and Clonidine Kapvay Low fi Selective norepinephrine Atomoxetine Strattera Low amphetamine produce signi cant sub- reuptake inhibitor jective effects; amphetamine is nearly CR, controlled release; ER, extended release; LA, long acting; XR, extended release; SR, sustained release. twice as potent as methylphenidate at a Indicates that generic formulation is available. equivalent doses.66 Research performed b Relative abuse potential is suspected based on length of action and formulation of medication. in the 1970s revealed that stimulants do not reliably produce these subjec- Misuse of Stimulant Medications prescription stimulants in their life- tive effects in individuals with ADHD.67 68 Misuse and diversion of stimulant time. Nonmedical use of prescription Fredericks and Kollins found that medications are more widespread stimulants was associated with pre- individuals with ADHD displayed a high- problems than abuse or addiction.59 vious use of illicit substances as well er preference for methylphenidate com- Wilens et al54 conducted a systematic as alcohol and marijuana dependence. pared with placebo, although other review of the literature examining measures of abuse potential, specifically misuse and diversion of prescription Diversion of Stimulant Medications participant-rated effects of methylpheni- ADHD medications. Of the 21 studies Diversion of stimulant medication is date on mood, were not elevated. Thus, reviewed, rates of past-year non- common. Between 16% and 23% of the preference for methylphenidate may prescribed stimulant use ranged from school-aged children reported that they reflect its therapeutic efficacy rather 5% to 9% in grade school and high have been approached to sell, give, or than abuse potential. Most of the studies school children and from 5% to 35% trade their prescription stimulant evaluating abuse potential of stimulant in college-aged individuals. In a large medication.60,61 Boys are more likely medications used short-acting prepara- public university in the mid-Atlantic to divert their stimulant medications tions, and there is evidence that region, Arria et al55 found that 18% of than girls.62 The most common source sustained-release and longer acting students who were not prescribed of diverted medications is friends preparations have decreased abuse po- stimulants engaged in nonmedical and family members.63 More than one- tential.59,69 Indeed, short-acting medi- stimulant use, more than one-quarter quarter of university students reported cations are more likely to be misused or (26.7%) of students with diagnosed that diverted stimulant medications are abused, and amphetamine preparations ADHD reported having used more easy or somewhat easy to obtain.56 are misused and abused more fre- medications than prescribed, and Individuals with ADHD who have co- quently than methylphenidate prepa- 15.6% reported using someone else’s occurring SUDs and/or conduct rations.53,70,71

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SAFE STIMULANT-PRESCRIBING Screen Older Children and Provide Anticipatory Guidance PRACTICES Adolescents for Use of Alcohol, Anticipatory guidance regarding Marijuana, and Other Drugs In light of the high risk of SUDs among proper use of stimulant medications individuals with ADHD, pediatricians The AAP recommends screening, brief should be part of every patient en- should seek to accurately diagnose intervention, and referral to treat- counter in which medications for ADHD and treat symptoms appropriately. ment as part of routine health care ADHD are discussed. Table 2 lists Several precautions may help to reduce for older children and adolescents.74 points that should be included in this stimulant misuse, abuse, and diversion. This recommendation is particularly discussion. The pediatrician should important for adolescents with ADHD, discuss that medications should only whoaremorelikelytousesub- be taken as prescribed by the phy- Before Prescribing, Confirm a Diagnosis of ADHD stances and to develop an SUD than sician, even with very young children, their peers. Adolescents with ADHD in a developmentally appropriate Inattention is multifactorial. Many who use alcohol, marijuana, or other manner. As children enter the upper children or adolescents who are de- substances are also more likely to elementary school years, the con- pressed, anxious, neglected, or having divert stimulant medication and thus versation should evolve to include fi academic dif culty because of require increased attention and discussion about the proper use of a learning disorder may present as monitoring by their prescriber. medication. Children and parents inattentive. ADHD is a primary dis- The AAP policy statement titled should be aware of the risk for mis- order of attention. According to the “ use, diversion, and abuse. Children diagnostic criteria for ADHD in the Substance Use: Screening, Brief In- tervention, and Referral to Treatment should understand that trading or DSM-5,3 ADHD symptoms must be for Pediatricians”74 provides a com- selling stimulant medication is ille- present during childhood; thus, par- gal. Children who live in areas of ticular caution is warranted before plete review of recommended screen- ing tools and brief interventions for high-crime rates should have a con- making a new diagnosis of ADHD, es- crete, realistic safety plan for man- pecially in an adolescent. Although it adolescent substance use. The AAP “ aging their medication. For children is possible that symptoms in child- currently recommends the 3 open- ing questions” associated with the who are 12 years and older, the dis- hood were unnoticed, adolescents cussion should also include in- sometimes attempt to get a stimulant CRAFFT tool (see the following text) to detect past-year substance use. Al- formation about careful transitioning prescription by feigning symptoms of of administration of medication. Al- though currently an active area of ADHD.72 The diagnosis of ADHD is though the child should not be National Institutes of Health–funded made clinically in an individual who pushed to start self-administering fi research,75,76 these questions have ful lls the criteria for ADHD listed in medication, having this discussion not been validated to date, and it is the DSM-5.3 Standardized tools, such earlier with the family can alert them not known whether the “other drugs” as parent- and teacher-completed that transition of medication man- question is sensitive enough for ADHD rating scales, assist in making agement from caregiver to child identifying misuse or abuse of pre- a diagnosis and should be used in the should be a gradual and carefully 73 scription medications. An additional assessment. A thorough history, re- monitored one so that when the child question (eg, “Have you ever used view of medical and school records, is developmentally ready to assume someone else’s prescribed medica- and a collateral parent interview may more responsibility of medication fi tion?”) may be warranted to identify all help con rm a correct diagnosis. management, there is a plan in place misuse, particularly before pre- The criteria used for diagnosing ADHD to ensure that the transition is safe. and any history or evaluations that scribing a stimulant medication for were made to rule out other con- the first time. ditions that might be confused with “Opening questions” to identify past- Document Prescription Records ADHD (eg, sleep disturbances, other year substance use: Stimulant medication is a Drug En- learning disabilities, thyroid dysfunc- In the past year, have you: forcement Administration Class II tion) should be recorded in the controlled substance. Every prescriber 1. Had a drink with alcohol in it? patient’s medical record. The AAP’s must document and monitor the pre- Clinical Practice Guideline for ADHD 2. Used marijuana? scribing of stimulant medications. provides specific guidance about di- 3. Used any other substance to get Requests for early refills should be agnosis and management.4 high? explored and carefully documented to

PEDIATRICS Volume 134, Number 1, July 2014 e297 Downloaded from www.aappublications.org/news by guest on September 28, 2021 TABLE 2 Discussion Points for Anticipatory Guidance Regarding Stimulants and Substance Use medication, it may be best to start with

Proper administration a long-acting stimulant medication At each clinic visit, review with the patient how he or she is taking his or her stimulant medication. with low risk of misuse or diversion. • Only take the amount of medicine prescribed. Do not take extra medication. Long-acting preparations, especially • Take your stimulant medication exactly as prescribed. Do not change the dose or timing. Speak to your those with an osmotic controlled- doctor if you do not think your medication is working as it should or if you are experiencing adverse effects. release oral delivery system such as • Do not use alcohol, , marijuana, or other illicit substances. Drug use worsens problems with Concerta, have lesser likelihood of attention, leads to medication noncompliance, and can interact with stimulant medication. misuse or diversion.77 It is also rea- • If stimulant medication is administered at school, it should be dispensed at school nurse’soffice or other safe location with adult supervision. sonable to consider use of a non- Risk of misuse, diversion, and abuse stimulant preparation,78 even though For people who do have ADHD, when stimulant medications are taken as prescribed, there is no nonstimulant medications are less increased risk of abuse; rather, stimulant medication appears to decrease the risk of developing an fi 79 SUD. ef cacious than stimulants. The • Explain that some people who do not have ADHD may take stimulant medications inappropriately. prodrug formulation of dextroam- • Inform patient and parent that children and adolescents may be asked to give away or sell their phetamine, lisdexamfetamine, has stimulant medications but should never do so. Parents may role play appropriate responses so that a lower abuse potential than other the child will be prepared if asked. Have the patient and parents keep medication in a safe location (either at home or in a locked office at school). Medications should never be carried in a backpack or stimulants and thus may be consid- purse. ered.80,81 However, physicians should Transition of care be aware that any psychoactive med- Transitioning of administration of stimulant medication from caregiver to child/adolescent should be done incrementally. Parents and patients should be counseled that ADHD generally persists into ication can be misused. As for all adulthood. patients, it is important to carefully • To start a transition, the child/adolescent must be able to remember to take medication as prescribed. monitor medication adherence. Signs suggesting readiness should include the ability to name the medication, dose, and timing of administration as well as emerging signs of independence in other areas, such as being home alone, A special circumstance occurs when carrying a key, completing homework independently, or participating in care for a pet. a pediatrician prescribes stimulant • The caregiver should continue to periodically supervise medication administration and monitor the medications for college students and child’s/adolescent’s overall school, social, and family functioning. Weekly pill dispensers can allow burgeoning autonomy for the child/adolescent while allowing the caregiver to monitor doses and older patients living away from home. control the supply. A treatment plan should document • If concerns develop regarding medication misuse or diversion or use of other drugs, the parent how medication will be prescribed and should resume control of the medication, dispense each dose, and monitor carefully. how frequently the patient is expected to return for follow-up visits with the detect a pattern of frequent early symptoms of substance use may be pediatrician. Medication administra- requests. Similarly, it is important to indistinguishable from ADHD symp- tion by a student health staff member document communications between toms. In general, an active SUD should or keeping medications in a small multiple providers who share re- be treated (usually via referral to medication safe may reduce diversion sponsibilities for prescribing medi- a or addiction or theft. Follow-up visits should include cations or altering treatment regimens specialist) before beginning medica- self-report of medication efficacy, ad- for the same patient. tion to treat ADHD. However, for verse effects (appetite, abdominal patients with well-documented ADHD symptoms, headaches, and sleep dis- that predates the onset of substance turbance) and screening for medica- Prescribing Medications for ADHD use, it may be reasonable to treat both tion misuse, abuse, or diversion. in Context of Active SUD disorders concurrently. Consultation The patient’s responses should be Illicit substance use often results with a psychiatrist or addiction spe- documented in the medical record. in attention difficulties, hyperactivity, cialist when managing complex patients Reports or suggestions of new physi- and/or impulsivity, making a new di- is suggested. cal or mental health symptoms re- agnosis of ADHD difficult or impossible When considering which ADHD medi- quire reevaluation. to distinguish from symptoms related cation to prescribe to a patient with to ongoing substance use. In these a co-occurring SUD, a careful risk/ cases, reevaluation after a period of benefit assessment must be con- SUMMARY abstinence may be warranted. ducted. If the patient is currently ADHD is a common neurobehavioral Adolescents who have both previously abusing prescription stimulants or disorder of childhood, and individuals diagnosed ADHD and an active SUD there is a clear indication that the with ADHD are more likely to misuse may be difficult to monitor because patient would sell or divert stimulant alcohol, tobacco, and other illicit

e298 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS substances compared with children includes screening for SUDs and LEAD AUTHORS and adolescents without ADHD. Indi- providing anticipatory guidance Elizabeth Harstad, MD, MPH, FAAP viduals with ADHD and co-occurring around the appropriate and safe use Sharon Levy, MD, MPH, FAAP mental health conditions, such as of stimulant medications. Individu- disruptive behavior disorders or als with co-occurring ADHD and COMMITTEE ON SUBSTANCE ABUSE, 2013–2014 depression, are at even higher risk active SUDs require a careful, in- Sharon Levy, MD, MPH, FAAP, Chairperson of developing SUDs. Appropriate dividual risk/benefit assessment Seth D. Ammerman, MD, FAAP treatment of ADHD symptoms with regarding the safety of prescribing Pamela K. Gonzalez, MD, FAAP medication and behavior therapy a stimulant medication. Longer act- Sheryl A. Ryan, MD, FAAP may reduce the risk of development ing preparations of stimulant med- Lorena M. Siqueira, MD, MSPH, FAAP Vincent C. Smith, MD, MPH, FAAP of SUDs. Primary care providers ication, the prodrug formulation should seek to identify and treat of dextroamphetamine, and non- LIAISONS ADHD to prevent the development of stimulant medications for ADHD all Vivian B. Faden, PhD – National Institute of SUDs. However, the recommended have lower abuse potential than Alcohol Abuse and first-line medication therapy for ADHD short-acting preparations of stimu- Gregory Tau, MD, PhD – American Academy of is stimulant medications, which lant medication and, thus, their use Child and Adolescent themselves pose a risk of misuse, di- should be strongly considered if STAFF version, and abuse. Therefore, an im- there is a high risk of misuse, di- Renee Jarrett, MPH portantpartofADHDtreatmentand version, or abuse of stimulant James Baumberger, MPP stimulant medication management medications. Katie Crumley, MPP

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Attention-Deficit/Hyperactivity Disorder and Substance Abuse Elizabeth Harstad, Sharon Levy and COMMITTEE ON SUBSTANCE ABUSE Pediatrics 2014;134;e293 DOI: 10.1542/peds.2014-0992 originally published online June 30, 2014;

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