Treating ADHD may prevent smoking

Studies have found that young people with attention deficit and hyperactivity disorder (ADHD) were more likely to pick up cigarette smoking, start earlier when they do and become more seriously addicted to tobacco than peers without the disorder.

One reason for this, says Firas Rabi, MD, a pediatrician in private practice in Dublin, Ohio, is that the nicotine in cigarettes can improve attentiveness and performance. Teens and young adults with ADHD may find that nicotine enhances their attention and, in essence, use cigarette smoking as a form of self-medication. Another reason that smoking is more common is that children with ADHD often experience social difficulties and peer rejection as a result of behaviors or poor social skills. Adding insult to injury, smokers with ADHD are likely to have more severe nicotine dependence and more severe withdrawal symptoms when trying to quit.

Reducing the risk for smoking

There are no specific interventions that can be recommended to reduce the risk of smoking in children with ADHD. Treating people who have ADHD with stimulant medication could reduce their likelihood of taking up smoking, according to research from Duke Medicine in Durham, NC. Publishing their results in the journal Pediatrics, the Duke researchers found "a significant association" between stimulant treatment for ADHD and lower smoking rates. In addition, they concluded that those who took their medication consistently and for a longer period of time had an even lower risk of smoking. The findings are important given concerns raised about long-term impact of stimulant treatment on substance abuse in general and cigarette smoking in particular.

For clinicians treating patients with ADHD who are already smokers, it seems that use of stimulant medication does not have a negative impact on cessation for those interested in quitting. It is currently unclear if there is an effect on those who are not interested in quitting.

Nicotine replacement therapy seems to work equally as well for smokers with ADHD as it does for the general population.

Can a 2-year old have ADHD?

According to the Centers for Disease Control and Prevention (CDC), about 11% of children aged 4 to 17 years old have been diagnosed with ADHD as of 2011. The average age of ADHD diagnosis was 7 years of age, but there is recent evidence that toddlers as young as 2-years old are being diagnosed with ADHD and placed on stimulant medications. A study by the CDC estimated that 10,000 toddlers — children age 2 and 3 years old — are receiving medication for ADHD. This is despite the fact that the American Academy of Pediatrics has very specific criteria for the diagnosis of ADHD, but the guidelines do not apply to children younger than 4 years of age. Even for younger patients diagnosed with the disorder — those 4 to 5 years old — the CDC recommends behavioral treatment first and medication only after behavior interventions don't result in any improvement.

"A 2-year old who is hyperactive and difficult to control doesn't necessarily have ADHD," says Dr. Firas Rabi, a pediatrician who treats children with ADHD in Ohio. Some doctors say ADHD medications could be a last resort physicians turn to when toddlers might harm themselves, but others note having lots of energy and acting out is simply a part of being a young child. "Toddlers are naturally curious, strong willed, fidgety and come with never-ending energy," adds Dr. Rabi.

“Treating babies with stimulants is based on no research, is reckless and takes no account of the possible harmful, long-term effects of bathing baby brains with powerful neurotransmitter drugs,” Allen Frances, a professor emeritus at Duke University, wrote in a piece for the Huffington Post regarding the CDC’s recent findings.

Until we have more data regarding the long-term effects on neurostimulant medications on the developing brains of toddlers, and until physicians are better able to differentiate ADHD symptoms from those of the anxious or depressed toddler, it is best that current ADHD medications not be prescribed to those younger than 4 years old.

Anxiety in Children with ADHD

Up to half of children with ADHD also have anxiety, but the effect anxiety has on the functioning abilities of children with ADHD has received little attention. There is some evidence that children with both ADHD and anxiety are less impulsive, and other evidence that these children have more attentional difficulties than those with ADHD alone. Some studies have shown that anxiety may exacerbate social problems for children with ADHD, but this notion has been challenged by other researchers.

A recent Australian study examined the association between anxiety and the functioning in 561 children with ADHD. Sixty-five percent of these children had anxiety with their ADHD, with social phobia being the most common, followed by generalized anxiety, separation anxiety, obsessive compulsive, post-traumatic stress, and panic disorders. Eighty-five percent of these children were taking medication for their ADHD.

An interesting finding was that those children with ADHD and an anxiety disorder were more likely to have moderate or severe sleep problems, had more severe symptoms of ADHD, and were more likely to have parents with elevated mental health symptoms.

Because anxiety is common in children with ADHD, and since anxiety has a tendency to lead to worse ADHD symptoms, it is very important to screen all ADHD patients for anxiety. My practice at Northwest Pediatrics in Dublin, OH includes screening for anxiety in each of our ADHD initial conferences and during each successive follow-up visit. Systematically assessing and treating anxiety in children with ADHD has the potential to improve functioning in children with ADHD.

The details in this Australian study were published in Pediatrics April 2014 edition.

Suspicions

Do you remember when you first suspected that your child had ADHD? How old was he or she? What did you notice? Did both parents agree on the suspicion? Comment below and let me learn from you!

ADHD Facts

I suppose the first post on an ADHD page should provide some basic information about this disorder. While many people think that any child who is fidgety and inattentive can be classified as having ADHD, the reality is that there are specific criteria to meet this diagnosis. Per the CDC guidelines, a child with inattentive-type ADHD have SIX of the following features:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on tasks or play activities.

• Often does not seem to listen when spoken to directly.

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has trouble organizing tasks and activities.

• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted

• Is often forgetful in daily activities.

A child with hyperactive-predominant ADHD have five or six (depending on age) of the following:

• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often "on the go" acting as if "driven by a motor".
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

There are other criteria that must be met, and a diagnosis should not be made based simply on a checklist.

Firas Rabi, MD

About Me

My name is Firas Rabi. I've been a pediatrician since I completed training in New York City in 2005. Since then, I've completed a fellowship in pediatric critical care and have served on regional as well as national committees to advance the field of pediatrics. My forte is teaching and for a long time I enjoyed teaching medical students, residents, and fellows how to recognize severe illnesses and the various approaches of treatment based on the underlying physiology. My interaction with patients was intense was relatively short-term and I soon longed to return to the roots of pediatrics - the care of children and being a part of their life as they grow up.

That's why I have recently turned my attention to practicing pediatrics and teaching parents and children how to maintain their health. The satisfaction of being a long-term part of a child's health, growth, and development is incomparable.

I've taken a particular interest in helping children with learning difficulties, particularly those with attention deficit [and hyperactivity] disorder (ADD and ADHD). The goal of this blog is to chronicle the new developments in the diagnosis and treatment of ADD and ADHD. It is not my intent to provide medical advice, because only your (or your child's doctor) should do so. However, I would like to hear the stories of parents who have raised a child with ADHD, and it would be great to hear stories from people with ADHD themselves.