Understandably, one of the first questions parents ask when they learn their child has an attention disorder is “Why? What went wrong?”

Health professionals stress that since no one knows what causes ADHD, it doesn’t help parents to look backward to search for possible reasons.There are too many possibilities to pin down the cause with certainty. It is far more important for the family to move forward in finding ways to get the right help.

Scientists, however, do need to study causes in an effort to identify better ways to treat, and perhaps some day, prevent ADHD. They are finding more and more evidence that ADHD does not stem from home environment, but from biological causes.

When you think about it, there is no clear relationship between home life and ADHD. Not all children from unstable or dysfunctional homes have ADHD. And not all children with ADHD come from dysfunctional families.

Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child’s behavior.

Over the last decades, scientists have come up with possible theories about what causes ADHD. Some of these theories have led to dead ends,some to exciting new avenues of investigation. One disappointing theory was that all attention disorders and learning disabilities were caused by minor head injuries or undetectable damage to the brain, perhaps from early infection or complications at birth. Based on this theory, for many years both disorders were called “minimal brain damage” or “minimal brain dysfunction.”

Although certain types of head injury can explain some cases of attention disorder, the theory was rejected because it could explain only a very small number of cases. Not everyone with ADHD or LD has a history of head trauma or birth complications. Another theory was that refined sugar and food additives make children hyperactive and inattentive. As a result, parents were encouraged to stop serving children foods containing artificial flavorings, preservatives, and sugars. However, this theory, too, came under question. In 1982, the National Institutes of Health (NIH), the Federal agency responsible for biomedical research, held a major scientific conference to discuss the issue. After studying the data, the scientists concluded that the restricted diet only seemed to help about 5 percent of children with ADHD, mostly either young children or children with food allergies.

SIDEBAR: ADHD Is Not Usually Caused by:

— too much TV
— food allergies
— excess sugar
— poor home life
— poor schools

In recent years, as new tools and techniques for studying the brain have been developed, scientists have been able to test more theories about what causes ADHD. Using one such technique, NIMH scientists demonstrated a link between a person’s ability to pay continued attention and the level of activity in the brain.

Adult subjects were asked to learn a list of words. As they did, scientists used a PET (positron emission tomography) scanner to observe the brain at work. The researchers measured the level of glucose used by the areas of the brain that inhibit impulses and control attention. Glucose is the brain’s main source of energy, so measuring how much is used is a good indicator of the brain’s activity level.

The investigators found important differences between people who have ADHD and those who don’t. In people with ADHD, the brain areas that control attention used less glucose, indicating that they were less active. It appears from this research that a lower level of activity in some parts of the brain may cause inattention.

Brain scan images produced by positron emission tomography (PET) show differences between an adult with Attention Deficit Hyperactivity Disorder and an adult free of the disease.)The next step will be to research WHY there is less activity in these areas of the brain. Scientists at NIMH hope to compare the use of glucose and the activity level in mild and severe cases of ADHD. They will also try to discover why some medications used to treat ADHD work better than others, and if the more effective medications increase activity in certain parts of the brain.

Researchers are also searching for other differences between those who have and do not have ADHD. Research on how the brain normally develops in the fetus offers some clues about what may disrupt the process.Throughout pregnancy and continuing into the first year of life, the brain is constantly developing. It begins its growth from a few all-purpose cells and evolves into a complex organ made of billions of specialized, interconnected nerve cells. By studying brain development in animals and humans, scientists are gaining a better understanding of how the brain works when the nerve cells are connected correctly and incorrectly.

Scientists at NIMH and other research institutions are tracking clues to determine what might prevent nerve cells from forming the proper connections. Some of the factors they are studying include drug use during pregnancy, toxins, and genetics. Research shows that a mother’s use of cigarettes, alcohol, or other drugs during pregnancy may have damaging effects on the unborn child. These substances may be dangerous to the fetus’s developing brain. It appears that alcohol and the nicotine in cigarettes may distort developing nerve cells.

For example, heavy alcohol use during pregnancy as been linked to fetal alcohol syndrome (FAS), a condition that can lead to low birth weight, intellectual impairment, and certain physical defects. Many children born with FAS show much the same hyperactivity, inattention, and impulsivity as children with ADHD. Drugs such as cocaine–including the smokable form known as crack–seem to affect the normal development of brain receptors. These brain cell parts help to transmit incoming signals from our skin, eyes, and ears,and help control our responses to the environment.

Current research suggests that drug abuse may harm these receptors. Some scientists believe that such damage may lead to ADHD.Toxins in the environment may also disrupt brain development or brain processes, which may lead to ADHD. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline and paint were once used. It is also present in some water pipes. Some animal studies suggest that children exposed to lead may develop symptoms associated with ADHD, but only a few cases have actually been found.

Other research shows that attention disorders tend to run in families,so there are likely to be genetic influences. Children who have ADHD usually have at least one close relative who also has ADHD. And at least one-third of all fathers who had ADHD in their youth bear children who have ADHD. Even more convincing: the majority of identical twins share the trait.

At the National Institutes of Health, researchers are also on the trail of a gene that may be involved in transmitting ADHD in a small number of families with a genetic thyroid disorder.

AD/HD and Stimulant Medication Abuse

Treating adults and children with medication has been, and continues to be the subject of great controversy. Even in the face of years of scientific research, advances in understanding how these medications work, and significant improvement in the quality of life for millions around the world, there are still those who question, doubt, and attack the role that medication provides in the treatment of AD/HD.

Even more controversial is treating recovering alcoholics and addicts with stimulant medication. The “evils” of Ritalin have been the target of the media for years. Fear, which is often caused by the lack of accurate information, fuels anti-Ritalin and anti-medication groups. The media, which thrive on controversy, have recently been providing more accurate and scientific information when covering medications to treat AD/HD. Non-biased information that is based on sound research with proven results diminishes fear of the unknown, and squelches myths about the effective use of medication to treat AD/HD.

Stimulant Abuse and Addiction

There has been a flurry of high profile media about the abuse of stimulant medications. Many of these articles or shows focus on young people abusing Ritalin, Adderall, and Dexedrine. The truth is; these medications can be abused and the abuser can become addicted. Unfortunately the media tends to draw erroneous conclusions, such as, the use of stimulant medication to treat AD/HD causes drug addiction.

Most cases of stimulant abuse are among adolescents and adults who are not being treated for AD/HD. These are people that will abuse almost any drug if given the chance. Adderall and Dexedrine, are abused by people who are trying to get a high similar to speed. Ritalin, however, is often abused as a last resort because it doesn’t give the user the euphoria they crave.

Although rare, drug addicts and alcoholics abuse stimulant medication by taking more than prescribed, or by grinding it up to inhale or to mix with water and inject. Some of these people learned how to present as though they had AD/HD in order to obtain stimulants. In most cases, these people had been given large prescriptions with little or no ongoing treatment for AD/HD or addiction.

Facts About Stimulant Medication

Unfortunately, many still hold the inaccurate belief that treating AD/HD with stimulant medication leads to substance abuse later in life, when in fact the opposite appears to be true.

• Untreated AD/HD is a risk factor for developing a substance use disorder later in life. (Biederman et al. 1997, Wilens et al. 1997, Hechtman and Weiss. 1985, Wilens et al. 2003)
• Treating AD/HD with stimulant medication appears to reduces risk of later substance use disorders by half. (Wilens et al. 2003)
• Concurrent treatment for coexisting conditions if they are present (bipolar, anxiety disorders, obsessive thought patterns)

Comprehensive Treatment for Those with Addiction

A comprehensive treatment plan is the most effective way to avoid medication abuse or addiction relapse. Medication should not be used as the sole treatment for AD/HD. Taking pills to rebalance your neurotransmitters is not enough. This means that your AD/HD, eating disorders, other co-occurring conditions and/or addictions are treated at the same time. If you stray away from your addiction recovery, you will be at greater risk to relapse. If you don’t receive adequate treatment for your AD/HD, you’re at greater risk for relapse. A comprehensive treatment plan is one that contains the following components:

• AD/HD treatment in the form of education, coaching, and support groups
• Regular visits with your doctor and close medication management
• Therapy or counseling regarding AD/HD and recovery issues
• Involvement in addiction recovery programs
• Family and relationship counseling when needed

Taking Medication Versus Street Drugs

Here are some important differences between taking prescribed medication and using street drugs.

• Stimulant medication is taken orally, at specific times, in dosages that do not create a “high” or euphoria.
• Due to the low dosage and lack of euphoria, most people do not develop a tolerance to stimulant medication.
• The dosage and quality of medication will not vary. Street drugs can be diluted or cut with baby powder, ephedrine, and who knows what.
• Street amphetamines produce a “high” as a result of much higher doses (several hundred times higher), and the route of administration (smoking, snorting, injecting).
• The intense euphoria produced by high doses of street amphetamines can cause cravings for more and quickly lead to addiction.
• Unlike street drugs, your intake of stimulant medication will be closely monitored by your doctor and other members of your support system.

Conclusion

Many substances including sugar have the potential to be abused by certain individuals. A genetic predisposition for addiction is not the only cause of addiction. Who becomes addicted and who doesn’t is determined by a variety of factors. Environment, stress, trauma, life circumstances, and coexisting conditions such as depression, anxiety, post traumatic stress disorder (PTSD), and AD/HD are important contributing factors.

Stimulant medication such as Adderall, Dexedrine, and Ritalin are abused by those who are drug seeking, or addicted. Most people who take stimulant medication to treat their AD/HD do not abuse it. As a matter of fact, the greater problem is that they forget to take it.

Research indicates that those with untreated AD/HD are at greater risk to self-medicated with substances. Stimulant medication has a protective effect for some with AD/HD and decreases self-medicating. Medication should not be used as the sole treatment for AD/HD. A comprehensive treatment plan is the most effective way to avoid medication abuse or addiction.

References

Biederman, J., Wilens, T., Mick, E., Faraone, S.V., Weber, W., Curtis, S., Thornell, A., Pfister, K., Jetton, J.G., & Soriano, J. (1997). Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 21-29.

Blum, K., Cull, J., Braverman, E., Comings, D. (1996). Reward deficiency syndrome. American Scientist, 84, 132-145.

Bonci, A., Bernardi, G., Grillner, P., Mercuri, N.B. (2003). The dopamine-containing neuron:maestro or simple musician in the orchestra of addiction. Trends Pharmacological Science, 24, 4, 172 April.

Hechtman, L. (1985). Adolescent outcome of hyperactive children treated with stimulants in Childhood: a review, Psychopharmacol Bul, 21:178-191.

Hechtman, L, Weiss, G. (1986). Controlled prospective fifteen year follow-up of hyperactives as adults: non medical drug and alcohol use and anti-social behaviour. Can J Psychiatry, 31:557.

Richardson, W. (1997). The link between ADD and addiction: Getting the help you deserve. Colorado Springs: Piñon Press.

Thompson, L.L., Riggs, P.D., Mikulich, S.K. & Crowley, T.J. (1996). Contribution of ADHD symptoms to substance abuse problems and delinquency in conduct-disordered adolescent. Journal of Abnormal Child Psychology, 24, 325-347.

Whitman, B. (2000). Adult outcomes for persons with attention deficit/hyperactivity disorder. In Accardo, P., Blondis, T., Whitman, B., & Stein, M. (Eds.) Attention Deficits and Hyperactivity in Children and Adults: Diagnosis, treatment, management. 2nd ed., Revised and expanded. New York: Marcel Dekker, Inc.

Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2003). Does Stimulant Therapy Of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse? A Meta-Analytic Review Of The Literature. Pediatrics, 111(1), 179-185.

Wilens TE, Biederman J, Bredin E, Hahesy AL, Abrantes A, Neft D, Millstein R, Spencer TJ. (2002). A Family Study Of The High-Risk Children Of Opioid- And Alcohol-Dependent Parents. The American Journal On Addictions. Winter, 11(1):41-51.

About the Author: Wendy Richardson, M.A., MFT, CAS is a Licensed Marriage, Family Therapist, and Certified Addiction Specialist in private practice in Soquel, California. Wendy is the author of The Link Between ADD & Addiction, 1997, Piñon Press. She has contributed chapters on AD/HD to books focusing on criminology and on women with AD/HD. She has also authored numerous articles on AD/HD and co-occurring conditions. She is a consultant, trainer, and is a frequent presenter at national AD/HD, addiction, criminal justice, and learning disorder conferences.