This is a guest post by Nancy Konigsberg, an occupational therapist and applied behavioral analysis therapist who has a son with ADHD.

Every time I see an article debating the benefit and/or consequences of giving children stimulant medication for ADHD I take notice. When I read recently that that researchers found a link between ADHD and substance abuse, but no link between medication specifically and substance abuse, I wanted to know why, and why people were speculating that the use of stimulant medications might contribute to substance abuse.

This matters to me personally because my son has ADHD and he takes stimulant medication. But I am also a pediatric O.T. and I recently completed a post-graduate program in Applied Behavior Analysis. What my professional experience and education have taught me is that a disorder does not define behavior. The principle of behavior analysis is that behavior has a function—a child acts in order to get something tangible, or get attention, or to escape something, for instance. Behavior is either strengthened or diminished by the history of reinforcement. Whatever consequence immediately follows a behavior reinforces (negatively or positively) that behavior. If a child is having a tantrum and the parent says “I will give you a treat if you stop tantrumming” and the child stops and gets the treat, the tantrum was just reinforced. That is, the child understands that having a tantrum results in getting a treat.

Until my son was in first grade, when he started on stimulant medication, I would get calls and complaints about his behavior on almost a daily basis. He was thrown out of programs and demoted. It’s not that he was badly behaved per se. It was just that he couldn’t sit still, he couldn’t follow directions and that he had a hard time adjusting to a group environment. Almost the minute he started the meds, his life started to change. He could listen and attend and interact appropriately with his peers. This allowed him to do well academically. And it wasn’t just in academics that he started to excel. He was named “outstanding music student of the year” and “most improved swimmer” on the swim team. Prior to taking the medication he had difficulties with motor skills. It seems that the medication allowed him to process information much better. Slowing him down allowed him to learn. And when he learned, he started to succeed. When he succeeded he got rewarded with commendations, trophies and good grades. The reinforcement of recognition and praise keeps my son on track.

This makes me wonder about the link between ADHD and substance abuse: whether those kids who have ADHD and don’t get positive feedback turn to drugs because of their history of reinforcement. When children aren’t behaving appropriately or aren’t doing well in school they usually hear criticism instead of praise. If all they ever hear is “Why can’t you do better?” or “Why did you get detention?” or “Why can’t you do anything right?” they develop poor self-esteem. They don’t get feedback that will keep them on a good path. Their history of reinforcement is one of negativity. Ultimately, they seek approval from peers or escape or just a means to feel good. They achieve this with substances such as drugs and alcohol.

The study linking ADHD and substance abuse itself offers evidence for this hypothesis. The researchers noted that children with comorbid ADHD and ODD/CD (oppositional defiant disorder/conduct disorder) may be much more at risk than those with just ADHD. They observed that the ODD/CD might be the problem rather than the ADHD. They also noted that there is evidence that parental maltreatment is more likely to independently predict substance abuse problems than childhood ADHD. The point here is that the history of reinforcement might be the most relevant factor in contributing to future substance abuse.

Why do I bring all of this up? It is easy to form misconceptions when we hear that children with ADHD are three times more likely to develop substance use problems than typical children. And it is easy to shy away from trying stimulant meds when you hear that they may be related to addiction. But the ADHD or stimulants might not have a causal relationship with substance use. It may well be that it is the history of reinforcement for a child which is much more predictive of future behavior.