1. Problem & Objectives Methods Preventing Smoking in Adolescents with ADHD: A High Risk Population Results  Universal smoking prevention programs may prove more effective if supplemented by programs that target specific populations.  Intervention should occur at the level of risk in order to prevent future smoking behavior. Recommendations Steven W. Evans, Ph.D. Amy L. Williams, B.S. Sheryle A. Moore, B.S. Zewelanji Serpell, Ph.D. Lindsay Barnett Jennifer Capito, B.A. As part of a long-term treatment study, researchers developed a comprehensive treatment program to address specific risk factors associated with ADHD so as to prevent future smoking behavior. As a number of individuals are typically involved in treating adolescents with this disorder, development of this program was collaborative in nature, incorporating feedback and expertise of teachers, physicians, clinicians, and parents of children of ADHD. The ultimate goal was to develop a treatment program that is both effective for treating these symptoms of ADHD that place adolescents at risk for smoking and feasible for implementation in community settings. The Challenging Horizons Program The resulting program, the Challenging Horizons Program (CHP), is a community-based treatment program that is currently being implemented in 2 middle schools and pediatric practices in Virginia. The program consists of a set of psychosocial interventions that are implemented at school, and a medication algorithm. CHP treatments are designed to target the academic and social impairments characteristic of ADHD that place adolescents with this disorder at risk for smoking. Researchers recruited 40 sixth-grade participants from four middle schools. Participants attending schools assigned to the treatment condition receive the treatments described above. Participants attending schools assigned to the control condition (n=20) receive typical care for ADHD. For all participants, ADHD symptoms and impairment, tobacco use, exposure, and experimentation were measured upon entry into the program. ADHD symptoms and impairment that serve as risk factors for smoking were assessed by the Disruptive Behavior Disorders Rating Scale (DBD) and the Social Skills Rating System (SSRS). Smoking behavior was assessed using the Substance Use Questionnaire (SUQ). Results from baseline assessments for 29 of the participants who have completed initial evaluations follow. Adolescents with Attention Deficit Hyperactivity Disorder (ADHD) smoke at a significantly greater rate than their peers without ADHD, suggesting that ADHD is a risk factor for tobacco use. A study by Milberger et al (1997) revealed that ADHD, particularly when comorbid with other disorders, predicted early initiation of cigarette smoking. In another study, participants with inattention problems were found to be more likely to experiment with cigarette smoking and to become regular tobacco users (Tercyak, Lerman, Audrain, 2002). The apparent link between ADHD and smoking suggests symptoms associated with this disorder might serve as risk factors for smoking. It has been argued that the inattention, impulsivity, and social impairment characteristic of ADHD contribute to substance experimentation and use. In one study, impairment in social functioning (common in youth with ADHD) was the sole significant predictor of alcohol and substance abuse, as well as smoking (Greene, Biederman, Faraone, Wilens, Mick, & Blier, 1999). Because, similar to stimulant medication, nicotine has been shown to improve attention, the possibility also exists that smoking may serve as a form of self-medication for youth with ADHD (Patton et al., 1996). Such findings suggest that by specifically targeting the risk factors associated with ADHD, there is a unique opportunity to prevent smoking in this youth population. Our initial objective was to recruit participants and assess the extent to which they exhibited the aforementioned risk factors for smoking and also establish that our method and design would facilitate intervention before the onset of smoking in this high risk population. Research supported by a grant from the Virginia Tobacco Settlement Foundation Baseline assessment data was available for 29 study participants all of whom were in the sixth grade at one of the participating middle schools. Participants included 20 males and 9 females between the ages of 10 and 13. All 29 participants met criteria for ADHD as outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). 20 met criteria for combined type ADHD and nine met criteria for predominantly inattentive type. Social Impairment - Impairment in social functioning was assessed using parent report on the SSRS. Results indicate that out of 29 participants, 4 were rated by their parents as being average or above in social skills, the rest were rated as below average, some significantly impaired. Smoking Behavior - Results from the SUQ reveal that of the 29 participants, only 2 reported ever having tried a cigarette and neither of them reported ever having smoked a cigarette beyond simply trying one. Works Cited Tercyak, K., Lerman, C., & Audrain, J. (2002) Association of attention-deficit /hyperactivity disorder symptoms with levels of cigarette smoking in a community sample of adolescents. Journal of American Academy of Children and Adolescents, 41(7), 799-805. Greene, R., Biederman, J., Faraone, S., Wilens, T., Mick, E., & Blier, H. (1999) Further validation of social impairment as a predictor of substance use disorders: Findings from a sample of siblings of boys with and without ADHD. Journal ofClinical Child Psychology, 28(3), 349-354. Lerman, C. Audrain, J., Tercyak, K., Hawk, L., Bush, A., Crystal- Mansour, S., Rose, C., Niaura, R., & Epstein, L. (2001) Attention deficit hyperactivity disorder ADHD symptoms and smoking patterns among participant in a smoking cessation program. Nicotine and Tobacco Research, 3(4), 353-359. Biederman, J., Wilens, T., Mick, e., Spencer, T., & Faraone, S. (1999). Pharmacotherapy of Attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics, 104, 1-5. Lambert N. & Hartsough, C. (1998). Prospective study of tobacco smoking and substance dependencies among samples of ADHD and Non-ADHD participants. Journal of Learning Disabilities, 31(6), 533-544. Milberger, S., Biederman, J., Faraone, S., Chen, L., & Jones, J. (1996). Further Evidence of an association between Attention- deficit/hyperactivity disorder and cigarette smoking. The American Journal on Addictions, 6(3), 205-215. Conclusions & Rationale for Recommendations Results from baseline assessment establish the presence of at least two risk factors for smoking in the sample, inattention and social impairment. Consistent with studies reporting the average age of smoking initiation in adolescents with ADHD is 15.5 years (Milberger et al., 1997), results also show that the majority of participants did not classify themselves as smokers or report ever having tried smoking. Because participants are recruited in the sixth grade, at an age that is lower than the typical age of smoking onset for this population, our method and design can successfully target youth before the critical period when they are likely to initiate smoking. The impairment that is associated with ADHD that places students at risk for smoking will be evaluated for each participant over the course of the next five years. Future work will therefore examine the effectiveness of the Challenging Horizons Program as a prevention program for smoking in this high risk population.