|Home | About | Journals | Submit | Contact Us | Français|
ObjectiveTo examine whether a recent prescription for stimulant medication is associated with peer victimization among youth with attention deficit/hyperactivity disorder (ADHD).MethodsData from 4,965 adolescents attending five public schools who completed an annual web survey over 4 years were used to examine recent stimulant medication prescription and self-reported frequent victimization.ResultsAdolescents with ADHD and recent stimulant prescription reported more victimization than those without ADHD, but similar to adolescents with ADHD and no recent prescription. Adolescents with ADHD and past 12-month diversion of their prescribed stimulants were at greatest risk of 12-month frequent victimization compared with adolescents without ADHD and adolescents with ADHD but no recent prescription. Youth approached to divert reported more victimization than youth not approached. Youth who diverted reported more victimization than those who did not divert.ConclusionsClose parent–prescriber collaboration is needed to ensure effective medical treatment for ADHD without greater risk for victimization and treatment failure.
Attention deficit/hyperactivity disorder (ADHD) is a neurobiological disorder with childhood onset that affects development and well-being across the lifespan (Pliszka, 2007; Visser et al., 2014; Wilens et al., 2008). Children diagnosed with ADHD are more likely to experience anxiety, learning difficulties, peer difficulties, substance use disorders, and academic failure, as well as injuries and emergency room visits (Bagwell, Molina, Pelham, & Hoza, 2001; Visser et al., 2014). More than 1 in 10 school-aged children received a diagnosis of ADHD in the United States in 2011, a 42% increase from 2003 (Visser et al., 2014). There is evidence that stimulant medications can be an effective treatment for ADHD in terms of reducing long-term negative consequences and increasing school functioning (Biederman, Monuteaux, Spencer, Wilens, & Faraone, 2009; Wilens et al., 2008), reflected by a 27% increase in stimulant-treated ADHD between the years 2007 and 2011 (Visser et al., 2014; Wilens et al., 2008).
Current research provides evidence that proper use of stimulant medication to treat ADHD in youth decreases disruptive classroom behaviors such as impulsivity and hyperactivity (Katzman & Sternat, 2014; Pelham, Wheeler, & Chronis, 1998). Thus, there are observable differences between youth who are prescribed stimulants to treat their ADHD symptoms versus youth who are not, although it is unclear whether these behavioral improvements result in higher or normative academic achievement (Barnard-Brak & Brak, 2011; Molina et al., 2009). Previous research indicates that males, Caucasian youth, and youth with more severe symptoms of ADHD were more likely to be prescribed stimulants for treatment of ADHD (Barbaresi et al., 2006; Zuvekas & Vitiello, 2012); however, a more recent examination suggests that female youth are beginning to be prescribed at similar rates as their male counterparts (Barbaresi, 2014). It also appears that children who report more injuries are also more likely to be prescribed stimulant treatment for ADHD between childhood and adolescence (Dalsgaard, Leckman, Nielsen, & Simonsen, 2014). Overall, youth prescribed stimulant treatment did not appear to differ on key demographics including parental age, education, or marital status (Barbaresi et al., 2006). Additionally, youth with ADHD-Combined Type or ADHD-Hyperactive/Impulsive Type were more likely to be diagnosed and prescribed stimulants at younger ages than those youth diagnosed with ADHD-Inattentive Type (Barbaresi et al., 2006). There is also evidence that earlier treatment of ADHD is associated with fewer adverse consequences such as grade retention, anxiety, depression, later substance use problems and subsequent diagnoses of conduct disorder or oppositional defiant disorder (Biederman et al., 2008, 2009). Consequently, youth who divert their prescribed medications may be increasing their risk for a host of negative health outcomes owing to inadequate treatment of their ADHD symptoms.
Prescription stimulants such as amphetamine-dextroamphetamine combination agent and methylphenidate, which are frequently used to treat ADHD, are Schedule II controlled substances in part because they have abuse liability owing to pleasurable effects (Vitiello, 2001). In fact, stimulants prescribed to treat ADHD are one of the most diverted drug classes among adolescents and is a significant problem in this age-group (Cottler, Striley, & Lasopa, 2013; McCabe, West, Teter, et al., 2011), including the potential for abuse and dependence (Vitiello, 2001; Wilens et al., 2008). Moreover, research indicates that adolescents are more likely to misuse prescription stimulants “to get high,” for “experimentation,” to “help with concentration,” or to “increase alertness” (Boyd, McCabe, Cranford, & Young, 2006). Given the increasing and ongoing prescription of stimulant medication for ADHD treatment (Pliszka, 2007; Visser et al., 2014; Wilens et al., 2008) and the fact that these medications are being nonmedically used to improve school performance or enhance highs from other drugs (Kroutil et al., 2006), it seems issues related to ensuring the proper use of prescription stimulants among youth will be an ongoing concern. This commodification of prescription stimulants in tandem with the higher rates of peer difficulties among youth diagnosed with ADHD (Bagwell et al., 2001; Pliszka, 2007), and the higher rates of diversion of prescription stimulants among adolescents (Cottler et al., 2013; McCabe, West, Teter, et al., 2011), may indicate that adolescents with ADHD could be at particular risk for negative peer interactions in which the adolescents with ADHD feel pressured to divert their prescription stimulants. Consequently, we hypothesize that peer victimization (PV) among youth with ADHD may be related to youth’s diversion of their stimulant medication.
For the purposes of this study, we examine both relational PV and overt PV. Relational PV involves individuals manipulating others’ friendships and interpersonal relationships with the intent to harm or hurt, whereas overt PV is actual or threatened physical harm (Card & Hodges, 2008; Crick & Bigbee, 1998). Given that adolescents with ADHD experience more peer rejection (Bagwell et al., 2001; Wiener & Mak, 2009) and are more impulsive (e.g., acting without thinking, interrupting others, inability to regulate strong emotions; American Psychiatric Association, 2003) we would anticipate that adolescents with ADHD may be vulnerable to both types of PV. Research suggests that friendships and positive peer relationships can buffer against the negative consequences of PV such as school and social adjustment problems (Kawabata & Crick, 2015). Yet, adolescents with ADHD have more difficulties with peer interactions, more peer rejection, and have fewer close friends (Bagwell et al., 2001). These limited support systems and positive peer interactions may contribute to PV and diversion of stimulant medication among youth with ADHD in different ways. It may be that youth with few friends are vulnerable to PV by other adolescents hoping to have access to their prescribed stimulants. Alternatively, increased impulsivity among youth with ADHD may lead to their seeking opportunities to increase their social standing and peer relationships by diverting their stimulant medication, placing them in risky social situations that leave them vulnerable to PV. Given the evidence that some adolescents with ADHD have their stimulant medication stolen or are forced to give them away, we would expect that diversion would be associated with overt PV (Poulin, 2001). However, given that adolescents with ADHD are less likely to have strong friendships to buffer them from relational PV, pressure to divert stimulant medication may be expressed through relational PV as well (Bagwell et al., 2001).
PV among youth with ADHD is a significant problem because, as reported above, youth with ADHD are more likely to have a number of negative psychosocial and health outcomes. Youth with PV are also more likely to experience anxiety and depression, in addition to social withdrawal, low self-esteem, impaired concentration, avoidant behavior (e.g., skipping school), and poor academic performance (Hawker & Boulton, 2000). Moreover, researchers have found that adolescents with ADHD are more likely to experience PV than adolescents without ADHD, perhaps compounding the negative impact of either risk factor alone (Taylor, Saylor, Twyman, & Macias, 2010; Unnever & Cornell, 2003; Wiener & Mak, 2009). However, these studies did not examine stimulant medication and PV among youth with ADHD, nor are ethnic and gender difference well established, although male and Caucasian adolescents are more likely to receive ADHD stimulant medication therapy than are females and racial minority youth (Zuvekas & Vitiello, 2012).
Weiner and Mak (2009) found associations between PV and parental reports of ADHD symptoms, but they did not report whether children being treated with stimulants were more likely than those not being treated with stimulants to be victimized. Unnever and Cornell (2003) defined ADHD by asking youth whether they had ever taken medication for ADHD; thus their study also did not consider differences in PV between stimulant-treated youth versus non-stimulant-treated youth. Given the research, stimulant medication diversion may be associated with PV among youth with ADHD as a result of peers attempting to gain access to their controlled medications. Alternatively, diversion of stimulant medication and PV among youth with ADHD may be explained by Problem Behavior Theory, a key assumption of which is that problem behaviors are correlated with each other and are influenced by individual and environmental factors (Hawkins, Catalano, & Miller, 1992; Jessor, 1991). Problem Behavior Theory has been used to explain adolescent substance use, framing these behaviors in a larger social context (Barber & Olsen, 1997; Turbin et al., 2006). This framework may explain associations between PV and stimulant medication diversion among adolescents with ADHD. For example, adolescents with ADHD are more likely to commit peer aggression and other types of delinquent behavior, which are associated with PV (Coolidge, DenBoer, & Segal, 2004; Wiener & Mak, 2009). It may be that the link between PV and stimulant medication diversion is a result of the greater likelihood of youth with ADHD being involved in a constellation of problem behaviors.
The purpose of this study is to examine the association between ADHD stimulant medication and PV of youth with ADHD. We examined past 12-month frequent PV (most/every day) because previous studies have indicated that youth with frequent PV are at increased risk for adverse outcomes (e.g., social isolation, internalizing and externalizing disorders, suicide) (Carney, 2000; Shea & Wiener, 2003). Other studies have examined comparatively less frequent victimization (e.g., once a week) (Borowsky, Taliaferro, & McMorris, 2013; Unnever & Cornell, 2003; Wiener & Mak, 2009). However, examination of frequent PV among youth with ADHD has been limited (Shea & Wiener, 2003), with no studies to date that examine associations between recent stimulant prescriptions among youth with ADHD and frequent PV. Controlling for severity of psychiatric symptoms (e.g., depression, anxiety, and ADHD), substance use, sex, race, grade level, school district, whether they lived in a two-parent home, and parents’ education, we tested associations with the following hypotheses:
Hypothesis 1: Youth with an ADHD diagnosis and a past-year prescription for stimulant medication would be at greater risk of frequent PV than: (a) youth never diagnosed with ADHD and (b) youth with ADHD but no stimulant prescription in the past 12 months.
Hypothesis 2: Youth with ADHD who had a past-year prescription for stimulant medication and had been approached to divert their medication would be at greater risk of frequent PV than: (a) youth never diagnosed with ADHD and (b) youth with ADHD but no past-year prescription for stimulants.
Hypothesis 3: Among youth with ADHD who had a past-year stimulant prescription and who had been approached to divert their prescription stimulants, youth who diverted their prescribed stimulants would be at greater risk of frequent PV than: (a) youth never diagnosed with ADHD and (b) youth with ADHD but no past-year stimulant prescription.
The sample includes adolescents from five public middle and high schools in the Midwestern United States. Data came from cross-sectional web-based surveys conducted during the fall months on an annual basis across a 4-year period (2009/2010–2012/2013) among 7th–12th graders. The average response rate across the four waves of data was 68%. The response rates from this study are comparable with The Monitoring the Future study of substance use among secondary school adolescents in the United States (Johnston, O'Malley, Bachman, & Schulenberg, 2013). Active parental consent and adolescent assent were obtained and the appropriate institutional review board approved the study.
The study sample included 5,217 unique adolescent respondents across the four waves of the study. We excluded 252 adolescents across the four waves owing to incomplete data, leaving a final sample of 4,965. Excluded adolescents were more likely to be male (56.7% vs. 49.2%; χ2=5.40, df=1, p<.05), Black (63.5% vs. 32.2%; χ2=109.3, df=2, p<.001), and attending a high poverty school district (74.9% vs. 43.3%; χ2=95.5, df=1, p<.001).
We used 11 items to assess past-year PV (Goldstein, Young, & Boyd, 2008). The items asked adolescents how many times over the past 12 months they had experienced specific PV behaviors (Table II). Item response categories included: 0 (Never) to 4 (Every day).
Based on Goldstein, Young, and Boyd’s (2008) conceptualization of PV, we constructed two composite measures for overt and relational PV, averaging items within each sub-scale. Overt PV was measured by seven items (e.g., hit, pushed, or kicked you on purpose). Relational PV was measured by four items (e.g., told stories about you that were not true). We also constructed a measure that included all 11 types of PV (see Supplementary Appendix for details). For the analysis, values between 0 and 1.99 from the composite measures were assigned a value of 0 and represented respondents who “never” experienced PV (0), “rarely” experienced PV (0.01–0.99), or experienced PV on “some days” (1–1.99), while values between 2 and 4 were assigned a value of 1 and represented respondents who had PV “most days” (2–2.99) or “everyday” (3–4) (i.e., frequent PV). Overt PV (α=.800), Relational PV (α=.710), and All PV (i.e., all 11 types; α=.859) demonstrated adequate inter-item correlations.
We used five measures that assessed the following criteria: (1) were they ever diagnosed with ADHD during their lifetime (“Yes”/“No”); (2) were they ever prescribed ADHD medication during their lifetime (“Yes”/“No”); (3) on how many occasions did they use prescribed stimulant medications during the past 12 months (“0 occasions” to “40 or more occasions”); (4) on how many occasions were they approached to sell; trade; or give away (i.e., divert) their prescribed stimulants during the past 12 months (“0 occasions” to “40 or more occasions”); and (5) on how many occasion did they sell; trade; or give away (i.e., divert) their prescribed stimulants during the past 12 months (“0 occasions” to “40 or more occasions”). Six mutually exclusive categories were created from these measures for each of the four waves of data: (1) Never diagnosed with ADHD; (2) Diagnosed with ADHD; never prescribed stimulants during their lifetime; (3) Diagnosed with ADHD and prescribed stimulants, but not during the past 12 months; (4) Diagnosed with ADHD; prescribed stimulants during the past 12 months; and not approached to divert prescribed stimulants during the past 12 months; (5) Diagnosed with ADHD; prescribed stimulants during the past 12 months; approached to divert; but did not divert prescribed stimulants during the past 12 months; and (6) Diagnosed with ADHD, prescribed stimulants during the past 12 months, approached to divert, and did divert their prescribed stimulants during the past 12 months (Table I). Additional details regarding measures, methods, and skip patterns are available elsewhere (Boyd, Young, & McCabe, 2014; McCabe, West, Cranford, et al., 2011).
We accounted for psychiatric disorders (i.e., ADHD, depression, anxiety, and conduct disorders) by using the Youth Self Report (YSR/11-18) in the analyses (Achenbach & Rescorla, 2001). The YSR/11-18 assesses behavioral and emotional problems in children between the ages of 4 and 18 years (Achenbach & Rescorla, 2001) and includes scales consistent with Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic categories of ADHD, affective problems, anxiety problems, and conduct problems. For the analyses, continuous variables based on T-scores obtained through proprietary software (Achenbach & Rescorla, 2001) were used to account for severity of ADHD (α=.791), depression (α=.827), anxiety (α=.737), and conduct disorders (α=.882).
Analyses also included covariates to account for potential substance use disorders. The Drug Abuse Screening Test Short Form measures drug abuse or dependence (Skinner, 1982). Respondents with past-year drug use were asked whether they had experienced any of 10 drug-related problems in the past 12 months (e.g., “have you ever used more than one drug at a time?”). Respondents who positively endorsed three or more items were considered at risk for drug abuse or dependence and assigned a value of 1 (those who endorsed two items or less were assigned a value of 0; α=.766) (French, Roebuck, McGeary, Chitwood, & McCoy, 2001; Skinner, 1982). The CRAFFT was also used to measure substance abuse or dependence with alcohol and drugs (Knight et al., 1999). The “CRAFFT” assesses six different aspects of alcohol and drug abuse (i.e., Car, Relax, Alone, Forget, Friends, Trouble; yes/no). A score of≥2 has been used to detect adolescent substance abuse/dependence (Knight, Sherritt, Harris, Gates, & Chang, 2003). Respondents who endorsed two or more items were assigned a value of 1 (those who endorsed one item or less were assigned a value of 0; α=.771).
Finally, analyses also included: age of ADHD diagnosis (i.e., diagnosed at age≤7 years), gender, race, student’s grade level, school district, single-parent household, parental education, wave of assessment, and frequency of Secondary Student Life Survey (SSLS) participation (see Table I for details).
Analyses included: (1) descriptive statistics of key variables and (2) cross-sectional logistic generalized estimating equations (GEE) with an exchangeable correlation structure (Hanley, Negassa, Edwardes, & Forrester, 2003; Zeger, Liang, & Albert, 1988). For the logistic GEE analyses, adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs) were computed. Each of the Logistic GEE analyses controlled for the covariates identified above. Statistical analyses were performed using commercially available software (StataCorp, 2013).
Table I shows that 84.7% of adolescents were never diagnosed with ADHD across the four waves, with 3.6% diagnosed with ADHD and prescribed stimulants in the past 12 months, 8.2% diagnosed with ADHD and prescribed stimulants but not in the past 12 months, and 3.5% diagnosed with ADHD and never prescribed stimulants. Twenty percent of youth with prescribed stimulants were approached to divert their medication (1.3% of total sample), with 10% of youth diverting their prescribed stimulant across the four waves of the study (0.7% of total sample).
The proportion of adolescents indicating frequent PV during the past year across all types of PV (i.e., frequent overt and frequent relational PV) was 1.9%, while 15.0% indicated never being victimized (See Table II). 1.4% of adolescents indicated frequent overt PV during the past year, and 2.5% indicated frequent relational PV during the past year.
The odds of frequent PV (all types) were roughly two times larger for adolescents with an ADHD diagnosis and prescribed stimulants during the past 12 months, compared with adolescents never diagnosed with ADHD (AOR=1.79, 95% CI=1.00, 3.44; see Table III). Adolescents with ADHD and prescribed stimulants during the past 12 months had higher odds of frequent relational PV (AOR=2.16, 95% CI=1.25, 3.72), compared with adolescents never diagnosed with ADHD, but had similar odds of frequent overt PV (AOR=1.80, 95% CI=0.886, 3.67) during the past year, when compared with adolescents never diagnosed with ADHD.
Adolescents with ADHD and prescribed stimulants during the past 12 months had similar odds of frequent PV (all types), and overt and relational PV compared with adolescents with ADHD but no past-year prescription for stimulants (see Supplementary Appendix Table A to review nonsignificant findings discussed here).
Adolescents with ADHD who were approached to divert their prescribed stimulant medication during the past 12 months had higher odds of frequent PV (across the three composite measures of frequent PV) during the past year, when compared with adolescents never diagnosed with ADHD (see Table IV). For instance, the odds of past-year frequent PV (all types combined) were roughly three times higher for adolescents diagnosed with ADHD who were approached to divert their prescription stimulants during the past 12 months, compared with adolescents never diagnosed with ADHD (AOR=3.10, 95% CI=1.12, 8.58).
Adolescents with ADHD who were approached to divert their prescribed stimulant medication during the past 12 months had similar odds of frequent PV (all types), overt PV, and relational PV compared with adolescents with an ADHD diagnosis but no past-year prescription for stimulants (See Table IV).
Youth with ADHD who diverted their prescription stimulants during the past 12 months had higher odds of past-year frequent PV across each of the composite measures of PV, compared with adolescents never diagnosed with ADHD (see Table V). For instance, when compared with peers who were never diagnosed with ADHD, the odds of past-year frequent PV (all types combined) was roughly four and a half times higher for adolescents who diverted their prescription stimulants during the past 12 months (AOR=4.66, 95% CI=1.40, 15.5).
Compared with adolescents with ADHD who were not prescribed stimulants in the past 12 months, adolescents with ADHD who diverted their prescription stimulants during the past 12 months had higher odds of frequent PV across each of the composite measures of PV (see Table V). For instance, the odds of past-year frequent PV (all types combined) was roughly five times higher for adolescents with ADHD who diverted their prescription stimulants during the past 12 months, compared with adolescents with ADHD and no prescribed stimulants in the past 12 months (AOR=5.01, 95% CI=1.35, 18.5).
To the authors’ knowledge, this is the first study to examine the association between having a prescription for stimulant medication and adolescent PV among youth with ADHD. Lifetime prevalence of being prescribed stimulants for ADHD in the present study was consistent with national findings (McCabe & West, 2013). Although there is limited research, the rate of prescription stimulant diversion in this study was comparable with other studies (7%–24% of those with ADHD medication) (Cottler et al., 2013; Wilens et al., 2008). When compared with youth never diagnosed with ADHD, our results indicate that youth diagnosed with ADHD and prescribed stimulants in the past 12 months had higher odds of frequent PV, even after controlling for demographics, and severity of ADHD, depression, anxiety, and conduct disorders.
As proposed by Problem Behavior Theory, these associations may be the result of a constellation of problem behaviors related to ADHD (e.g., peer aggression, delinquency) (Waschbusch, 2002). Indeed, our finding that youth with ADHD and without stimulant treatment in the past year had similar odds of PV as youth with ADHD and with stimulant treatment in the past year might suggest it is not the medication but the ADHD symptoms and comorbid conditions that may be driving this association. However, compared with youth with no ADHD diagnosis, we found that youth with ADHD who had been prescribed stimulants, regardless of whether it was recent (past year), reported significantly more frequent PV. In contrast, youth with ADHD who had never been prescribed a stimulant reported no more frequent PV than youth who had never been diagnosed with ADHD. These findings held even when controlling for ADHD symptom severity and aggression/delinquency, suggesting that some factor(s) related to having a prescription for stimulants is related to PV among adolescents with ADHD. Given that a growing literature indicates that proper prescription stimulant treatment of ADHD may play a protective role for youth in terms of decreasing negative consequences and increasing school functioning (Biederman et al., 2009; Wilens et al., 2008), additional prospective research is needed.
Further investigation of our data suggests that the differentiating factor for youth with ADHD and a prescription for stimulants, and who report frequent PV, may be whether they divert their medication. Youth with an ADHD diagnosis who were approached to divert their prescription stimulants in the previous 12 months had higher odds of frequent PV than (a) youth with no ADHD diagnosis, but had similar odds of frequent PV compared with (b) youth with ADHD but no past-year prescription for stimulants. Youth who were approached to divert and had diverted their medications had the highest odds for frequent PV, compared with the same two groups above. Again, it is unclear whether this association was the result of a cluster of problem behaviors (i.e., Problem Behavior Theory), or a symptom of targeted PV toward a vulnerable group of youth. This raises questions regarding whether pressures to divert prescription stimulants are, in and of themselves, instances of PV. In other words, are pressures to divert prescription stimulants a symptom of PV or is stimulant diversion a goal of PV? Further research could help to elucidate this association.
Finally, youth with ADHD and prescribed stimulants were not at greater risk for overt PV compared with their non-ADHD counterparts or youth with ADHD but no prescribed stimulants. Those most at risk for overt PV were youth with ADHD and a stimulant prescription who diverted their stimulant medication. This association may be owing to increased problem behaviors associated with those who divert their medications, because those who diverted were more vulnerable to pressures to divert, or the act of diverting put them in riskier situations.
Nearly three of four youth in this sample reported experiencing some type of PV in the last 12 months. These estimates are higher than those typically reported (Hawker & Boulton, 2000; Wang, Iannotti, Luk, & Nansel, 2010). In contrast, our rates of frequent PV are relatively lower than other reports (~2–3% of the sample) (Bradshaw, Sawyer, & O'Brennan, 2007; Nansel et al., 2001). We applied a strict definition for frequent PV (i.e., occurring most days or every day) over a 12-month period, as this type of extreme PV may be more likely to result in serious consequences (e.g., suicidality) (Borowsky et al., 2013; Klomek et al., 2009), particularly among youth already struggling with the challenges of ADHD (CDC. “Attention Deficit/Hyperactivity Disorder, Data and Statistics,” 2013). Differences in our estimates of PV may reflect differences in definitions, methodologies, or time frames in which the PV was assessed (Borntrager, Davis, Bernstein, & Gorman, 2009). Our items asked about PV behaviors without prompting students with a definition of PV. Such definitions or prompts may influence a participant’s response (e.g., a participant may report being a victim of a behavior but not identify as a victim). Efforts to standardize definitions and measures will be useful for future research endeavors.
Youth who were approached to divert and who did divert in the past year were more likely to have been diagnosed with ADHD before the age of 7 years, be male, have more severe conduct disorders, and screen positive for a drug use disorder. Youth at highest risk of experiencing frequent PV were younger adolescents with ADHD who were diagnosed earlier in life, had greater likelihood of substance use problems, were prescribed stimulants in the past 12 months, were approached to divert their medication, and who did divert.
Although the wide range of measures and self-administration for sensitive behaviors are strengths of this study, the authors acknowledge that the regional sample, reliance on self-report, lack of details regarding dosage, and cross-sectional nature of our analyses may limit generalizability of the findings. We were also not able to explore the role of peer aggression perpetration in the associations found here. Our data did not allow for an examination of diversion when youth were not approached to divert. Future prospective studies with a large sample are needed to better understand the mechanisms driving the association between PV and prescription stimulant diversion. Finally, adolescents excluded from the sample were more likely to be males, African Americans, and living in lower socioeconomic status school districts. However, <5% of the sample was excluded and coupled with the strong response rates, we believe the impact of this is minimal. Given that few studies have examined associations between a recent prescription for stimulants and PV, we believe these findings make a unique and significant contribution to the literature.
The authors believe that many youth with ADHD benefit from stimulant medication; however, we believe that close parent-treatment provider collaborations must be encouraged to ensure that youth’s prescription stimulants are not being diverted. Whether youth are victimized by peers who want access to their prescription stimulants or youth are diverting their prescription stimulants as a component of other behavioral problems, diversion of stimulant medication may lead to treatment failure if youth do not take the medications prescribed for their ADHD symptoms. Alternatively, youth who are prescribed stimulant medication but who choose not to take them may also be at increased risk of PV if peers know that they have access to unused stimulant medication. Another question for consideration in future research would be whether youth prescribed stimulant medication by a treatment provider but who refuse to take the medication would be at increased risk of PV owing to the availability of leftover stimulant medication and/or untreated symptoms from the lack of stimulant treatment for the ADHD. Consequently, addressing the diversion of prescription stimulants is particularly important, as these youth transition to secondary schools and find themselves in cultures where youth with ADHD medication are more likely to be approached to divert their medications (McCabe, Teter, & Boyd, 2006; McCabe, West, Teter, et al., 2011). Sending new students into this context with a high demand commodity that is often shared between peers creates a potentially dangerous climate for PV and the perpetuation of stimulant diversion, misuse and abuse (McCabe, West, Cranford, et al., 2011). Additional support and care of these youth may be required to ensure that this highly vulnerable group has the opportunity to receive effective medical treatment for their ADHD symptoms without putting themselves at greater risk for PV.
This work was supported by the National Institute on Drug Abuse (NIDA grants R01 DA024678, R01 DA031160, R01 DA036541, and T32 DA007267), the National institute on Alcohol Abuse and Alcoholism (NIAAA grant K23AA022641), the National Center for Advancing Translational Sciences of the National Institutes of Health (2UL1TR000433), and the University of Michigan Injury Center, an Injury Control Research Center funded by the Centers for Disease Control and Prevention (grant CDC R49CE002099). The views expressed in this article are those of the authors and do not necessarily represent the views of NIDA, NIAAA, the National Institutes of Health, the Centers for Disease Control and Prevention, or the University of Michigan.
Conflicts of interest: None declared.