Does ADHD Affect the Course of Substance Abuse?: Findings From a Sample of Adults With and Without ADHD

The authors examined the effects of attention-deficit hyperactivity disorder (ADHD) and psychiatric comorbidity on recovery from psychoactive substance use disorder (PSUD) with 130 referred adults with ADHD and 71 non-ADHD adults, all of whom had a lifetime history of PSUD. Although PSUD remitted in 80% of both groups, the rate of remission and duration of PSUD was quite different in the ADHD vs. non-ADHD subjects. The duration of PSUD was 37.2 months longer in the ADHD than in non-ADHD subjects. The median time to PSUD remission was more than twice as long in ADHD than in control subjects (144 vs. 60 months, respectively). ADHD is associated with a longer duration of PSUD and a significantly slower remission rate. If confirmed, such findings extend previous work showing that ADHD is a risk factor for early initiation and specific pathways of PSUD, providing further evidence of the relevance of this association. (Am J Addict 1998; 7:156–163)     

Clinical Implications of the Relationship Between Attention-Deficit Hyperactivity Disorder and Psychoactive Substance Use Disorders

The author explores the nature of the relationship between attention-deficit hyperactivity disorder (ADHD) and psychoactive substance use disorder (PSUD). Researchers of ADHD in children and adolescents have posited that the development of conduct disorder and antisocial personality disorder is an unavoidable step in the path to PSUD. Some investigators of adult substance abusers do not subscribe to this opinion, and others give considerable weight to the self-medication theory. The choice of cocaine as a preferred drug for self-medication by adults with attention deficit disorder has been specifically reported. The author presents a critical review of this issue as well as methodological, nosological, and interpretive problems, and intervention implications.     

Further Evidence of an Association Between Attention-Deficit/Hyperactivity Disorder and Cigarette Smoking

The authors investigated the relationship between attention-deficit/hyperactivity disorder (ADHD) and cigarette smoking in siblings of ADHD and non-ADHD probands. They conducted a 4-year follow-up of siblings from ADHD and control-group families. In the siblings of ADHD probands, ADHD was associated with higher rates and earlier onset of cigarette smoking. There was also a significant positive association between cigarette smoking and conduct disorder, major depression, and drug abuse in the siblings, even after adjusting for confounding variables. Moreover, smoking was found to be familial among ADHD families but not control-group families. Our findings indicate that ADHD is a risk factor for early initiation of cigarette smoking in the high-risk siblings of ADHD probands.     

Substance Abuse Severity in Female Adolescents

The authors investigated the association between age at menarche and age at onset of substance use with frequency of alcohol consumption in mid-adolescence; age at first DSM-III-R diagnosis of psychoactive substance use disorder (PSUD); severity of physical health, substance use, and psychosocial problems; and psychiatric disorders in female adolescents. Twenty-eight PSUD female adolescents (age 14–18 years) were studied. Chronological age at first substance use, and not age at menarche, was associated with the four variables mentioned above. These findings indicate that substance use in this population is encompassed within significant psychiatric disturbance that most commonly precedes the onset of PSUD.     

ADHD, bruxism and psychiatric disorders: does bruxism increase the chance of a comorbid psychiatric disorder in children with ADHD and their parents?

There is an association between bruxism and ADHD. No published data on psychiatric comorbidities in attention-deficit/hyperactivity disorder (ADHD) children with bruxism were found. There is no satisfying treatment method for children with bruxism. If we understand its comorbidities well, a better treatment method could come out. This study was conducted to compare the frequency of comorbid psychiatric disorders in the parents and their ADHD children with and without teeth grinding. It was hypothesized that there is no association between bruxism and prevalence of comorbid psychiatric disorders in children with ADHD and their parental psychopathology. Eighty-nine ADHD children without teeth grinding were compared with 32 ADHD children with teeth grinding. Their parental psychiatric disorders were also compared. Structured interviews were used to diagnose comorbid psychiatric disorders. The demographic characteristics of the children and their parents were not different between the groups. The only psychiatric disorder in children, which was associated with the groups was oppositional defiant disorder. The rate of conduct disorder, tic disorder, major depressive disorder, separation anxiety disorder, generalized anxiety disorder, enuresis, and obsessive compulsive disorder were not different between the two groups of children. The rate of major depression was more in the mothers of children with teeth grinding than those without such children. These finding were not reported before. ADHD children with teeth grinding have a high prevalence of oppositional defiant disorder. Lack of association between anxiety disorder and presence of teeth grinding might not support the idea that anxiety is associated with teeth grinding. The association of ODD and teeth girding might be a clue about etiology of bruxism. Perhaps, this clue can probably lead to the development of a more satisfying treatment. With consideration of this clue, further studies should survey if there is any association between ODD and sleep micro-arousals.     

Prevention of Drug Abuse

Prevention efforts in alcohol and drug abuse have typically focused on the general population. However, most individuals who abuse addictive drugs either terminate consumption voluntarily or do not progress to a clinical diagnosis of psychoactive substance use disorder (PSUD). Because PSUD has such adverse effects on costs to society, prevention research and practice should emphasize the development and implementation of interventions for individuals who are at high risk for this disorder. This article proposes a conceptual framework for better understanding of the etiology of PSUD and for implementing prevention efforts that are targeted to specific vulnerabilities of an individual. These vulnerabilities are discussed with respect to their spatial organization (i.e., manifestations across multiple levels of biobehavioral organization) and temporal organization (i.e., manifestations across an individual's life span).     

Characteristics of adults with attention deficit hyperactivity disorder plus substance use disorder: the role of psychiatric comorbidity

The objective of the study was to investigate the characteristics of adults with Attention Deficit Hyperactivity Disorder (ADHD) or substance use disorder (SUD), especially in the context of comorbid psychiatric disorders. Subjects were adults (n = 78) participating in a controlled family study of ADHD and SUD. Four groups were identified based on a diagnosis of ADHD or SUD: ADHD, SUD, ADHD + SUD, and neither ADHD nor SUD. All diagnoses were determined by structured clinical interview for DSM IV. Rates of psychiatric comorbidity were lowest in the controls, intermediate in the ADHD and SUD groups, and highest in the ADHD + SUD group. Relative to controls, the ADHD, SUD, and ADHD + SUD groups had higher rates of major depression (z = 1.98, p = 0.05), conduct disorder (z = 2.0, p = 0.04), antisocial personality disorder (z = 2.6, p = 0.009), agoraphobia (z = 2.5, p = 0.01) and social phobia (z = 2.7, p = 0.007). Higher rates of psychiatric comorbidity, especially mood and anxiety disorders, exist in subjects with SUD + ADHD relative to subjects with SUD, ADHD, or controls. Clinicians need to be attentive to other psychiatric disorders that may occur in the large group of adults with ADHD + SUD.     

Psychiatric Disorders Among American Indian vs. Other Patients With Psychoactive Substance Use Disorders

In this study 100 American Indian (AI) patients and 200 non-AI patients with a psychoactive substance use disorder (PSUD) were studied with special reference to associated psychiatric disorders. Current Axis I diagnoses, previous psychiatric treatment, and family history of psychiatric disorder were compared among these two groups. AI patients from a university hospital clinical population had excess numbers of organic mental disorder (OMD), including both acute OMD (i.e., delirium tremens and alcoholic hallucinosis) and chronic OMD (i.e., alcohol amnestic disorder, alcohol dementia, and trauma-induced OMD). Overall, “dual diagnosis” was more frequent among the AI patients, due primarily to the excess incidence of OMD. The rate of other psychiatric diagnoses was comparable between the two groups. Within the non-OMD psychiatric diagnoses, a few differences did occur. AI patients manifested increased anxiety disorders, whereas non-AI patients had increased eating disorders. Previous psychiatric treatment and family history of psychiatric disorder did not differ between AI and non-AI patients. Treatment implications are based on these data combined with reports from the literature.     

Parental substance use disorder, mediating variables and adolescent drug use: a non-recursive model

Aims. To develop and test a non-recursive model that examines the effects of parental psychoactive substance use disorder (PSUD) on the reciprocal relationships among stressful life events, family attachment, peer drug use and adolescent drug use . Design. A 3-year prospective cohort study followed adolescents from three types of families defined by a parental diagnosis of a psychiatric disorder. Setting. A large metropolitan area in the upper Midwestern United States . Participants. Seven hundred and seventy-seven 10-16-year-old adolescents from three groups of families: 214 who resided in families in which a parent was diagnosed with PSUD, 181 who resided in families in which a parent was diagnosed with an affective disorder (but no co-morbid PSUD), and 382 who resided in families in which both parents were free of any diagnosable disorder . Measurements. Psychiatric disorder was defined by the Structured Clinical Interview for DSM-III-R (SCID). Two follow-up interviews of adolescent respondents were used to measure stressful life events via the Junior High Life Experiences Survey, family attachment via FACES-III and a child-parent strain index, peer drug use, and two self-reported drug use scales designed to measure past-year alcohol use and illicit drug use (e.g. marijuana, cocaine, inhalants). Findings. Nested structural equation models with latent variables revealed that adolescents from PSUD families were at heightened risk of stressful life events, peer drug use, attenuated family attachments and drug use during the first follow-up period. In turn, peer drug use was strongly associated with drug use during the second follow-up period. However, drug use during the first follow-up also led to greater peer drug use and attenuated family attachment during the second follow-up period. The findings support a non-recursive model describing relations among adolescent drug use, peer drug use and family attachment. Conclusions. Parental psychoactive substance use disorder puts adolescents at significant risk of becoming embedded in a cycle of drug use, associations with drug using peers, and poor family relations.     

Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care

BACKGROUND: Recognition and treatment of attention-deficit/hyperactivity disorder (ADHD) in adults in psychiatry and primary care have faced many obstacles. METHODS: Review by 50 psychiatrists and 50 primary care practitioners (PCPs) of 537 and 317 medical records, respectively, of adults diagnosed as having ADHD. Information on other psychiatric disorders, time of onset of ADHD, source of referral, use of referrals for diagnosis, ADHD treatment, and use of drug holidays was recorded. RESULTS: Forty-five percent of the patient records reviewed by psychiatrists and 65% reviewed by PCPs indicated previous diagnoses of ADHD. Only 25% of the adults with ADHD had been first diagnosed as having the disorder in childhood or adolescence. A diagnosis of ADHD was the initial cause for referral in 80% of psychiatric patients and 60% of PCP patients. Most patients with previously diagnosed and undiagnosed ADHD were self-referred. Among patients who had not received a prior diagnosis, 56% complained about ADHD symptoms to other health professionals without being diagnosed; PCPs were the least aggressive in diagnosing ADHD. In psychiatric and PCP settings, there was a statistical difference in the use of pharmacotherapy (91% vs 78%, respectively) and the proportion of patients taking drug holidays (24% vs 17%, respectively); most drug holidays were initiated by the patient (57%). Stimulants were the treatment of choice for adult ADHD (84% treated with stimulants). CONCLUSION: Data contained within this medical record review suggest that adult ADHD is a substantial source of morbidity in both psychiatric and PCP settings.     

The association between attention deficit hyperactivity disorder in adolescence and smoking in adulthood

This longitudinal study examined the interrelationships between early and/or middle adolescent attention deficit hyperactivity disorder (ADHD), middle adolescent conduct disorder (CD), and later adult smoking behavior. This is a prospective longitudinal study. Data were collected via structured interviews of representative families in the northeastern United States (N = 641). The mean ages of the offspring were as follows: 14 years (T2, 1983), 17 years (T3, 1985-1986), and 32 years (T6, 2002). The dependent variable was the participants' daily cigarette smoking in their early thirties. Logistic regression analyses indicated that the relationship between ADHD and daily smoking behavior was mediated by CD with control on gender, age, SES, and adolescent smoking. CD had a direct effect on daily smoking in adulthood. Our findings suggest that ADHD is related to CD, which in turn is associated with daily smoking. Therefore, interventions with ADHD adolescents who have ADHD at an early age might lead to some reduction in later smoking provided that the intervention has a positive effect on CD. For those adolescents who never had ADHD, our findings suggest that prevention or treatment aimed at reducing CD may be most successful in reducing daily smoking later in adulthood.     

The role of childhood risk factors in initiation of alcohol use and progression to alcohol dependence

AIMS: To identify childhood risk factors that predict (a) age of first drink and (b) time from first use to alcohol dependence (AD) onset, using survival analysis. PARTICIPANTS: The sample consisted of 1269 offspring (mean age = 20.1 years) of male twins from the Vietnam Era Twin Registry; 46.2% were offspring of alcohol-dependent fathers. MEASUREMENTS: DSM-IV psychiatric diagnoses and substance use behaviors were assessed by structured telephone interview. FINDINGS: First drink occurred on average at 15.7 years; AD onset at 19.1 years. A Cox proportional hazard regression analysis revealed conduct disorder (CD) as the most potent predictor of early alcohol initiation (HR 2.48; CI 1.85-3.32). Attention deficit hyperactivity disorder (ADHD), maternal AD, paternal AD, male gender and parental divorce were also associated with early first use (HR 1.20-1.52; CI 1.04-1.39-1.18-1.96). A Cox proportional hazard regression analysis modeling first drink to AD identified nicotine dependence (HR 3.91; CI 2.48-6.17) and generalized anxiety disorder (GAD) (HR 3.45; CI 2.08-5.72) as robust predictors of progression to AD. CD (HR 1.75; CI 1.10-2.77) and cannabis abuse (HR 1.88; CI 1.22-2.90) were also associated with rapid transition to AD. CONCLUSIONS: Results highlight the role of psychiatric and substance use disorders in progression from first drink to AD, underscore the continuity of risk associated with CD and indicate that (with the exception of CD) different factors play a role in transition to AD than in initiation of alcohol use. Distinctions between stages are interpreted in a developmental framework.     

Service Needs and Utilization for Dual-Diagnosis Patients

The authors examined treatment patterns for two groups of dually diagnosed psychiatric inpatients, those with a) co-occurring, but independent mental and substance use disorders (IMD + PSUD); and b) substance-induced organic mental disorders (PSUD-OMD). Assessments included the Addiction Severity Index for perceived service needs, discharge records for recommended treatments, and the Quality of Life Interview for follow-up treatment utilization. As expected, the groups differed on treatment patterns. Both received fewer services than needed during the 1-year follow-up. In particular, the IMD + PSUD patients utilized few substance abuse services and the PSUD-OMD utilized few psychiatric services.     

Attention Deficit Hyperactivity Disorder and substance use disorders: is there a causal link?

Attention-deficit hyperactivity disorder (ADHD), characterized by restless, inattentive and hyperactive behaviours, is a relatively common childhood disorder that affects approximately 5% of the general population. There has been controversy about whether ADHD increases risks of developing substance use disorders. The available evidence suggests that, in the absence of conduct disorder , ADHD is not associated with an increased risk of substance use problems in males. There is only limited evidence on the role of ADHD in the aetiology of substance use disorders among females. While ADHD has traditionally been considered as a childhood disorder, it may also occur in adults; research needs to examine the extent to which ADHD in adulthood increases the risk of substance use disorders.     

Is Bipolar Disorder a Risk for Cigarette Smoking in ADHD Youth?

Despite emerging literature linking juvenile bipolar disorder (BPD) and substance abuse, little is known about a link between BPD and cigarette smoking. To this end, we evaluated the association between BPD and cigarette smoking in youth. Subjects were 31 bipolar adolescents derived from a cohort of boys with DSM-III-R ADHD (N = 128) and non-ADHD comparisons (N = 109) followed prospectively for 4 years into mid-adolescence. Information on cigarette smoking was obtained in a standardized manner blind to the proband's clinical status. Logistic regression models were used to determine risk for smoking at follow-up. BPD was associated with a higher risk for cigarette smoking in mid-adolescence, which was largely accounted for by conduct disorder. The developmental onset of BPD in adolescence (age 13-18 years) conferred a greater risk for cigarette smoking compared to those youths with the onset of their BPD prepubertally (< or = 12 years; odds ratio = 10.8, p < 0.01), even after controlling for conduct disorder and other confounds. The naturalistic treatment of BPD with combined counseling and pharmacotherapy appeared to reduce the risk for cigarette smoking. BPD, particularly when it onsets in adolescence, is a significant risk factor for the early initiation of cigarette smoking in these ADHD youths. These data coupled with the literature strongly suggest that juveniles with BPD need to be carefully monitored for the early initiation of cigarette smoking and substance abuse.     

The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder

Objective: The current study examined the association between asthma and attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample. Methods: Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a co-morbid asthma diagnosis were identified and matched by age to a group of 71 patients with only ADHD. Results: Children with asthma and ADHD were more likely to display clinically elevated levels of hyperactivity, externalizing behaviors, anxiety, and hyperactive/impulsive behaviors compared to children with ADHD alone. Boys with asthma and ADHD had more symptoms than boys with only ADHD of somatization and emotional internalizing, while girls with asthma and ADHD had more symptoms of hyperactivity/impulsivity, conduct problems, anxiety, and emotional internalizing compared to girls with only ADHD. Conclusions: Findings suggest that in children with ADHD, co-morbid asthma is associated with increased behavioral and internalizing symptoms, with distinct gender differences present. Increased behavioral and internalizing symptoms seen in children with both asthma and ADHD may be due to the burden of their medical condition. No difference was found on cognitive variables, suggesting chronic hypoxia may be less influential in explaining these differences. Future research should determine the specific mechanisms of these differences.     

Motives underlying smoking in college students with ADHD

Background. The positive association between attention deficit hyperactivity disorder (ADHD) symptoms and smoking in youth has been well documented. Less research has examined why individuals with ADHD, particularly college students, are at increased risk for smoking. Objectives. This longitudinal study examined whether smoking motives [cognitive enhancement, tolerance, negative reinforcement (smoking to reduce negative affect or stress), craving, social influences, and weight control] helped to explain the relation between ADHD symptoms (inattention and hyperactivity/impulsivity) and cigarette smoking among college students. Methods. Participants were 889 undergraduates (21% men) and their parents who completed online surveys at the beginning and end of the Fall semester regarding their smoking behaviors, ADHD symptoms, and smoking motives. Structural equation modeling was used to analyze data and answer research questions. Results. Nineteen percent of students reported smoking, while 20% reported one or more inattentive symptoms, 35% reported one or more hyperactive/impulsive symptoms, and 3.3% met criteria for ADHD. All smoking motives significantly moderated the relation between inattentive symptoms and smoking, while most smoking motives (negative reinforcement, tolerance, craving, cognitive enhancement, and weight control) moderated the link between hyperactive/impulsive symptoms and smoking. Results remained significant after controlling for stimulant medication use and conduct disorder symptoms. Conclusions/Importance. Addressing negative reinforcement, craving, social influences, and tolerance in prevention and intervention efforts on college campuses may reduce smoking. Results also highlight the importance of assessing a range of ADHD symptoms in college students as ADHD symptoms, even at subthreshold levels, were associated with increased smoking rates among college students.     

The “Younger-Sibling-at-Risk Design”: a Pilot Study of Adolescents with ADHD and an Older Sibling with Substance Use Disorder

Introduction: This article introduces a “younger at-risk sibling” design to study progression from other psychopathologies to their substance use disorder (SUD) complications. The design selects not-yet-SUD adolescents with high-risk-for-SUD psychopathology only if an older sibling has SUD. This “proof of concept” pilot study examines the design’s feasibility if the younger sibling has attention deficit hyperactivity disorder (ADHD). Method: Subjects were recruited from families at substance abuse treatment centers that had a non-SUD younger child with ADHD, from families at behavior disorder clinics that had a younger child with ADHD and SUD older child, and through general advertisements. Subjects were seen weekly for at least 3 months and monthly thereafter for 3 months. All were treated with open-label lisdexamfetamine dimesylate 30–70 mg per day. Outcomes explored were recruitment, compliance, diversion, ADHD improvement, and substance use interest. Results: 25 families were screened, 13 evaluated, and 8 began medication. ADHD Rating Scale-IV scores obtained by parent–adolescent consensus improved as expected with a stimulant. Rating forms could quantify substance use interest in subjects with some drug culture exposure but encountered a floor effect in those without. The design’s complexity and implicit commentary on family dynamics complicated recruitment but may have facilitated retention. Conclusion: Sibling pairs in which the older sibling has substance use and the younger sibling has ADHD exist. Such younger siblings can be recruited into a treatment study. The design may shed light on the pathogenesis and prevention of SUD complications from ADHD and theoretically other SUD comorbidities.     

A Comparison of Children Affected by Prenatal Alcohol Exposure and Attention Deficit, Hyperactivity Disorder

Behavioral deficits are often noted in children with fetal alcohol syndrome (FAS) and other individuals with prenatal alcohol exposure, including mental retardation, learning problems, social problems, and deficits in attention. Because attention deficit, hyperactivity disorder (ADHD) has been diagnosed so frequently in children with FAS and other alcohol related birth defects, there has been speculation that alcohol is an etiological factor in ADHD. To examine the relationship between behavior characteristics of children with fetal alcohol exposure and those seen in children with a diagnosis of ADHD, 149 low socioeconomic status (SES), African-American children (mean age = 7.63 years) were given a battery of neuropsychological and behavioral tests. One hundred and twenty-two were a sub-sample from a longitudinal study of prenatal alcohol exposure, whereas twenty-seven were identified in an ADHD Clinic. Children were given two sets of tests: (1) “traditional model” of conventional behavioral and psychiatric measures of ADHD and externalizing behavior; and (2) measures of neurocognitive functioning reflecting a four-factor model of the neurological basis of the components of attention (Mirsky AF, in Integrated Theory and Practice in Clinical Neuropsychology, Hillsdale, NJ, Lawrence Erlbaum Associates, 1989). Results indicated that children with the physical characteristics associated with prenatal alcohol exposure and those with a diagnosis of ADHD had equivalent intellectual abilities with both clinical groups performing more poorly than contrast children from the same SES and ethnic groups. However, there were clear distinctions on behavioral and neurocognitive measures between the two clinical groups with those with ADHD performing more poorly on conventional tests sensitive to attentional problems and conduct disorder. When these two groups were compared on measures designed to measure the model of the four factors of attention by Mirsky, they were noted to have distinct patterns of deficits. These results suggested that the alcohol-affected children did not have the same neurocognitive and behavioral characteristics as children with a primary diagnosis of ADHD.     

Comparison of Clinical and Research Diagnoses of Substance Use Disorders in a First-Admission Psychotic Sample

In a sample of 294 first-admission psychotic subjects participating in an epidemiologic study, a diagnosis of comorbid psychoactive substance use disorder (PSUD) was made less frequently by clinicians at the treating facilities (17.7%) than by the research diagnosticians (28.9%). The level of agreement was moderate (kappa = 0.49), and the clinical diagnoses showed high specificity (0.95) but low sensitivity (0.48). Concordance between clinical and research diagnosis of PSUD was not significantly associated with demographic or clinical characteristics; the major reason for the discordance was criterion variance.