Prospective effects of attention-deficit/hyperactivity disorder, conduct disorder, and sex on adolescent substance use and abuse

CONTEXT: Attention-deficit/hyperactivity disorder (ADHD), an early manifestation of externalizing behavior, may identify children at high risk for later substance abuse. However, the ADHD-substance abuse relationship often disappears when co-occurring conduct disorder (CD) is considered. OBJECTIVE: To determine whether there is a prospective relationship between ADHD and the initiation of substance use and disorders, and whether this relationship depends on the ADHD subtype (hyperactive/impulsive or inattentive), CD, or sex. DESIGN, SETTING, AND PARTICIPANTS: Dimensional and categorical measures of ADHD and CD were examined via logistic regression analyses in relation to subsequent initiation of tobacco, alcohol, and illicit drug use by 14 years of age and onset of substance use disorders by 18 years of age in a population-based sample of 11-year-old twins (760 female and 752 male twins) from the Minnesota Twin Family Study. MAIN OUTCOME MEASURES: Structured interviews were administered to adolescents and their mothers regarding substance use and to generate diagnoses. RESULTS: For boys and girls, hyperactivity/impulsivity predicted initiation of all types of substance use, nicotine dependence, and cannabis abuse/dependence (for all, P < .05), even when controlling for CD at 2 time points. By contrast, relationships between inattention and substance outcomes disappeared when hyperactivity/impulsivity and CD were controlled for, with the possible exception of nicotine dependence. A categorical diagnosis of ADHD significantly predicted tobacco and illicit drug use only (adjusted odds ratios, 2.01 and 2.82, respectively). A diagnosis of CD between 11 and 14 years of age was a powerful predictor of substance disorders by 18 years of age (all odds ratios, > 4.27). CONCLUSIONS: Hyperactivity/impulsivity predicts later substance problems, even after growth in later-emerging CD is considered, whereas inattention alone poses less risk. Even a single symptom of ADHD or CD is associated with increased risk. Failure in previous research to consistently observe relationships between ADHD and substance use and abuse outcomes could be due to reliance on less-sensitive categorical diagnoses.     

Effects of ADHD, conduct disorder, and gender on substance use and abuse in adolescence.

OBJECTIVE: The relationships of attention deficit hyperactivity disorder (ADHD), conduct disorder, and gender to substance abuse were studied in a large population-based sample of adolescent twins. METHOD: Structured interviews were administered to 626 pairs of 17-year-old twins (674 girls and 578 boys) and their mothers to generate lifetime psychiatric diagnoses, and computerized measures of current substance use were obtained. Hierarchical logit analyses were performed to assess the independent effects of ADHD, conduct disorder, and gender on current substance use, frequency of substance use, and DSM-III-R diagnoses of substance use disorders. RESULTS: Conduct disorder was found to increase the risk of substance use and abuse in adolescents regardless of gender. In contrast, independent of its association with conduct disorder, an ADHD diagnosis did not significantly increase the risk of substance use problems. CONCLUSIONS: This study found no significant gender differences in the effects of ADHD and conduct disorder on substance use and abuse, although there was some suggestion that girls with ADHD might be at slightly higher risk than boys for substance abuse. In addition, increased risk of substance abuse among adolescents with conduct disorder may be primarily confined to those with persistent conduct disorder.     

Life History of Aggression scores are predicted by childhood hyperactivity,conduct disorder,adult substance abuse,and low cooperativeness in adult psychiatric patients

The prevention of aggressive behaviours is a core priority for psychiatric clinical work, but the association between the diagnostic concepts used in psychiatry and aggression remains largely unknown. Outpatients referred for psychiatric evaluations of childhood-onset neuropsychiatric disorders (n = 178) and perpetrators of violent crimes referred to pre-trial forensic psychiatric investigations (n = 92) had comprehensive, instrument-based, psychiatric assessments, including the Life History of Aggression (LHA) scales. Total and subscale LHA scores were compared to the categorical and dimensional diagnoses of childhood and adult DSM-IV axis I and II mental disorders, general intelligence (IQ), Global Assessment of Functioning (GAF), and personality traits according to the Temperament and Character Inventory (TCI). Overall, the two groups had similar LHA scores, but the offender group scored higher on the Antisocial subscale. Higher total LHA scores were independently associated with the hyperactivity facet of attention-deficit/hyperactivity disorder (AD/HD), childhood conduct disorder, substance-related disorders, and low scores on the Cooperativeness character dimension according to the TCI. IQ and GAF-scores were negatively correlated with the LHA subscale Self-directed aggression. Autistic traits were inversely correlated with aggression among outpatients, while the opposite pattern was noted in the forensic group. The findings call for assessments of aggression-related behaviours in all psychiatric settings.     

Parental substance use disorder and child abuse: risk factors for child maltreatment?

Although the literature consistently shows an association between parental substance use disorders (SUDs) and child abuse, it is unknown what factors discern non-abusive and abusive parents with SUDs. This study aims to investigate which specific risk factors are associated with child abuse in clinically treated parents with SUDs in the Netherlands. It examines two groups of parents with SUDs in a clinical setting, with and without known instances of child abuse. These groups were compared on SUD-related factors such as the type and severity of the SUDs, and variables addressing psychological disability such as comorbid diagnoses and quality of life. Other than a marginally significant difference in severity of addiction and a lower mean age of the parents in the child abuse group, no significant differences were found. The small sample size and the inherent difficulty of studying SUDs in a clinical sample is likely to have affected the results.     

Executive functioning and emotion recognition in youth with oppositional defiant disorder and/or conduct disorder

Abstract

Objectives: Executive functioning and emotion recognition may be impaired in disruptive youth, yet findings in oppositional defiant disorder (ODD) and conduct disorder (CD) are inconsistent. We examined these functions related to ODD and CD, accounting for comorbid attention-deficit/hyperactivity disorder (ADHD) and internalising symptoms.

Methods: We compared executive functioning (visual working memory, visual attention, inhibitory control) and emotion recognition between youth (8–18?years old, 123 boys, 55 girls) with ODD (n?=?44) or CD (with/without ODD, n?=?48), and healthy controls (n?=?86). We also related ODD, CD, and ADHD symptom counts and internalising symptomatology to all outcome measures, as well as executive functioning to emotion recognition.

Results: Visual working memory and inhibitory control were impaired in the ODD and CD groups versus healthy controls. Anger, disgust, fear, happiness, and sadness recognition were impaired in the CD group; only anger recognition was impaired in the ODD group. Deficits were not explained by comorbid ADHD or internalising symptoms. Visual working memory was associated with recognition of all basic emotions.

Conclusions: Our findings challenge the view that neuropsychological impairments in youth with ODD/CD are driven by comorbid ADHD and suggest possible distinct neurocognitive mechanisms in CD versus ODD.     

Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder.

The relationship between history of specific types of substance abuse (alcohol, stimulants, cannabis, hallucinogens, narcotics) and demographic and diagnostic variables was evaluated in a large (n = 263) sample of schizophrenic, schizoaffective, major depression and bipolar disorder patients. Prevalence rates were also compared with rates observed in a previous study (1983-1986) conducted using the same methods. Demographic characteristics (gender, age, race, educational level) were strong predictors of type of substance abuse. Patients with a history of cocaine abuse had fewer prior hospitalizations, suggesting that less impaired psychiatric patients may be more prone to illicit substance abuse. Diagnoses were not related to most types of substance abuse, although there was a trend for bipolar patients to have a history of alcohol abuse. The results demonstrate the importance of matching groups on demographic characteristics when exploring diagnostic differences in preference to abuse specific types of substances.     

Maternal and child expressed emotion as predictors of treatment response in pediatric obsessive-compulsive disorder

Expressed emotion (EE) is associated with symptoms and treatment outcome in various disorders. Few studies have examined EE in pediatric OCD and none of these has assessed the child’s perspective. This study examined the relationship among maternal and child EE, child OCD severity, and OCD-related functioning pre- and post-treatment. At pre-treatment, mothers completed speech samples about the child with OCD and an unaffected sibling. Children with OCD completed speech samples about parents. There were low rates of high maternal EE (child with OCD: 16.1%; sibling: 2.6%) and high child EE about parents (mothers: 11.9%; fathers: 10.2%). High EE was primarily characterized by high criticism, not high overinvolvement. High maternal EE and child EE regarding fathers were associated with pre-treatment child OCD severity but not post-treatment severity. High child and maternal EE were predictive of post-treatment OCD-related functioning. EE may be an important child and maternal trait associated with pre-treatment OCD severity and generalization of treatment gains.     

P300 decrements in teenagers with conduct problems: implications for substance abuse risk and brain development.

BACKGROUND: The purpose of this study was to evaluate the effects of conduct disorder problems, family history, gender, and age on P300 electroencephalographic potentials in teenagers. METHODS: The 257 subjects, aged 15 to 20 years, were assigned to one of twelve groups defined by the crossing of three between-subjects factors: 1) gender; 2) ranking below vs above the median number of conduct disorder problems for their gender; and 3) no family history of alcohol or drug dependence vs familial alcohol dependence vs familial heroin or cocaine dependence. RESULTS: P300 amplitude was smaller among subjects reporting a greater number of conduct problems prior to age 15 vs those reporting fewer problems of this type. No family history effects were detected. Another set of analyses examined the effects of age on conduct problem-related decrements in P300. Smaller P300 amplitudes within the posterior scalp region were associated with a greater number of conduct problems among subjects younger than 16.5 years. Among subjects greater than this median age, the effects of these behaviors were only apparent over the frontal scalp. CONCLUSIONS: It is concluded that P300 decrements previously attributed to familial alcohol/substance dependence might be the result of a coincident increase in the prevalence of conduct disorder problems. The analysis of age interactions suggests that P300 amplitude decrements observed at posterior scalp sites among subjects with more conduct problems disappear at approximately 16 to 17 years of age. After that age, decrements in frontal brain function may begin to emerge in the subset of conduct problem subjects who are at risk for developing adult antisocial personality disorder.     

Maternal affective disorders, illness, and stress: risk for children's psychopathology

Stressful circumstances that covary with maternal affective disorder may account for some of the risk to children for psychological dysfunction. Children (ages 8-16) of mothers with unipolar or bipolar disorders were compared with children of mothers who had chronic medical illness and children of normal mothers. Comparisons included Kiddie-SADS (Schedule for Affective Disorders and Schizophrenia) diagnoses and evaluations of behavior problems, school functioning, and social competence. Compared to the other groups, children of mothers with affective disorder (especially unipolar) had high rates of diagnosis. With the effects of chronic stress statistically controlled, psychosocial outcome variables showed fewer differences between groups but indicated particular impairment for children of unipolar mothers.     

Drug use and the risk of major depressive disorder,alcohol dependence,and substance use disorders

BACKGROUND: The Children in the Community Study is a prospective longitudinal study investigating the association between early drug use (childhood, adolescence, and early 20s) and later psychiatric disorders (in the late 20s). METHODS: Using data from a community-based sample of 736 adults (50% female) from upstate New York, the subjects were interviewed at the mean ages of 14, 16, 22, and 27 years. Psychiatric disorders, measured by age-appropriate versions of the University of Michigan Composite International Diagnostic Interview, and participant's drug use were assessed. RESULTS: Adolescent and young adult tobacco use was significantly associated with an increased risk of alcohol dependence and substance use disorders at a mean age of 27 years, but not with new episodes of major depressive disorder. Earlier alcohol use significantly predicted later major depressive disorder, alcohol dependence, and substance use disorders in the late 20s, as did early marijuana use and other illicit drug use. Except for the effect of tobacco use on major depressive disorder, early drug use was significantly related to later psychiatric disorders, even after statistically controlling for age, sex, parental educational level, family income, and prior episodes of major depressive disorder and substance use disorders. CONCLUSIONS: Our results suggest that early drug use is associated with and predicts later psychiatric disorders. Preventive implications stem from the importance of studying a range of psychiatric disorders in the context of substance use assessed over a wide age range.     

未治疗抑郁障碍患者自杀风险与认知情绪调节策略的关系

目的探讨具有自杀风险的抑郁障碍患者在认知情绪调节策略方面的特征及其影响因素,以早期识别具有自杀风险的患者,有针对性地给予干预。方法选取117例来自北京回龙观医院门诊、经简明国际神经精神访谈(MINI)5. 0中文版筛查符合抑郁障碍诊断标准的未治疗抑郁障碍患者,根据MINI 5. 0中文版自杀模块的访谈结果,将患者分为自杀风险组(n=52)和无自杀风险组(n=65)。采用认知情绪调节问卷(CERQ-C)进行认知调节策略的测评,采用汉密尔顿抑郁量表17项版(HAMD-17)评定抑郁症状的严重程度。结果抑郁障碍患者自杀风险发生率为44. 4%(52/117)。与无自杀风险组相比,自杀风险组患者更多见于女性、未婚、平均年龄更小、发病年龄更早、HAMD-17总评分更高、伴精神病性症状率较高,自杀风险组自我责难、接受、沉思、灾难化4个认知调节策略维度及消极认知情绪调节评分均高于无自杀风险组(P均<0. 05)。Logistic回归分析显示,女性(OR=3. 539,95%CI:1. 383~9. 057)、发病年龄(OR=0. 931,95%CI:0. 895~0. 968)、HAMD-17总评分(OR=1. 207,95%CI:1. 063~1. 370)和灾难化(OR=1. 143,95%CI:1. 002~1. 305)与抑郁障碍患者自杀风险相关(P均<0. 05)。结论女性、发病年龄早、抑郁症状严重和灾难化可能为未治疗抑郁障碍患者自杀风险的危险因素。     

Bipolar disorder with comorbid substance abuse: diagnosis, prognosis, and treatment

Alcohol and drug abuse occur frequently in individuals with bipolar disorder, but clinicians may often feel ill-prepared to identify such multi-diagnosis syndromes, to contextualize drug abuse alongside affective symptoms, and to formulate appropriate treatment strategies. Plausible explanations for high comorbidity rates between bipolar illness and substance use disorders are complex and likely embrace numerous factors that extend beyond simple, older theories about drug use as sheer "self-medication." Evidence from epidemiologic, family-genetic, pharmacologic, psychosocial, and clinical psychopathology studies suggest that a majority of bipolar patients are at risk for developing lifetime drug or alcohol-related problems, which may in turn contribute to more varied and complex clinical presentations, accelerated relapses, worsening of depressive features, poorer lithium response, functional disability, and elevated suicide risk. In this article, the author reviews essential concepts about the phenomenology and treatment outcome of bipolar illness with substance use comorbidities and offers a systematic approach to the diagnosis and management of patients with such dual diagnoses.     

Influence of parental and grandparental major depressive disorder on behavior problems in early childhood: a three-generation study

OBJECTIVE: This aim of this study was to examine the influence of grandparental (G1) and parental (G2) major depressive disorder (MDD) and other forms of psychopathology on behavior problems in very young offspring (G3). METHOD: Oregon Adolescent Depression Project (OADP) participants who had children over a 3-year period were invited to participate in a study of infant and child development. We attempted to collect diagnostic history from the original OADP (G2) participants, their coparents, the parents of the original OADP participants (G1), and the parents of the coparents. Child (G3) outcomes at 24 months of age were based on parent reports of behavior problems. RESULTS: Univariate correlations indicated that G1 and G2 familial loadings for MDD were associated with higher levels of G3 internalizing and externalizing behavior problems. Multiple regression analyses revealed a significant interaction between G1 and G2 MDD on G3 internalizing (but not externalizing) behavior problems. A higher familial loading for MDD in either the parental or grandparental generation was associated with elevated grandchild internalizing problems, but higher loadings for MDD in both generations did not convey additional risk. CONCLUSIONS: Parental MDD and grandparental MDD are both associated with elevated levels of internalizing problems in young grandchildren, but MDD in both the G1 and G2 generations does not confer additional risk. One important implication is that MDD in the grandparental generation is associated with increased risk to grandchildren even in the absence of parental MDD. Future studies should examine the mechanisms through which grandparental psychopathology influences behavior problems in grandchildren.     

Review of treatment recommendations for persons with a co-occurring affective or anxiety and substance use disorder

OBJECTIVE: The authors review and evaluate the literature and guidelines on care for individuals with a co-occurring affective or anxiety disorder and substance use disorder. METHODS: MEDLINE and PsycINFO computerized searches of the English language literature were conducted for the period 1990-2002. These articles were supplemented with searches of the Cochrane Database of Systematic Reviews (1990 to 2002) and with articles that were sent to the authors by experts in the field to review. Bibliographies of selected papers were hand searched for additional articles. From these searches a total of 219 articles were found, of which 127 were selected for review. RESULTS AND DISCUSSION: The literature shows that, over the past several decades, treatment for co-occurring disorders has undergone a broad shift in approach, from treating substance abuse before providing mental health care to providing simultaneous treatment for each disorder, regardless of the status of the comorbid condition. Many treatment recommendations are supported by a broad consensus. However, despite this broad agreement, recommendations are often not specific enough to guide clinical care. Most recommendations with specificity are for acute pharmacotherapy, but even specific recommendations lag behind current clinical practice. Although the use of psychotropic medication for mental illness is encouraged, experts disagree as to whether it is necessary to wait for abstinence before beginning pharmacotherapy. In addition, most diagnosis-specific guidelines are silent as to whether the specific treatment recommendation applies to co-occurring disorders. Finally, empirical evidence is lacking for most recommendations. The authors conclude that the mental health and substance abuse treatment fields need to consider its research priorities and how to address the multitude of potential combinations of disorders.     

The spectrum of substance abuse in bipolar disorder: reasons for use, sensation seeking and substance sensitivity

OBJECTIVES: To examine the spectrum of alcohol and substance abuse, including reasons for use, in patients with bipolar I disorder, compared with patients with substance use disorder and healthy controls, with a specific focus on the relationship between substance use, substance sensitivity, other comorbid psychiatric symptoms and traits related to sensation seeking. METHODS: This study included 104 patients with bipolar I disorder (BPD I), of whom 57 (54.8%) met DSM-IV criteria for lifetime alcohol or substance use disorder (BPD + SUD), 35 patients with substance use disorder (SUD) and no psychiatric disorder and 50 healthy controls. Assessments included the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Structured Clinical Interview for the Spectrum of Substance Use (SCI-SUBS). RESULTS: Patients with BPD + SUD and SUD had significantly higher scores on the SCI-SUBS domains of self-medication, substance sensitivity and sensation seeking compared with patients with BPD and healthy controls. Reasons for substance use did not differ between patients with BPD + SUD and patients with SUD. Those most frequently cited were: improving mood; relieving tension; alleviating boredom; achieving/maintaining euphoria; and increasing energy. CONCLUSIONS: Recourse to substances is associated with increased mood and anxiety symptoms, substance sensitivity, and sensation seeking among patients with BPD + SUD and SUD. Substance sensitivity and sensation seeking traits should be investigated in all patients with BPD as possible factors associated with a development of SUD, in order to warn patients of the specific risks related to improper use of medications and substances.