Developmental progression to early adult binge drinking and marijuana use from worsening versus stable trajectories of adolescent attention deficit/hyperactivity disorder and delinquency

AUD in perspective

Alcohol is a major cause of pre-mature death and individual suffering worldwide, and the importance of diagnosing and treating AUD cannot be overstated. Given the global burden and the high attributable factor of alcohol in a vast number of diseases, the need for additional interventions and the development of new medicines is considered a priority by the World Health Organization (WHO). As of today, AUD is severely under-treated with a treatment gap nearing 90%, strikingly higher than that for other psychiatric disorders. Patients often seek treatment late in the progress of the disease and even among those who seek treatment only a minority receive medication, mirroring the still-prevailing stigma of the disease, and a lack of access to effective treatments, as well as a reluctance to total abstinence. To increase adherence, treatment goals should focus not only on maintaining abstinence, but also on harm reduction and psychosocial functioning. A personalised approach to AUD treatment, with a holistic view, and tailored therapy has the potential to improve AUD treatment outcomes by targeting the heterogeneity in genetics and pathophysiology, as well as reason for, and reaction to drinking. Also, the psychiatric co-morbidity rates are high in AUD and dual diagnosis can worsen symptoms and influence treatment response and should be considered in the treatment strategies.

Adolescent Cannabis Use, Comorbid Attention-Deficit/Hyperactivity Disorder, and Other Internalizing and Externalizing Disorders

Cannabis use often co-occurs with attention-deficit/hyperactivity disorder and other internalizing and externalizing disorders. Treatment planning, including pharmacologic and psychosocial interventions, for these comorbid disorders require thorough diagnostic evaluation to determine the extent of social, emotional, and behavioral impairments, severity of substance use, and motivation for change. Improved understanding of these comorbid disorders will inform treatment planning that address current symptoms and behaviors and may also prevent the development of mental health and substance use disorders in early adulthood.

Prenatal alcohol exposure and attention-deficit/hyperactivity disorder independently predict greater substance use in young adulthood

BACKGROUND

The degree to which prenatal alcohol exposure (PAE) may influence alcohol and drug use in adulthood is difficult to determine. That is because PAE is highly correlated with environmental factors, including low socioeconomic status and exposure to parental drinking, and with behavioral problems, such as, attention-deficit/hyperactivity disorder (ADHD), which are correlated with alcohol use and abuse.

METHODS

Participants were 121 young adults from our Detroit Longitudinal Cohort study. Mothers were recruited during pregnancy and interviewed about their alcohol consumption using a timeline follow-back procedure. At 19 years, their offspring were interviewed regarding current and past use of alcohol, cigarettes, and other illicit drugs.

RESULTS

PAE was associated with greater alcohol, cannabis, and cigarette use. PAE, assessed using overall alcohol intake during pregnancy and alcohol dose per occasion, was associated with larger quantities of alcohol per occasion and greater alcohol tolerance in early adulthood. These effects persisted after control for demographic background, sex, age and education of participant, home environment, other prenatal drug exposure, and postnatal alcohol and drug use by the primary caregiver. Whereas ADHD predicted average alcohol consumed/month during young adulthood, PAE predicted alcohol dose/drinking occasion, and the effect on dose/occasion was not mediated by ADHD.

CONCLUSIONS

The effects of PAE on alcohol and cannabis use in young adulthood are not attributable to being reared in an environment that is socioeconomically disadvantaged or in one in which there is extensive maternal drinking. Furthermore, PAE was related to enhanced alcohol tolerance in young adults, a risk factor for alcohol use disorder later in life. Although ADHD was associated with greater alcohol consumption in early adulthood, it did not mediate the effect of PAE on offspring's alcohol use.

Exploring the Link between ADHD and Cannabis Use in Swedish Ninth Graders: The Role of Conduct Problems and Sensation-Seeking

Background: Attention deficit hyperactivity disorder (ADHD) has in several studies been linked to substance use, including cannabis use. However, crucial gaps remain regarding how to understand this association. Analyzing the association between ADHD and substance use is complicated because of a pronounced overlap between ADHD, conduct problems, and traits such as sensation-seeking. Objectives: Using data from a large and nationally representative study among Swedish adolescents, this study explored the role of conduct problems, but also of sensation-seeking, in accounting for the association between ADHD and cannabis use. Results: There was a notable association between ADHD and cannabis use that was attenuated when conduct problems were controlled for. The association between cannabis use and conduct problems, in turn, was attenuated when sensation-seeking was controlled for. Individuals with both ADHD and conduct problems were more likely to have used cannabis than individuals with ADHD only, but not compared with individuals with conduct problems only. Conclusions: Whereas conduct problems largely explain the link between ADHD and cannabis use, sensation-seeking seems to account for the association between conduct problems and cannabis use.

Adolescent Cannabis Use, Comorbid Attention-Deficit/Hyperactivity Disorder, and Other Internalizing and Externalizing Disorders

Cannabis use often co-occurs with attention-deficit/hyperactivity disorder and other internalizing and externalizing disorders. Treatment planning, including pharmacologic and psychosocial interventions, for these comorbid disorders require thorough diagnostic evaluation to determine the extent of social, emotional, and behavioral impairments, severity of substance use, and motivation for change. Improved understanding of these comorbid disorders will inform treatment planning that address current symptoms and behaviors and may also prevent the development of mental health and substance use disorders in early adulthood.

Paths to postsecondary education enrollment among adolescents with and without childhood attention-deficit/hyperactivity disorder (ADHD): A longitudinal analysis of symptom and academic trajectories

We examined developmental trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms, standardized achievement, and school performance for adolescents with and without ADHD who did and did not enroll in postsecondary education (PSE; N = 749; 79% boys; 63% White, 17% non-Hispanic Black, 10% Hispanic, and 10% other ethnicities). In a multisite study (recruitment based in New York, North Carolina, Pennsylvania, California, and Quebec), participants were originally enrolled between 1994 and 1998 at ages 7 to 9.9 and followed up through 2012 (M_age = 25 at final follow-up). Adolescents who eventually enrolled in PSE had less severe symptoms, but differences were modest and trajectories were similar over time. For all adolescents, standardized achievement trajectories declined up to two thirds of a standard deviation from ages 9 to 17. By the end of high school, the average GPA of adolescents with ADHD was three quarters of a point higher for those who eventually enrolled in PSE compared to those who did not. Overall, school performance mattered more than academic achievement for understanding eventual enrollment of adolescents with ADHD.

Alcohol use disorders and ADHD

Despite a growing literature on the complex bidirectional relationship of ADHD and substance use, reviews specifically focusing on alcohol are scarce. ADHD and AUD show a significant genetic overlap, including genes involved in gluatamatergic and catecholaminergic neurotransmission. ADHD drives risky behavior and negative experiences throughout the lifespan that subsequently enhance a genetically increased risk for Alcohol Use Disorders (AUD). Impulsive decisions and a maladaptive reward system make individuals with ADHD vulnerable for alcohol use and up to 43 % develop an AUD; in adults with AUD, ADHD occurs in about 20 %, but is vastly under-recognized and under-treated. Thus, routine screening and treatment procedures need to be implemented in AUD treatment. Long-acting stimulants or non-stimulants can be used to treat ADHD in individuals with AUD. However, it is crucial to combine medical treatment for ADHD with pharmacotherapy and psychotherapy for AUD, and other comorbid disorders. Identification of individuals at risk for AUD, especially those with ADHD and conduct disorder or oppositional defiant disorder, is a key factor to prevent negative outcomes.

Naturalistic exploratory study of the associations of substance use on ADHD outcomes and function

BACKGROUND

Although Attention Deficit Hyperactivity Disorder (ADHD) is associated with an increased risk of substance use disorder (SUD), existing literature on how SUD interacts with ADHD outcomes is limited. This study investigates whether SUD among individuals with ADHD is associated with worse ADHD outcomes and prognosis, and the association between overall functioning and SUD. In addition, we seek to understand whether heavy cannabis use is a better predictor of poorer outcomes compared to SUD status alone.

METHOD

We conducted a retrospective analysis on 50 ADHD patient charts, which were allocated based on SUD status. Subgroup analysis was performed on the total sample population, with allocation based on heavy cannabis use. Mann-Whitney and Chi-Square tests were used for both the primary and subgroup analyses.

RESULTS

SUD status highly correlated with more ADHD-related cognitive impairments and poorer functional outcomes at the time of diagnosis. ADHD patients with comorbid ADHD-SUD scored significantly lower (p = < 0.0001) on objective cognitive testing (Integrated Auditory and Visual Continuous Performance Test (IVA/CPT)) than ADHD patients without SUD. The correlation with poorer ADHD outcomes was more pronounced when groups were allocated based on heavy cannabis use status; in addition to significantly lower IVA/CPT scores (p = 0.0011), heavy cannabis use was associated with more severe fine motor hyperactivity and self-reported hyperactivity/impulsivity scores (p = 0.0088 and 0.0172, respectively).

CONCLUSION

Future research is needed to determine how substance abuse can be a barrier to improved ADHD outcomes, and the effect cannabis and other substances have on cognitive function and pharmacotherapy of ADHD.

Depression and ADHD-Related Risk for Substance Use in Adolescence and Early Adulthood: Concurrent and Prospective Associations in the MTA

Childhood attention-deficit/hyperactivity disorder (ADHD) is prospectively linked to substance use and disorder. Depression emerging in adolescence is an understudied risk factor that may explain some of this risk. In the present study, we considered mediating and moderating roles of adolescent depression in explaining this association by using longitudinal data from the prospective 16-year follow-up of the Multimodal Treatment Study of ADHD (MTA). Participants were 547 children diagnosed with DSM-IV ADHD Combined Type, and 258 age- and sex-matched comparison children. In adolescence, depressive symptoms did not exacerbate effects of childhood ADHD on any substance use. For both groups, time-varying and average depressive symptoms were associated with more frequent use of all substances. Prospectively, we found no evidence of depression mediation to adult substance use. However, adolescent depression moderated the association between childhood ADHD and adult marijuana use. Although adults without ADHD histories used marijuana more frequently if they had elevated depressive symptoms in adolescence, marijuana use by adults with ADHD histories was independent of their adolescent depression. In adulthood, depression diagnoses and ADHD persistence continued to operate as independent, additive correlates of substance use risk. Our findings suggest a circumscribed role for depression in substance use risk that adds to, but does not alter or explain, ADHD-related risk.

Affective Drinking Motives, Delinquency and Binge Drinking: A Comparison of Male and Female High School Seniors

Aim

The purpose of this study was to determine whether the association between affective drinking motives, delinquency and binge drinking varied as a function of sex and if so, whether delinquency moderated the relationship between affective drinking motives and binge drinking in late adolescent males and females.

Methods

Participants were 623 (257 males, 366 females) high school seniors from the 2018 Monitoring the Future study. A principal components analysis was initially performed to create component scores for the first factor of a 15-item drinking motives scale subsequently labeled affective drinking motives. These scores, along with sex and a measure of delinquency, were then entered into a three-way interaction. The interaction was found to correlate significantly with binge drinking. Because of the significant three-way interaction, analyses were performed on male and female participants separately.

Results

Analyses conducted on male participants revealed a moderate correlation between affective drinking motives and binge drinking but no evidence of an interaction between affective drinking motives and delinquency. Analyses performed on female participants, on the other hand, identified a significant main effect for affective drinking motives and a negative interaction between affective drinking motives and delinquency, indicating that the relationship between affective drinking motives and binge drinking was strongest when delinquency was low.

Conclusions

These results suggest that while delinquency had no apparent impact on the affective drinking motive–binge drinking correlation in boys, low delinquency clearly amplified the counter-binge drinking effects of low affective drinking motives in girls.

Heterogeneous Trajectories of Problematic Alcohol Use, Depressive Symptoms, and their Co-Occurrence in Young Adults with and without Childhood ADHD

The literature is inconsistent regarding whether childhood ADHD confers risk for adulthood problematic alcohol use, depressive symptoms, and their co-occurrence. These inconsistencies could be due to meaningful heterogeneity in the adulthood outcomes of children with ADHD that were obscured in traditional group-based analyses. The current study tested this possibility, as well as the contribution of adulthood ADHD symptom persistence, in order to clarify long-term risk in this population. Children diagnosed with ADHD and demographically-similar children without ADHD were followed longitudinally into adulthood and repeatedly assessed on heavy drinking, alcohol problems, and depressive symptoms from ages 21-29 (84.1% White (not Hispanic); 86.9% male; 51.2% childhood ADHD; 14.7% adulthood-persistent ADHD; N = 320). Group-based multi-trajectory modeling identified six groups with different combinations of trajectories across these variables. Heterogeneous longitudinal outcomes for those with ADHD were found. Some children with ADHD showed increased risk as typically predicted, with a higher likelihood of membership in a group with stable-moderate alcohol outcomes and stable-severe depression (adulthood persistent ADHD also predicted this group), whereas some children with ADHD were more likely to belong to a group with virtually no alcohol outcomes and low depression. Additionally, adulthood persistent ADHD predicted membership in a group with stable-severe alcohol outcomes and stable-moderate depression. Given the severity associated with co-occurring alcohol and depressive disorders, studies of early risk and protective factors and long-term outcomes for these disparate trajectory patterns are needed, particularly for those with childhood and persisting ADHD.

Outcomes of ADHD Symptoms in Late Adolescence: Are Developmental Subtypes Important?

Objective: Substantial individual variation exists in the age of onset and course of ADHD symptoms over development. We evaluated whether, within this variation, meaningful developmental subtypes can be defined. Method: Using growth mixture modeling in a community-based sample (N = 1,571), we analyzed ADHD symptom trajectories based on measures taken at ages 7, 8, 9, 10, 11, 13, and 15 years. We evaluated whether those showing developmental trajectories characterized by later onsets versus early onsets differed in terms of mental health and behavioral outcomes in late adolescence (age 17 years). Result: The late onset category was best conceptualized as a milder subtype than early onset. The former was, however, more similar in outcomes to the latter than to the unaffected category, suggesting that later onsets are still associated with impairment. Conclusion: Considering diagnoses for those affected by ADHD symptoms but who do not meet current age of onset criteria may be important for ensuring that they receive appropriate support.

Momentary fluctuations in impulsivity domains: Associations with a history of childhood ADHD, heavy alcohol use, and alcohol problems

BACKGROUND

The current study examined if fluctuation in in-the-moment impulsivity was more pronounced for adults with, versus without, a childhood history of ADHD and if ADHD group moderated the association between fluctuation in impulsivity and alcohol use behaviors.

METHODS

Two hundred and eleven adult drinkers (52% ADHD) completed a 10-day, 6 times/day, momentary assessment of state impulsivity. Self-reported trait impulsivity, alcohol problems, and frequency of 5+ drinks in the past 12 months were also assessed.

RESULTS

The ADHD group had more variability in three domains of state impulsivity (negative urgency, positive urgency, sensation seeking) compared to the nonADHD group. After including global trait impulsivity, the ADHD and nonADHD groups only differed on state sensation seeking. Fluctuation in two domains of state impulsivity were related to frequency of 5+ drinks (lack of planning: ADHD RR = 3.60, p < 0.001, nonADHD RR=0.90, p = 0.81; negative urgency: ADHD RR=4.32, p = 0.01, nonADHD RR=0.49, p = 0.24) and number of different alcohol problems (lack of planning: ADHD RR=4.87, p < 0.001, nonADHD RR=0.58, p = 0.29; negative urgency: ADHD RR=4.96, p = 0.01, nonADHD RR=0.24, p = 0.04) for participants with a history of ADHD but were not related (or related to fewer problems) for those without childhood ADHD. Higher variability in positive urgency was related to more alcohol problems for the participants with childhood ADHD but not the nonADHD participants (ADHD RR=3.00, p = 0.03, nonADHD RR=0.50, p = 0.25).

CONCLUSIONS

Findings highlight the importance of assessing fluctuation in several domains of impulsivity and may elucidate important treatment targets for alcohol problems for adults with ADHD histories.

Risk of Alcohol Abuse in Humans with Attention-deficit/Hyperactivity Disorder Symptoms

The relationship between attention-deficit/hyperactivity disorder (ADHD) and the risk of alcohol abuse is widely studied. Even though this topic has been of interest for several years, it is heavily debated. We studied various papers and conducted a systematic review using PubMed as the main source of data collection. We found that several studies put forward the concept of a positive association between alcohol abuse and ADHD symptoms, but a minority of them also showed opposing and contradictory results. We discovered that this inconsistency observed in studies could be a result of a biased approach in studies and a subjective attempt in interpretations. These biases could be studied in terms of sample size involved in the analysis, age at which studies are conducted among other statistical parameters. We believe that the deviations in the outcomes prove that the studies may be incomplete and that a standardized method of interpretation is required. Therefore, this paper recommends the need for further research to explore the connection between alcohol abuse in patients showing ADHD symptoms.

Attention Deficit Hyperactivity Disorder (ADHD) in the Prison System

PURPOSE OF REVIEW

To examine recent advances in the understanding of attention deficit hyperactivity disorder (ADHD) among the prison population.

RECENT FINDINGS

Efforts have been made to develop useful tools for assessing ADHD among prisoners. Prisoners with ADHD demonstrate incremental vulnerability due to comorbid psychiatric disorders, neurodevelopmental disorders and traumatic brain injury. Compared with prisoners without ADHD, prisoners with ADHD become involved in the criminal justice system at a younger age and have higher rates of recidivism in adulthood. Recent studies demonstrate the effectiveness of extended release stimulant medication and psychological interventions. Early identification and treatment of prisoners with ADHD have the potential to demonstrate health economic benefits. Our understanding of ADHD among prisoners continues to develop. However, further research is needed, particularly among neglected groups such as females. Much more attention is needed by the prison service to engender better outcomes for this at-risk population.

The Effect of Childhood Conduct Problems on Early Onset Substance Use: An Examination of the Mediating and Moderating Roles of Parenting Styles

This study examines the role that effective parenting plays in the relationship between childhood conduct problems and the early onset of drug use. Effective parenting is posited to have a direct protective effect on drug use, a moderating effect on the relationship between conduct problems and early onset, and mediate the relationship between conduct problems and early onset. Two-generational panel data are used to examine these relationships among 263 parent–child dyads. Support is found for the direct protective effect of effective parenting on early onset .and for a partial mediating effect of parenting in the relationship between conduct problems and early onset. There was no support found for parenting moderating the risk that is posed by having childhood conduct problems. Implications for preventing childhood conduct problems from resulting in early onset of drug use through enhancing efforts to help parents cope with such problems are discussed.

Psychological Risk Factors for Alcohol, Cannabis, and Various Tobacco Use among Young Adults: A Longitudinal Analysis

BACKGROUND

Alcohol, cannabis, and tobacco use are prevalent in young adults and may be differentially related to psychological symptoms characterized as externalizing or internalizing.

OBJECTIVES

This study examined the use of alcohol, cannabis, and various tobacco products in relation to externalizing (ADHD) versus internalizing factors (depression, anxiety), hypothesizing alcohol and cannabis use are associated with externalizing factors whereas tobacco use is related to internalizing factors.

METHODS

Data from a 2-year longitudinal study of 2,397 US college students (aged 18-25) launched in 2014 were analyzed. Adult ADHD Self-Report Scale, Patient Health Questionnaire-9 item (assessing depressive symptoms), and the Zung Self-Rating Anxiety Scale scores were examined in relation to subsequent past 30-day use of alcohol, cannabis, and tobacco products (cigarettes, little cigars/cigarillos, smokeless tobacco, e-cigarettes, hookah), as well as nicotine dependence per the Hooked on Nicotine Checklist.

RESULTS

Participants were 20.49 (SD = 1.93) years old, 64.7% female, and 65.5% White. In multivariable analyses, greater ADHD symptoms predicted alcohol and cannabis use (p = .042 and p = .019, respectively). Cigarette and little cigar/cigarillo use were predicted by greater depressive (p = .001 and p = .002, respectively), and anxiety symptoms (p = .020 and p = .027, respectively). Nicotine dependence was correlated with greater anxiety symptoms (p = .026). Counter to hypotheses, smokeless tobacco use was predicted by greater ADHD symptoms (p = .050); neither e-cigarette nor hookah use were predicted by these psychological symptoms. Conclusions/Importance: Research examining risk factors for tobacco use must distinguish among the various tobacco products. Moreover, interventions may need to differentially target use of distinct substances, including among the range of tobacco products.

Pharmacotherapeutic strategies for the treatment of attention-deficit hyperactivity (ADHD) disorder with comorbid substance-use disorder (SUD)

INTRODUCTION

Substance use disorder (SUD) is very common amongst patients with attention deficit hyperactivity disorder (ADHD). The two disorders share partially overlapping features and SUD in ADHD is characterized by an early age of onset, high likelihood of poly-substance use, increased risk of suicide attempts, more hospitalizations, and scarce treatment adherence.

AREAS COVERED

This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in patients with ADHD and SUD. The authors include open label and observational studies.

EXPERT OPINION

Stimulant and non-stimulant treatments should be used to aid ADHD symptomatology in patients with SUD. SUD seems to be less responsive, suggesting a relative independence of the two conditions. For this reason, the association of ADHD-specific drugs and SUD-treatments should be recommended in a large proportion of patients suffering from both disorders. The rate and the quality of ADHD response to specific pharmacological treatments is highly variable, depending on the dose and the duration of the treatment, the age of the patient, and the severity and the chronicity of addiction. Further research is necessary to explore the divergences in treatment response of different ADHD subtypes in different subtypes of SUD.

How Substance Users With ADHD Perceive the Relationship Between Substance Use and Emotional Functioning

OBJECTIVE

Although substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative-quantitative approach to explore this relationship.

METHOD

Narrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old).

RESULTS

SU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters.

CONCLUSION

Perceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

Substance use through adolescence into early adulthood after childhood-diagnosed ADHD: findings from the MTA longitudinal study

BACKGROUND

Inconsistent findings exist regarding long-term substance use (SU) risk for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The observational follow-up of the Multimodal Treatment Study of Children with ADHD (MTA) provides an opportunity to assess long-term outcomes in a large, diverse sample.

METHODS

Five hundred forty-seven children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD and 258 classmates without ADHD (local normative comparison group; LNCG) completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25.

RESULTS

In adulthood, weekly marijuana use (32.8% ADHD vs. 21.3% LNCG) and daily cigarette smoking (35.9% vs. 17.5%) were more prevalent in the ADHD group than the LNCG. The cumulative record also revealed more early substance users in adolescence for ADHD (57.9%) than LNCG (41.9%), including younger first use of alcohol, cigarettes, marijuana, and illicit drugs. Alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early SU predicted quicker SU escalation and more SU in adulthood for both groups.

CONCLUSIONS

Frequent SU for young adults with childhood ADHD is accompanied by greater initial exposure at a young age and slightly faster progression. Early SU prevention and screening is critical before escalation to intractable levels.

Associations between childhood ADHD, gender, and adolescent alcohol and marijuana involvement: A causally informative design

BACKGROUND

We report whether the etiology underlying associations of childhood ADHD with adolescent alcohol and marijuana involvement is consistent with causal relationships or shared predispositions, and whether it differs by gender.

METHODS

In three population-based twin samples (N = 3762; 64% monozygotic), including one oversampling females with ADHD, regressions were conducted with childhood inattentive or hyperactive-impulsive symptoms predicting alcohol and marijuana outcomes by age 17. To determine whether ADHD effects were consistent with causality, twin difference analyses divided effects into those shared between twins in the pair and those differing within pairs.

RESULTS

Adolescents with more severe childhood ADHD were more likely to initiate alcohol and marijuana use earlier, escalate to frequent or heavy use, and develop symptoms. While risks were similar across genders, females with more hyperactivity-impulsivity had higher alcohol consumption and progressed further toward daily marijuana use than did males. Monozygotic twins with more severe ADHD than their co-twins did not differ significantly on alcohol or marijuana outcomes, however, suggesting a non-causal relationship. When co-occurring use of other substances and conduct/oppositional defiant disorders were considered, hyperactivity-impulsivity remained significantly associated with both substances, as did inattention with marijuana, but not alcohol.

CONCLUSIONS

Childhood ADHD predicts when alcohol and marijuana use are initiated and how quickly use escalates. Shared familial environment and genetics, rather than causal influences, primarily account for these associations. Stronger relationships between hyperactivity-impulsivity and heavy drinking/frequent marijuana use among adolescent females than males, as well as the greater salience of inattention for marijuana, merit further investigation.

Between- and within-person associations between negative life events and alcohol outcomes in adolescents with ADHD

Escalations in alcohol use during adolescence may be linked with exposure to negative life events, but most of this research has focused on between-person associations. Moreover, adolescents with attention-deficit hyperactivity disorder (ADHD) may be an especially vulnerable population, reporting more life events and alcohol involvement and may even be more sensitive to the effects of life events on alcohol outcomes compared with those without ADHD. We tested the between- and within-person effects of the number and perceptions of negative life events on the development of alcohol use outcomes from age 14 to 17 years in 259 adolescents with and without ADHD using generalized estimating equations. Between-person differences in exposure to negative life events across adolescence, but not the perception of those events, were associated with a higher likelihood of alcohol use and drunkenness at age 17 years. Within-person differences in life events were associated with alcohol use above and beyond that predicted by an adolescents' typical trajectory over time. Parent- and teacher-reported ADHD symptoms were associated with more negative perceptions of life events and with greater alcohol use and drunkenness at age 17 years, but symptoms did not moderate the life event-alcohol association. Interventions should consider the variables that produce vulnerability to life events as well as the immediate impact of life events. That the accumulation of life events, rather than their perceived negativity, was associated with alcohol outcomes indicates that interventions targeting the reduction of negative events, rather than emotional response, may be more protective against alcohol use in adolescence. (PsycINFO Database Record

A Clinician's Guide to Co-occurring ADHD among Adolescent Substance Users: Comorbidity, Neurodevelopmental Risk, and Evidence-based Treatment Options

This article introduces neurodevelopmental and clinical considerations for treating adolescents with co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD) and substance use (ASU) in outpatient settings. We first describe neurobiological impairments common to ADHD and ASU, including comorbidity with conduct disorder, that evoke a profile of multiplicative developmental risk. We then present two evidence-based options for targeting ADHD-related problems during ASU treatment. Medication integration interventions utilize family ADHD psychoeducation to prompt decision-making about ADHD medication and integrate medication management into behavioral services. Clinic-based academic training interventions utilize family interventions to improve the home academic environment and boost organization skills. We conclude with recommendations for ADHD assessment and intervention sequencing.

Progression of impairment in adolescents with attention-deficit/hyperactivity disorder through the transition out of high school: Contributions of parent involvement and college attendance

Long-term, prospective follow-up studies of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) show that symptoms tend to decline with age, but impairments in daily life functioning often persist into adulthood. We examined the developmental progression of impairments before and after the transition out of high school in relation to parent involvement during adolescence, parent support during adulthood, and college attendance, using 8 waves of data from the prospective 16-year follow-up of the Multimodal Treatment of ADHD (MTA) study. Participants were 548 proband children diagnosed with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV; American Psychiatric Association, 2000) ADHD Combined Type and 258 age- and sex-matched comparison children (Local Normative Comparison Group; LNCG) randomly sampled from probands' schools. Impairment was assessed consistently by parent report from childhood through adulthood. Results showed that impairment worsens over time both before and after the transition to adulthood for those with ADHD histories, in contrast to non-ADHD peers, whose impairments remained stably low over time. However, impairment stabilized after leaving high school for young adults with ADHD histories who attended college. Involved parenting in adolescence was associated with less impairment overall. Attending college was associated with a stable post-high school trajectory of impairment regardless of parents' involvement during adolescence, but young adults with histories of involved parenting and who attended college were the least impaired overall.

Alcohol and marijuana use trajectories in a diverse longitudinal sample of adolescents: examining use patterns from age 11 to 17 years

AIMS

We tested race/ethnic differences in alcohol and marijuana (AM) trajectories (comprising an intercept term, reflecting overall probability of use, and a slope term, reflecting change in probability of use) during adolescence, whether AM use trajectories predicted high school outcomes, and whether outcomes differed by race/ethnicity after controlling for trajectory of AM use.

DESIGN

This longitudinal study involved 6509 youth from 16 middle schools in Southern California surveyed from age 11.5 (2008) to age 17 (2015) years; all surveys assessed AM use, and the final survey also examined high school outcomes.

SETTING

Youth completed five surveys in middle school and two on-line surveys in high school.

PARTICIPANTS

The sample was 50% male and 80% non-white.

MEASUREMENTS

Intercept (at 2.75 years post-baseline) and slope of AM use were examined as outcomes for race/ethnic differences. AM use trajectories were examined as predictors of academic performance and unpreparedness, social functioning, mental and physical health and delinquency.

FINDINGS

We found differences in trajectories of use by race/ethnicity, with white youth reporting a higher overall intercept of alcohol use compared to all other groups (versus Asian P < 0.001, black P = 0.001, multi-ethnic P = 0.008). Overall, examination of trajectories of use showed that adolescents with a higher alcohol use intercept term reported greater academic unpreparedness (P < 0.001) and delinquency (P < 0.001) at wave 7 in high school. In addition, youth with a higher intercept for marijuana use reported greater academic unpreparedness (P < 0.001) and delinquency (P < 0.001), and poorer academic performance (P = 0.032) and mental health (P = 0.002) in high school. At wave 7, compared to white youth, Hispanic and multi-ethnic youth reported poorer academic performance (P < 0.001 and P = 0.034, respectively); Asian, black and Hispanic youth reported higher academic unpreparedness (P < 0.001, P = 0.019, and P = 0.001); and Asian youth and multi-ethnic youth reported poorer physical health (P = 0.012 and P = 0.018) controlling for AM use.

CONCLUSIONS

Greater AM use was associated with worse functioning in high school for all youth. After controlling for AM use, non-white youth reported worse outcomes in high school for academics and health.

Burden of illness and health care resource utilization in adult psychiatric outpatients with attention-deficit/hyperactivity disorder in Europe

OBJECTIVE

To assess the burden of illness and health care resource utilization of adult nonpsychotic psychiatric outpatients with attention-deficit/hyperactivity disorder (ADHD) in Europe.

METHODS

This was a multicountry, cross-sectional, observational study where unselected routine patients from clinical psychiatric outpatient settings were screened and assessed for ADHD. Patients were evaluated using the Clinical Global Impressions of Severity (CGI-S) scale, the Sheehan Disability Scale (SDS), and the EuroQol-5 Dimensions questionnaire. Data on comorbidities, functional impairment, and health care resource utilization were captured.

RESULTS

The study enrolled 2284 patients, of whom 1986 completed the study. The prevalence of ADHD was 17.4%, of whom 46.0% had a previous ADHD diagnosis. Patients with ADHD had a high clinical burden with psychiatric comorbidities, especially depression (43.0%) and anxiety disorders (36.4%). Substance abuse (9.2% vs. 3.4%) and alcohol abuse (10.3% vs. 5.2%) were more common in the ADHD cohort vs. the non-ADHD cohort. Only 11.5% of the patients with ADHD had no other psychiatric disorder. Various measures indicated a significantly poorer level of functioning for patients with ADHD than without ADHD, as indicated by higher scores for CGI-S (3.8 vs. 3.3) and SDS (18.9 vs. 11.6) and higher percentages of debt (35.5% vs. 24.3%) and criminality (13.8% vs. 6.1%). Lastly, the health care resource utilization was considerable and similar between adult psychiatric outpatients diagnosed and not diagnosed with ADHD.

CONCLUSIONS

Although care was taken when choosing the sites for this study, to make it representative of the general outpatient adult psychiatric population, caution should be advised in generalizing the findings of our study to the general ADHD or psychiatric outpatient population. This was an observational study, thus no inference on causality can be drawn. Having ADHD imposes a considerable health and social burden on patient and health care resource utilization comparable to other chronic psychiatric disorders.

The indirect effects of childhood attention deficit hyperactivity disorder on alcohol problems in adulthood through unique facets of impulsivity

BACKGROUND AND AIMS

Research has not studied unique impulsivity dimensions as prospective links between childhood attention deficit hyperactivity disorder (ADHD) and alcohol problems. We examined the association between childhood ADHD, five facets of impulsivity and alcohol problems in adulthood and the indirect effects of childhood ADHD-to-impulsivity-to-alcohol problems.

DESIGN, SETTING AND PARTICIPANTS

Participants were from a longitudinal study (n = 289, meanage  = 28.67) of individuals with (n = 170) and without (n = 119) childhood ADHD. The ADHD sample, as part of an ADHD summer treatment program, was diagnosed initially in childhood (1987-96, Pittsburgh, PA, USA) via structured parent interview and standardized parent/teacher ratings. The ADHD sample and demographically similar individuals without ADHD (living in the greater Pittsburgh area) were recruited to participate in the Pittsburgh ADHD Longitudinal Study (PALS) between 1999 and 2003.

MEASUREMENTS

Self-reported impulsivity (UPPS-P) and alcohol-related problems were assessed in adulthood (2011-14).

FINDINGS

Adults with, compared with those without, childhood ADHD had more alcohol problems (β = 0.34, P < 0.05) and higher levels of negative urgency, positive urgency, lack of perseverance and lack of planning (βs = 0.24-0.31, Ps < 0.001). Impulsivity facets (except sensation-seeking) were related to number of alcohol problems (βs = 0.34-0.61, Ps < 0.05). Negative (β = 0.26, P < 0.01) and positive (β = 0.27, P < 0.01) urgency mediated the association between childhood ADHD and number of adult alcohol problems.

CONCLUSIONS

Elevated levels of emotional impulsivity (negative/positive urgency) may place children with attention deficit hyperactivity disorder at increased risk for alcohol problems in adulthood.

The association of psychiatric symptomatology with patterns of alcohol, tobacco, and marijuana use among Brazilian high school students

BACKGROUND AND OBJECTIVES

Studies have highlighted psychosocial factors associated with drug use among adolescents. Association of specific psychiatric comorbidity with substance use has not been properly established in Brazil. This study aimed to investigate alcohol, tobacco, and marijuana use by 15-18-year-old high school Brazilian students and to estimate associations with psychiatric symptoms.

METHODS

A cross-sectional survey of 4,034 students from 128 public and private schools in São Paulo State was carried out using a two-step probability sample. Data were collected through self-report standardized questionnaires including questions on substance use patterns and the Strengths and Difficulties Questionnaire (SDQ). Key outcome variables were past-month use and past-month frequent use of alcohol, tobacco and marijuana. Questionnaires with missing information were excluded, resulting in a final sample of 2,532 adolescents. Weighted data was analyzed through logistic regressions, adjusted by gender and by socio-economic status (SES).

RESULTS

Regarding SDQ total score, 43.6% of students had no psychiatric symptoms, 7.9% had subclinical symptoms and 48.5% presented clinically significant symptoms. Respondents with a clinically significant SDQ score were more likely to be past month alcohol (aOR = 1.51; 95%CI 1.22-1.88), tobacco (aOR = 1.82; 95%CI 1.25-2.66), and marijuana (aOR = 1.79; 95%CI 1.21-2.64) users as compared to those with no symptomatology.

DISCUSSION AND CONCLUSIONS

Psychopathological symptoms were associated with alcohol, tobacco and marijuana use by 15-18-year-old adolescents. These associations should also be considered when planning public policies of mental health promotion.

SCIENTIFIC SIGNIFICANCE

This study discusses the importance of the association between psychopathological symptoms and substance use in a middle-income country, with high level of social inequalities, in a state representative sample. (Am J Addict 2016;25:416-425).

Mediating effect of anxiety and depression on the relationship between Attention-deficit/hyperactivity disorder symptoms and smoking/drinking

Attention-deficit/hyperactivity disorder (ADHD) has been often found to be comorbid with other disorders, including anxiety, depression, and unhealthy behaviors such as drinking alcohol and smoking. These factors were often discussed separately, and the mediating effects of mental health on substance use are unknown. To study the mediating effects of anxiety and depression on the relationship between ADHD and drinking/smoking behaviors, we conducted a cross-sectional study of 1870 college students from Shanghai, China. The Adult ADHD Self-Report Scale (ASRS-v1.1) and Wender Utah Rating Scale (WURS) were used to identify the current and past ADHD. Structural Equation Modeling was carried out to clarify the mediating effect of anxiety and depression on the relationship between core ADHD symptoms and smoking/drinking behaviors. We found that inattention as one of the core symptoms of ADHD was associated with an increased risk of depression as a direct effect, as well as slightly increased risk of smoking/drinking behaviors by an indirect effect of depression. Hyperactivity-impulsivity, as another core symptom of ADHD had a robust impact on smoking and drinking behaviors, while being mediated by anxiety and depression. In conclusion, anxiety and depression was associated with further increased risk behaviors of smoking/drinking alcohol among those students with ADHD.