Minimal brain dysfunction symptoms claimed by primary and secondary alcoholics: relation to cognitive functioning

Attention deficit/hyperactivity disorder and substance abuse. Diagnostic and therapeutic considerations

Patterns of association between attention deficit hyperactivity disorder (ADHD) and substance-use disorders are considered. Recent investigations have found that up to 50% of individuals with continuing ADHD symptoms have a substance-use disorder. ADHD appears to represent an independent risk factor for substance abuse. We review clinical challenges posed by the diagnosis of ADHD in substance-abusing populations. Nicotine dependence is also substantially more common among adults with ADHD (40%) than in the general population (26%). While several classes of substances of abuse may ameliorate various symptoms of ADHD, individuals with ADHD may also be vulnerable to substance use because of poor judgment or impulsive behavior in social settings. Evidence is reviewed from genetic studies examining the role of the dopamine D2 (DRD2) gene in the etiology of ADHD. The presence of ADHD may affect the course of adolescent substance abuse in several ways: predicting earlier age of onset, longer duration of substance-use disorder, and progression of alcohol abuse to another drug-use disorder. Individuals with ADHD have been noted to have a shorter interval between the onsets of drug abuse and drug dependence. Such individuals are also at greater risk for treatment failure, as their disruptive behaviors interfere with treatment access and response. Lastly, we review advances in pharmacotherapeutic agents used for treating ADHD and consider the impact of these interventions on comorbid substance-use disorders. We suggest promising areas of focus for clinical research trials targeting the subpopulation of substance abusers with concurrent ADHD.

A review of the effects of moderate alcohol intake on psychiatric and sleep disorders

In this chapter we discuss the effects of moderate ethanol consumption on the treatment of psychiatric and sleep disorders. A review of the literature on the interactions of ethanol with neurotransmitters and psychotropic medications suggests that although ethanol affects the clinical course of psychiatric and sleep disorders by different mechanisms, it does so principally through perturbations it causes in the balance of central nervous system neurotransmitter systems, which may modify the clinical course of primary psychiatric and sleep disorders and undermine the therapeutic response to psychotropic medications. Neurotransmitter responses may also be manifested clinically by rebound phenomena, akin to a subsyndromal withdrawal, which affect sleep and precipitate anxiety and mood symptoms. In addition, ethanol also modifies the clearance and disposition of a variety of psychotropic metabolites and interferes with their clinical effectiveness. We recommend that most psychiatric patients, and all patients with sleep disorders, should abstain from even moderate ethanol use, as this may adversely affect their clinical course and response to treatment.

Risk factors for substance use by Mexican American youth with and without learning disabilities

This survey study was designed to (a) investigate the prevalence of minor and major substance use among low socioeconomic status elementary and middle school Mexican American students identified with learning disabilities (LD; n = 150) and without LD (n = 150), and (b) identify psychosocial and environmental risk factors that may lead to the use of various substances among both non-learning disabled (non-LD) students and students with LD in an all-Mexican American sample. No differences were found in the use of substances between the two groups. Risk factors that were found to influence the use of minor substances for students identified as learning disabled, as opposed to the non-LD students, included use of substances by close friends and susceptibility to peer influence. Risk factors that were found to affect the use of major substances for students identified as learning disabled, as opposed to the non-LD students, included the number of minor substances used and stressful life events. Findings are discussed in the context of differing pathways leading to the use of substances for non-LD students and students with LD within an intraethnic group study.

Behavioral dysfunction and cognitive efficiency in male and female alcoholics

This study was conducted to examine the role of childhood behavioral disorders (CBDs) and residual attention deficit disorder (ADDRT) in alcohol-related cognitive dysfunction in male and female subjects. Alcoholic (n = 44 females, 56 males) and control (n = 40 females, 40 males) subjects completed assessments that included measures of CBDs, ADDRT, and cognitive and psychosocial functioning. Cognitive tests were specifically designed to assess efficiency in function. As expected, alcoholics were inferior to controls in their cognitive efficiency [F(1,171) = 10.43, p = 0.0015]. Alcoholics reported more CBDs [F(1,161) = 12.02, p = 0.0007], regardless of sex. They also reported more ADDRT [F(1,173) = 44.12, p = 0.0001] than did controls. There were also sex [F(1,173) = 13.31, p = 0.0004] and group by sex effects [F(1,173) = 3.93, p = 0.05]. Female alcoholics reported more ADDRT symptoms than any other group. Regression equations conducted to clarify the relation between group, sex, CBDs, ADDRT, and cognitive efficiency indicated that the best predictor of cognitive efficiency was group classification (alcoholic versus control). That is, although symptoms of behavioral disorders were reported significantly more frequently by both male and female alcoholic subjects, these symptoms could not account for the cognitive impairment observed in either sex.

The role of antisocial, affective, and childhood behavioral characteristics in alcoholics' neuropsychological performance

Chronic alcoholics demonstrate cognitive deficits when compared with nonalcoholics. These deficits are typically attributed to the direct effects of ethanol and its metabolites on the central nervous system (CNS). There are other factors, however, that differentiate alcoholics from controls, such as personality or behavioral characteristics. These factors may affect neuropsychological performance and thus alter the interpretation of alcoholic cognitive deficits as resulting solely from alcohol's toxic effects. To investigate this question, male and female alcoholics and peer nonalcoholic controls were compared on personality, behavioral, and cognitive measures. Alcoholics had greater numbers of antisocial behaviors, childhood behavioral disorder symptoms (CBD), and affective symptomatology, and had poorer neuropsychological performance than controls. The three personality and behavioral factors were positively intercorrelated with each other, and were negatively related to cognitive performance. The CBD factor proved to be the most consistent predictor of neuropsychological performance for both alcoholics and controls, and males and females. While the behavioral factors differentiated alcoholics from controls and predicted performance, significant differences between the groups in cognitive performance still remained when these factors were taken into account.

Measuring the learning potential of abstinent alcoholics

The performance of 89 Finnish alcoholics was measured on a Vygotskian test of learning potential. There were four questions to analyse: (1) can the performance of alcoholics be improved by means of instruction in non-verbal problem solving tasks; (2) how extensive is the transfer effect; (3) how does the duration of abstinence affect test performance; and (4) how does the actual performance level affect post-test results? Results indicated that instruction had a clear positive effect on the performance of alcoholics in simple tasks, but no transfer effect was evident in the more complex tasks. The duration of abstinence had no general effect. Although analysis of the mean scores of time-level groups showed some improvement in performance with increasing duration of abstinence, intra-group deviation was so high that the trends were not statistically significant. The subjects' actual performance level, on the other hand, was a very relevant factor. This was particularly evident in complex transfer tasks.

Prediction of resumption of drinking in posttreatment alcoholics

The ability of five factors (depressive symptomatology, neuropsychological performance, psychosocial maladjustment, previous treatment history, and childhood attention deficit disorder symptomatology) to predict relapse was examined in a follow-up experimental design. Fifty-eight male and 45 female alcoholics were interviewed immediately following release from inpatient treatment units. Fourteen months later, 41 subjects (41%) were classified as resumers; 62 (59%) were abstainers. Resumers showed significantly poorer scores than abstainers on all five of the predictor variables. Discriminant function analysis resulted in 75% correct classification of resumers and abstainers (chi 2 = 22.1, p less than .001). Stepwise multiple regression resulted in isolation of depressive symptomatology as the best single predictor of relapse.

The HK/MBD questionnaire: factor structure and discriminant validity with an adolescent sample

A somewhat revised four-factor structure emerged for the HK/MBD questionnaire with a sample of nonclinical adolescents. The three factors of hyperactivity/impulsivity, antisocial/oppositional behaviors, and learning problems largely retained their factor integrity, but a distinct peer dysfunction factor replaced attentional/socialization problems with the adolescent sample. Acceptable levels of internal consistency were found for three of the factors (excluding learning problems), and interrater reliability between adolescents and their primary caregivers was significant for all four factors. High factor intercorrelations were reported for hyperactivity/impulsivity and antisocial/oppositional behaviors. Differential predictive relations were found between the four factors and adolescent problem behaviors. Specifically, hyperactivity/impulsivity and antisocial/oppositional behaviors were most highly correlated with externalizing symptoms such as alcohol problems, delinquency, illicit drug use, and poor school performance. Peer dysfunction was most highly correlated with internalizing, depressive symptoms. Learning problems correlated most highly with poor school performance, and moderately with alcohol problems and depressive symptoms. There were no statistically significant differences in the strength of the interrelations between the factors of the HK/MBD questionnaire and adolescent problem behaviors for males and females.

Does neuropsychological test performance predict resumption of drinking in posttreatment alcoholics?

The prediction of resumption of drinking in posttreatment alcoholics was investigated as a function of five possible confounding variables: depression, anxiety, childhood symptoms of attention deficit and conduct disorders and family history of alcoholism. Male and female detoxified alcoholics (n = 103) in inpatient treatment programs were administered a neuropsychological battery and retested as outpatients 14 months later; peer nonalcoholics (n = 73), given the same battery, had a similar interest interval. Alcoholics who resumed drinking (N = 41) performed significantly poorer on an overall neuropsychological performance index than abstainers (N = 62) who performed significantly poorer than nonalcoholics. Stepwise multiple regression equations using the variables noted above revealed that depressive symptoms, ADD and the performance index were the only variables to enter the prediction (R2 = .26, p less than .001); depression accounted for most of the variance. At retest all three groups improved significantly, but not differentially, and were as significantly different at retest as at initial testing. Implications of these results are discussed.

The HK/MBD questionnaire: replication and validation of distinct factors in a nonclinical sample

Although Tarter et al.'s (1977) HK/MBD questionnaire has been found useful in subtyping populations of clinical alcoholics, its potential utility in nonclinical populations has yet to be determined. The current study examined the family history, personality, and substance use/abuse correlates of Tarter et al.'s HK/MBD questionnaire and factor analytically derived subscales (Alterman and McLellan, 1986) in a nonclinical sample of 580 young, adult males. In addition, a factor analysis of the HK/MBD questionnaire was undertaken to assess the extent to which the factor structure determined on a clinical alcoholic sample replicates in a nonclinical sample. Results indicated that each of the HK/MBD subscales showed relatively unique patterns of correlations with the various personality measures employed suggesting that they are measuring separate constructs. Perhaps of greatest importance, the HK/MBD items that appear to be of greatest relevance for understanding substance use/abuse are those related to antisocial behavior. Finally, the factor structure of the HK/MBD questionnaire in the nonclinical sample was found to be quite similar to the structure obtained in a clinical sample. These results demonstrate the multidimensional structure of the HK/MBD questionnaire and the utility of using the more homogeneous subscales in research with both clinical and nonclinical samples.

Predictive validity of four factors derived from an 'hyperactivity/MBD' questionnaire

Two studies were conducted to evaluate the differential predictive validity of four factors--hyperactivity/impulsivity, attention/socialization problems, antisocial behavior, learning problems--derived from Tarter's 'hyperactivity/MBD' questionnaire. One hundred forty five inpatient alcoholic men were evaluated in the first study and 34 first or second year college men in the second study. Our previous research had revealed significant relationships between the total hyperactivity/MBD score and psychopathology (MMPI, Psychopathic State Inventory), alcohol use patterns and consequences/and several areas of life functioning (Addiction Severity Index). Factor 1 was revealed in both studies to be associated with hypomania and impulsive behaviors. Factor 2 was associated with many of the same MMPI scales as the total hyperactivity/MBD score, including psychopathic deviate, psychasthenia and social introversion, as well as other measures of sociopathy and criminal behavior. A subsequent breakdown of Factor 2 into its attention and socialization components provided further meaningful differentiations. Factor 3 was found in both studies to be predictive of antisocial and criminal personality and behavior. Both factors 2 and 3 were also closely associated with difficulties in interpersonal relations. Factor 4 bore few relationships with personality, but was found to be related to visuospatial performance deficits. The research therefore supported the differential predictive validity of the four factors. The examination of the individual relationships of these factors enabled a more precise delineation of underlying relationships than was achieved by the total hyperactivity/MBD score.

A factor-analytic study of Tarter's "hyperactivity-MBD" questionnaire

A number of studies have suggested a relationship between childhood hyperactivity and subsequent alcohol abuse. Research with alcoholics has utilized retrospective, self-report questionnaires to examine the relationship between childhood hyperactivity and alcoholism. Since it is now recognized that "hyperactivity" has been rather loosely and broadly defined, it would seem reasonable to determine the independent behavioral dimensions subsumed within it. The present study factor analyzed the data of 145 alcoholic inpatients on Tarter's 'hyperactivity/MBD' questionnaire. Four factors which included 26 of Tarter's original 50 items were derived--hyperactivity-impulsivity, attentional-socialization problems, antisocial behavior, and learning disability. These factors and the items contained therein were compared with four scales developed on a rational basis by the Hesselbrocks. Additionally, the factor scores of the subjects were cluster analyzed yielding six interpretable clusters. A number of these, such as hyperactivity-impulsivity alone, hyperactivity-impulsivity combined with attentional-socialization problems, and hyperactivity-impulsivity combined with antisocial behavior, are of considerable theoretical interest. Accordingly, further requirements for establishing the validity of the factor analyzed scales and the cluster analysis-based responder groupings were delineated.

Chronic alcoholism in males: cognitive deficit as a function of age of onset, age, and duration

Performance on a cognitive rule-learning task was studied in detoxified alcoholics having early/late onset and short-/long-term drinking histories, and in matched nonalcoholic controls. There were pronounced cognitive deficits in early onset and long-term alcoholics. Impairment was severest in the early onset group, even though they were on the average 15 years younger than the late onset group. Early onset alcoholics were relatively more impaired on both the abstract and the verbal Shipley measures. This group also manifested a relative deficit in ability to show positive transfer across problems. Chronicity of alcoholism also interfered with acquisition of an abstract relationship between concrete stimulus attributes. Age negatively influenced ability to perform abstractions, but not commonly tested verbal skills. The findings suggest that an early onset of alcoholism, regardless of duration of problem drinking, is particularly predictive of cognitive impairment.

Assessing the influence of confounding subject variables in neuropsychological research in alcoholism and related disorders

With the recent emphasis on clinical research there has developed a greater sophistication in identifying and uncovering possible confounding subject variables. The investigator searching for etiologies and underlying relationships is accordingly increasingly faced with the question of how to deal with, or control numerous subject variables which may covary with the condition or disorder under study. The present paper describes some of these variables and the problems their presence raises for the conduct of clinical research. Although most of the examples described such as childhood hyperactivity, head injury, psychopathology, and physical disorders of the subjects are specifically relevant to neuropsychological research in alcoholism, many of them should be pertinent also for related areas of inquiry. The difficulties and problems in controlling, ruling out and taking such variables into account, as well as guidelines and strategies for their treatment and management, are considered. The question of the generality of findings which arises when so many subject variables are controlled is discussed. It is concluded that we are just on the threshold of identifying and clarifying the behavioral effects of numerous subject variables, conditions and disorders. The implications of this situation for the validity of our current research findings are discussed.

Reliability and validity of the Primary/Secondary Alcoholism Classification Questionnaire and the Hk/MBD Childhood Symptoms Checklist

Primary vs. Secondary Alcoholism and claimed childhood symptoms of hyperkinesis/minimal brain dysfunction (Hk/MBD) have been shown to predict cognitive differences in alcoholics. The reliability and validity of the methods used to measure these variables were investigated in three separate studies. High test-retest reliability of the Primary/Secondary Classification Questionnaire and the Hk/MBD Childhood Symptoms Checklist was found in the first study (N = 45). In the second, the validity of the Hk/MBD Checklist was investigated by comparing childhood symptoms claimed by the alcoholics with those ascribed by relatives to them (N = 53). A significant positive correlation was found. Finally, a satisfactory percent agreement between the Primary/Secondary Classification Questionnaire and a clinical interview to elicit the same information was obtained in two samples (N = 38). These self-administered instruments, the Primary/Secondary Classification Questionnaire and the Hk/MBD Childhood Symptoms Checklist, should prove useful in future research on diagnosis and treatment of alcoholism.