ADHD and SUBSTANCE ABUSE

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ADHD and SUBSTANCE ABUSE

• LITERATURE REVIEW
• AND
• TREATMENT IMPLICATIONS

Michael D. Reed, M.S./LLP, CAC-R, CAAC
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Objectives of this presentation and Questions we
want to answer
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An Historical perspective.
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An Historical perspective.
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An Historical perspective.
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An Historical perspective.
Attention Deficit/Hyperactivity Disorder A
handbook for Diagnosis and Treatment. Russell A.
Barkley, PH.D., 1990 ADHD is no longer a
disorder that will be outgrown in
adulthood. Co-morbid disorders such as Conduct
Disorder and Mood Disorders strongly impact the
symptomatology of ADHD. ADHD individuals,
especially when effected by a co-morbid disorder,
are 12 more likely to develop a Substance Abuse
Disorder.
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ADHD DSM-IV TR
A.  Either 1 or 2

• Six (or more) of the following symptoms of
  inattention have persisted for at least 6 months
  to a degree that is maladaptive and inconsistent
  with developmental level

2) Six (or more) of the following symptoms of
hyperactivity- impulsivity have persisted for at
least 6 months to a degree that is maladaptive
and inconsistent with developmental level
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ADHD Diagnostic Specifiers
B.  Some hyperactive-impulsive or inattentive
symptoms that caused impairment were present
before 7 years of age. C.  Some impairment
from the symptoms is present in 2 or more
settings (eg, at school or work or at home).
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ADHD Diagnostic Specifiers
D.  There must be clear evidence of clinically
significant impairment in social, academic, or
occupational functioning. E.  The symptoms do
not occur exclusively during the course of a
pervasive developmental disorder,
schizophrenia, or other psychotic disorder and
are not better accounted for by another mental
disorder (eg, mood disorder, anxiety disorder,
dissociative disorder, or personality disorder).
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ADHD TYPES

• ADHD Predominately Inattentive

 a) Often fails to give close attention to
details or makes careless mistakes in
schoolwork, work, or other activities        
b)  Often has difficulty sustaining attention
in tasks or play activities         c)  Often
does not seem to listen when spoken to directly
               
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ADHD Predominately Inattentive - Continued
d)  Often does not follow through on instructions
and fails to finish schoolwork, chores, or
duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
        e) Often has difficulty organizing
tasks and activities         f) Often avoids,
dislikes, or is reluctant to engage in tasks
that require sustained mental effort (such as
schoolwork or homework)
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ADHD Predominately Inattentive - Continued
g) Often loses things necessary for tasks or
activities    h) Is often easily distracted by
extraneous stimuli         i) Is often
forgetful in daily activities.
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ADHD Predominately Hyperactive-Impulsive
ADHD TYPES
Hyperactivity         a) Often fidgets with
hands or feet or squirms in seat        
b) Often leaves seat in classroom or in other
situations in which remaining seated is expected
        c) Often runs about or climbs
excessively in situations in which it is
inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
               
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ADHD Predominately Hyperactive-Impulsive Continued
d)  Often has difficulty playing or engaging in
leisure activities quietly         e) Is often
"on the go" or often acts as if "driven by a
motor"         f) Often talks excessively
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ADHD Predominately Hyperactive-Impulsive -
Continued
Impulsivity         g) Often blurts out answers
before questions have been completed        
h) Often has difficulty awaiting turn        
i) Often interrupts or intrudes on others
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ADHD Combined
If both criteria A1 and A2 are met for the past 6
months.
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ADHD - NOS
The category is for those individuals who do not
meet criteria for ADHD

• Individuals whose symptoms and impairment meet
  the criteria for ADHD, Predominately Inattentive
  but whose age of onset is 7 years or after.
• Individuals with clinically significant
  impairment who present with inattention and whose
  symptom pattern does not meet the full criteria
  for the disorder but have a behavioral pattern
  marked by sluggishness, daydreaming, and
  hypoactivity.

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ADHD and Comorbid Conditions
Oppositional Defiant Disorder 21 60 Conduct
Disorder 25 40 Mood Disorder 25
overall Substance Use Disorder
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Oppositional Defiant Disorder
Temper tantrums, arguing, defiant and
disrespectful, blames others, touchy, angry and
resentful, spiteful and vindictive.
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Conduct Disorder

• Aggression to people and and/or animals
• Destruction of property
• Deceitfulness and theft
• Serious rule violations

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Mood Disorders
Depressive disorders Anxiety based
disorders Bipolar Disorders
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Is ADHD over-represented in subjects with SUD?
Between 25 and 50 of adolescents with SUD have
been reported to have ADHD - Wilens and
Biederman 2006 - DeMilio 1989
Between 15 25 of adults referred for SUD have
been treated for or diagnosed with ADHD. Wilens
and Biederman 2006 Wilens 2004
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People with ADHD may develop substance use
disorders at an earlier age - Hazelden
Foundation 2007 - Wilens, Biedermanet et al.
1997
ADHD is 5 10 times more common in treatment
referred adult alcoholics - Web MD 2008
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Molina and Pelham Journal of Abnormal
Psychology, 2003, Vol 12 3 497 - 507
Childhood Predictors of Adolescent Substance Use
in a Longitudinal Study of Children With ADHD
Problems that exist with the current research
and most longitudinal research
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Molina and Pelham

• Diagnosing substance abuse or dependence in
  adolescence when rates of disorder have not yet
  reached their peak can miss emerging problems
  that may be more appropriately measured as
  continuous variables.

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Molina and Pelham

• For substances widely experimented within
  adolescence
• Alcohol
• Cigarettes
• Marijuana
• analysis of frequency or quantity of use,
  including heavy use, rather than any use over the
  lifetime or dependence, is more important and
  relevant toward development of later problematic
  use.

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Molina and Pelham
3. The age of first substance use is well
established as a predictor of later problematic
substance use that has not been sufficiently
included in ADHD studies.
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Molina and Pelham

• Molina and Pelham proposed to clarify the
  magnitude of risk for early substance use and SUD
  in clinic-referred children with ADHD compared to
  non-ADHD children.
• The researchers measured both elements of ADHD as
  well as antisocial behavior.
• They tested to see of the severity of the
  symptomatology in the ADHD sample predicted
  elevated substance use 5 years later.

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Molina and Pelham

• They evaluated for a full range of substance
  use variables, at developmentally appropriate
  age ranges
• Age of onset
• Lifetime use
• Quantity and frequency
• Substance use disorder.

• They assessed for the separate roles of the
  persistence of ADHD and the development of CD in
  adolescence on substance use.

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Molina and PelhamResults
Probands (ADHD subjects) were not significantly
more likely than controls (non-ADHD subjects) to
have tried alcohol, cigarettes, or marijuana when
controlled for adolescent developmental level.

• Probands were, however, three times (10.6) more
  likely to have reported polysubstance use than
  controls (3.0).
• Inhalants
• Cocaine
• Stimulants

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Molina and PelhamResults
Probands were more likely to have reported
episodes of drunkenness in the previous 6 months.
23.2 of probands, versus 12.0 of controls were
intoxicated more than once in the previous 6
months.
Probands scored significantly higher problem
scores on alcohol use assessmet tools in the
previous 6 months than did controls
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Molina and PelhamResultsAge of first substance
use
Probands were more likely to have used tobacco
(cigarettes) than controls and were more likely
to have smoked more in the previous 6 months.
Probands smoked their first cigarette, began
daily smoking, and first used illict drugs (not
marijuana) at earlier ages.
Age of first drink, age of first getting drunk,
and age of first marijuana for probands was not
significantly different than controls.
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Molina and PelhamResultsChildhood predictors of
substance use in Probands
Statistical methods were used to test the
predictive factors of proband substance use from
the predictors of Inattention, Hyperactivity-Impul
sivity and ODD/CD.
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Molina and PelhamResultsChildhood predictors of
substance use in Probands

• Childhood inattention predicted substance use in
  seven of the nine tests.
• Childhood hyperactivity-impulsivity predicted
  substance use in two of the nine tests.
• ODD/CD predicted substance use in two of the nine
  tests.
• After controlling for the effects of ODD/CD and
  H/I the effects of inattention remained
  significant.

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Molina and PelhamResultsChildhood predictors of
substance use in Probands
HOWEVER! For illicit drug use (inhallents,
cocaine, hallucinogens, prescribed medications),
one standard deviation of increase in ODD/CD
symptoms resulted in an 81 increase in the odds
of using illicit drugs.
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Molina and PelhamResults

• The presence of ADHD in childhood is associated
  with an increased risk of elevated use and abuse
  of alcohol and heavier and earlier use of tobacco
  and other drugs by the teenage years.
• The inattention dimension of ADHD predicted later
  substance use by the probands to a greater degree
  than antisocial behaviors and H/I most especially
  for tobacco.
• The development of Conduct Disorder along with
  ADHD was associated with the highest levels of
  substance use.

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Wilens and Biderman Journal of Psychopharmacology,
2006 Vol. 20 4, Pgs 580 -588 Alcohol,
drugs, and attention-deficit/hyperactivity
disorder a model for the study of addictions in
youth. A review of the current research
investigating the relationship between ADHD and
SUD.
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Wilens and Biderman

• The majority of SUDs originate in adolescence.
• SUD is increasingly being conceptualized as a
  developmental disorder.
• It is reasonable to consider that the earlier in
  the course of illness an intervention is
  initiated, the more likely a successful outcome.

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Wilens and Biderman
Is ADHD over-represented in subjects with SUD?
Between 25 50 of adolescents with SUD have
been reported to have ADHD. DeMilio,
1989 Hovens et al, 1994 In studies of
adolescents identified with SUD, mood and conduct
disorder (CD) were frequently observed in ADHD
youth with SUD. Wilens, 2004a
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Wilens and Biderman
Studies of subjects with alcohol and drug use
disorders indicate that 15 25 of adults
referred for SUD have ADHD Wilens, 2004a
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Wilens and Biderman
Does gender play a role?
Epidemiological and clinical samples suggest that
girls have a higher risk for smoking and
substance use by early adolescence relative to
boys. Biederman et al, 1999 Studies show
higher ager-corrected risk for SUD in ADHD girls
compared to similarly ascertained boys.
Biederman et al, 1999s Finding across
multiple studies suggest that girls with ADHD
develop SUD approximately 2 years earlier than
boys with ADHD. Reasons are unclear, at this
time.
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Wilens and Biderman
Do co-morbid presentations impact the development
of SUD in ADHD patients?
A plethora of studies cited by Wilens and
Biderman demonstrated that childhood CD (and the
adult antisocial counterpart) is one of he most
robust and predictable risks in foretelling early
onset SUD in adolescent and young adults.
Within ADHD data indicated that adolescents
with ADHD and CD started smoking earlier and at a
higher frequency than ADHD controls.
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Wilens and Biderman
Do co-morbid presentations impact the development
of SUD in ADHD patients?
Approximately 20 of CD substance abusing boys
have a depressive disorder not secondary to the
SUD Open antidepressant treatment of youth with
mood disorders and CD have shown to reduce both
mood and CD symptoms, suggesting that depression
may be an important treatable co-morbid condition
in CD adolescents with SUD.
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Wilens and Biderman
Are there overlapping pathways for SUD and ADHD?
Adolescents with ADHD are at higher risk for the
development of cigarette smoking compared to
matched adolescents without ADHD. Cigarette
smoking subsequently is a strong predictor for
subsequent SUD. Biederman, 2006.
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Wilens and Biderman
Are there overlapping pathways for SUD and ADHD?
Treatment with stimulant pharmacotherapy of ADHD
protects the onset of cigarette smoking in
adolescents. Monuteaux, et al, 2004 Studies in
ADHD adults suggest that the persistance of ADHD
results in continued misuse and and abuse of
substances after dependence, a longer duration of
SUD and a lower rate of remission. Biderman et
al, 1998 Taken together these studies appear to
indicate that ADHD influences the initiation,
transitions, and recovery from SUD.
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Wilens and Biderman
Do ADHD individuals self-medicate with drugs and
alcohol?
Shedler and Block, 1990, American
Psychologist The self medication hypothesis is
plausible in ADHD considering that the disorder
is chronic and often associated with
self-regulatory deficits, comorbid affective
symptoms, demoralization, and failure, factors
frequently associated with SUD in adolescents.
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Wilens and Biderman
Do ADHD individuals self-medicate with drugs and
alcohol?
Kollins, 2008, Journal of Attention In treating
patients with ADHD and comorbid substance use,
psychostimulants may be a useful pharmacologic
alternative. However, the risks of such
treatment with high-risk populations must be
considered alongside potential benefits. March
03, 2008, WebMD interview with Dr. Michael
Monuteaux who conducted a 10-year follow-up study
with 112 participants Stimulant use for the
treatment of ADHD was found to have no impact on
later substance abuse. This is strong evidence
that treatment doesn't not increase the risk of
SUD.
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Wilens and Biderman
Do ADHD individuals self-medicate with drugs and
alcohol?
Ritalin has reportedly become the poor mans
cocaine. Ritalin can lead to dependence if
abused. Ritalin takes about an hour to increase
dopamine levels in the brain. Cocaine takes
seconds to increase dopamine levels in the
brain. The doses of Ritalin and other
stimulants used to treat ADHD tend to be lower
and longer acting, which reduces the risk of
addiction. WebMD, May 18, 2008
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Wilens and Biderman
What about family ties?
The familial association between ADHD and SUD has
been documented in first- and second-degree
family members of children with ADHD for nearly
40 years. (Morrison and Stewart, 1971) A
multitude of studies of family ADHD genetics have
supported the independent transmission of SUD and
ADHD.
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Wilens and Biderman
What about family ties?
Genetics play a role. Biology plays a role.
Environment plays a role.
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Is ADHD over represented in SUD?
YES
Persons diagnosed with ADHD are more likely to be
diagnosed with a SUD while persons presenting for
SUD treatment have a greater likelihood of having
suffered ADHD symptoms.
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What Now?
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ASSESSMENT

• Do a genogram.
• Talk to the parents.
• Get medical information.
• Determine the family lifestyle.
• Observe the child.

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DIAGNOSIS

• Closely review DSM IV TR criteria.
• Provide ongoing monitoring for the emergence of
  co-morbid characterists.

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TREATMENT

• Participation.
• Monitor for family participation.
• Provide education.
• Assist the family in addressing co-morbid
  characteristics.
• Treat SUD and ADHD like they are bonded by super
  glue.