CHILDHOOD ATTENTION DEFICIT/HYPERACTIVITY DISORDER AND ALCOHOL DEPENDENCE: A 1-YEAR FOLLOW-UP

Eyüp Sabri Ercan*, Hakan Coskunol1, Azmi Varan1 and Kaan Toksöz2

Departments of Child Psychiatry and
1 Psychiatry, Ege University, School of Medicine, Bornova, Izmir and
2 Manisa SSK Hastanesi, Turkey

Received 11 September 2002; in revised form 5 November 2002; in revised form 14 February 2003; accepted 14 March 2003


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To investigate the onset and outcome of alcohol dependence in subjects with childhood attention deficit/hyperactivity disorder (ADHD) in a Turkish sample. Methods: Among patients being treated for alcohol dependence, 15 had a history of childhood ADHD [ADHD (+)] and 45 did not [ADHD (–)]. ADHD history was assessed according to DSM-IV criteria by a child and adolescent psychiatrist who interviewed the subjects and their close relatives. Severity of dependence was measured by the Michigan Alcoholism Screening Test. Subjects were followed up for 1 year for the assessment of relapse. Results: The age of onset for alcohol drinking, alcohol abuse and alcohol dependence were significantly lower in the ADHD (+) group than in the ADHD (–) group. Comorbid substance use was more prevalent in the ADHD (+) group. The study found no significant difference in the severity of alcohol dependence between ADHD (+) and ADHD (–) groups. During follow-up, 80% of the ADHD (+) subjects relapsed, compared with 55.6% in the ADHD (–) group. Relapse occurred on average 2.74 months earlier in the ADHD (+) group than in the ADHD (–) group. Conclusions: As found in other countries, alcohol dependence in Turkish subjects with childhood ADHD starts early and is relatively resistant to treatment. Early diagnosis and treatment of ADHD might help prevent alcohol- and substance-related disorders.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Attention deficit/hyperactivity disorder (ADHD) is a disorder that starts in early childhood and affects 5% of all children and adolescents (American Psychiatric Association, 1994Go). Many studies investigating the course of ADHD have shown that it is not a transitory disorder that fades away as the person moves from childhood into adulthood, but continues to be a problem for 50% of the cases in their adult life, and is thus a major health problem (Gittelman et al., 1985Go; Weiss et al., 1985Go; Barkley et al., 1990Go; Wilens et al., 1998Go). ADHD is frequently accompanied by oppositional/defiance disorder, conduct disorder, major depression, substance abuse disorder or anxiety disorders. Children with ADHD are likely to be diagnosed with one or more of these disorders during the course of their ADHD (Biederman et al., 1991Go, 1992Go).

There is concern about the development of substance abuse disorder in children and adolescents with ADHD. Since ADHD develops earlier than substance use disorder, ADHD is regarded as a risk factor for developing substance use disorders (Wilens et al., 2000Go). Data from a number of follow-up studies on children with ADHD and studies on ADHD adults have revealed a high risk for substance abuse in these subjects (Gittelman et al., 1985Go; Weiss et al., 1985Go; Barkley et al., 1990Go). Concurrence of ADHD and alcohol or substance dependence is more frequent than would be expected by chance (Tarter et al., 1977Go; Kaminer, 1991Go; Carroll and Rounsaville, 1993Go). Compared with the normal population, the risk of substance use disorders appears to be twice as high among people with ADHD, and four times as high among people with ADHD with comorbid conduct disorder (Biederman et al., 1995Go). The percentage of alcohol or substance use disorders among pure ADHD subjects was reported to be 40% by Biederman et al. (1995)Go, who concluded that ADHD on its own constituted a risk factor for the development of alcohol or substance use disorder. Tarter et al. (1977)Go reported high percentages of ADHD in alcohol-dependent adults and found a positive correlation between the severity of alcohol dependence and ADHD symptoms. Goodwin et al. (1975)Go reported that the percentage of childhood ADHD history was higher among alcohol-dependent subjects than among controls. Carroll and Rounsaville (1993)Go found that in cocaine-addicted subjects with a childhood ADHD history, cocaine abuse started at a relatively earlier age, its symptoms were more pronounced and it was more frequently accompanied by antisocial personality disorder. Although a number of studies have reported a significantly higher percentage of substance misuse among subjects who continued to have a diagnosis of ADHD in adolescence, others failed to find significant differences between ADHD adolescents and controls in terms of substance misuse rates. In a 4-year study that extended from childhood to adolescence, Biederman et al. (1997)Go compared 140 children with 120 controls and found no significant differences between the two groups in terms of age of onset of substance use and dependence.

The relationship between alcohol or substance use disorders and ADHD has been well documented. However, most of these studies have been carried out in North America. The objective of this study was to investigate in a Turkish sample the relationship between childhood ADHD, and the clinical and prognostic characteristics of associated alcohol dependence.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Subjects and diagnostic assessments
This study was conducted in the Alcohol and Drug Dependence Clinic of the Psychiatry Department of the Ege University in Izmir, Turkey. All patients admitted to the clinic between May 1999 and March 2000 were eligible if they had been drinking during the preceding month. Subjects who had not consumed alcohol in the preceding month were not included, because we did not wish to include subjects already ‘in early remission’. Patients who subsequently failed to complete the 4-week dependence treatment programme were also excluded from the study.

Patients were assessed by the semi-structured interview SCID-I (Structured Clinical Interview for DSM-III-R Axis I Disorders), adapted for use in Turkey by Sorias et al. (1988)Go. This interview evaluated alcohol abuse and dependence and subjects’ comorbidity on Axis I. The subjects were assessed for anti-social personality disorder by the SCID-II and completed the Michigan Alcoholism Screening Test (MAST) and a questionnaire prepared by the authors to gather basic socio-demographic information. MAST was adapted by Coskunol et al. (1995)Go. A child and adolescent psychiatrist assessed childhood ADHD according to DSM-IV criteria for ADHD, using a semi-structured interview of the subjects and their close relatives. Clinic staff were not told about the ADHD diagnoses until the end of the study.

Fifteen alcohol-dependent subjects with childhood ADHD history formed the study group. Forty-five alcohol-dependent subjects with no history of childhood ADHD acted as controls.

Treatment
The first 7–10 days of the 1-month dependence treatment programme involved detoxification. Subjects with comorbid disorders were provided with extra medication for the treatment of the accompanying disorder(s). Two weeks after their admission to the clinic, the subjects were prescribed a daily dose of 250 mg of disulfiram, and vitamins B1 and B6. During their 1-month stay in the clinic, all subjects attended the clinic’s counseling and education programmes, meetings with family members, Alcoholics Anonymous and relapse prevention meetings.

Outcome assessments
Subjects were followed by the clinic for 12 months. An alcoholic relapse was defined as any episode of problematic drinking, however brief or limited, declared by the patient, family members or a close friend.

Statistical analyses
In the analysis of categorical variables the {chi}2 test was used. Score data were analysed by Student’s t-test. Alpha levels of ≤0.05 were considered significant.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Demographic characteristics
Alcohol-dependent subjects with childhood ADHD history and their counterparts with no history of childhood ADHD were similar in terms of primary demographic variables (Table 1Go). Statistical analyses revealed no significant differences between the ADHD (+) and ADHD (–) groups with respect to age (t = 16.61; df = 58; P > 0.05), marital status ({chi}2 = 0.023; df = 1; P > 0.05), education ({chi}2 = 0.705; df = 2; P > 0.05) and employment status (Fisher’s exact test, P > 0.05).


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Table 1. Demographic characteristics of alcohol-dependent subjects with [ADHD (+)] or without [ADHD (–)] childhood ADHD history
 
Past and present alcohol use and misuse
When alcohol-dependent subjects with childhood ADHD history were compared with those with no history of ADHD, significant differences were observed with respect to age of onset of drinking, abuse and dependence (Table 2Go). Alcohol-dependent subjects with ADHD history were, on average, 4 years younger than subjects with no childhood ADHD history, with respect to both drinking and abusive drinking onset age. Alcohol dependence developed about 6 years earlier in the ADHD (+) group as compared with the ADHD (–) group. In the same way, the time from drinking onset to abusive drinking or to alcohol dependence, although statistically not significant, was relatively shorter in the ADHD (+) group. The two groups did not differ significantly in terms of daily alcohol consumption and mean MAST score. There was also no significant difference between the two groups in terms of the number of times they sought treatment in the Alcohol and Substance Dependence Clinic.


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Table 2. Comparisons of age of onset of use, abuse and dependence, daily alcohol consumption and mean MAST scores of the ADHD (+) and the ADHD (–) groups
 
Accompanying substance use and smoking
Both substance use and smoking were more prevalent among the subjects with childhood ADHD history (Table 3). Substance use was significantly related to childhood history of ADHD (Fisher’s exact test, P < 0.01). Almost half of subjects in the ADHD (+) group reported substance use, compared with about 10% in the ADHD (–) group. Out of the seven subjects who reported substance use in the ADHD (+) group, two (13.4%) used cannabis and five (33.5%) used sedative, hypnotic drugs. In the ADHD (–) group, three subjects reported cannabis use (6.6%). One subject (2.2%) reported opiate use and one (2.2%) reported use of sedative, hypnotic drugs. Smoking was widespread in both groups, but was not related to presence or absence of childhood ADHD history (Fisher’s exact test, P > 0.05). Nine (60%) of the ADHD (+) group and 13 (28.9%) of the ADHD (–) group subjects smoked two packs or more a day. Alcohol-dependent subjects with childhood ADHD history started smoking at a significantly earlier age compared with the subjects in the ADHD (–) group. The mean age (± SD) of onset for smoking was 15.67 ± 3.20 years for the ADHD (+) group compared with 17.71 ± 3.73 years in the ADHD (–) group (t = 2.05; df = 58; P = 0.05).

Axis I and Axis II comorbidity
Neither Axis I nor Axis II comorbidity rates were related to history of childhood ADHD. Three ADHD (+) (20%) and 5 (11.1%) ADHD (–) subjects were diagnosed with antisocial personality disorder; a non-significant difference (Table 4).

Legal problems
The percentage of traffic accidents reported by the subjects in the ADHD (+) group was significantly higher than that reported by ADHD (–) subjects (Table 5Go), being twice as high in the ADHD (+) group. The two groups were similar in terms of reported percentages of the remaining variables of fighting when drunk, arrests and imprisonment.


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Table 5. History of legal problems in the ADHD (+) and ADHD (–) groups
 
Social problems
Data concerning familial, relational and occupational problems are given in Table 6Go. A high percentage of familial problems were reported by both the ADHD (+) and the ADHD (–) subjects. Problems in friendships were lower in the ADHD (+) group [53.3% compared with 71% in the ADHD (–) group]; however, this difference did not reach statistical significance. Although the percentage of subjects reporting problems at work was significantly lower in the ADHD (+), a higher percentage of job loss was reported by the ADHD (+) subjects.


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Table 6. Percentages of familial, relational and occupational problems in the ADHD (+) and ADHD (–) groups
 
Relapse
Eighty percent of the subjects in the ADHD (+) reported relapse, compared with 57% in the ADHD (–) group (Table 7Go). The mean (± SD) time from treatment to relapse was 5.40 ± 3.18 months for the 25 subjects who reported relapse in the ADHD (–) and 3.42 ± 1.73 months for the 12 subjects who relapsed in the ADHD (+) group (t = 2.46; df = 35; P < 0.05).


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Table 7. Relapse values and time in the ADHD (+) and ADHD (–) groups
 

    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Past and present alcohol use and misuse
In line with the existing findings, Turkish alcohol-dependent subjects with childhood ADHD history started drinking at an earlier age than those with no such history. Abusive drinking and dependence on alcohol also developed at an earlier age in the ADHD (+) subjects. The difference between the two groups was especially striking in the case of age of dependence onset, with about a 6.5-year difference between the two groups. Although the development of both abusive drinking and dependence took less time in the ADHD (–) group, the differences between the two groups did not reach statistical significance.

The two groups, however, were similar in terms of their present alcohol consumption and MAST scores. We found that childhood ADHD history seems to accelerate the development of alcohol dependence, but does not necessarily lead the person to a more severe alcohol dependence, contrary to existing findings. This contradictory finding could be partly explained by the characteristics of the sample. All of the subjects were severe and chronic enough to be given inpatient treatment. The homogeneity of the sample in terms of severity and chronicity of alcohol dependence was also reflected in the mean number of previous referrals to the clinic.

Accompanying substance use and smoking
Alcohol-dependent subjects with ADHD harbour a higher risk of substance use disorder (Alterman and Ratter, 1986Go; Horner and Scheibe, 1997Go; Wilens et al., 1998Go) related to the accompanying features of impulsivity, academic underachievement and excitement-seeking behaviour. Our findings in a Turkish sample replicated this.

In reports of ADHD continuing into adulthood, the most frequently used substance is cannabis, followed by cocaine and stimulants (Biederman et al., 1995Go). Biederman et al. (1997)Go found no significant difference between adolescents diagnosed with ADHD and their controls in terms of the preferred substance use. In the present study, the preferred substance was cannabis in the ADHD (–) group and sedative/ hypnotic drugs in the ADHD (+) group. In the light of these findings, it does not seem possible to define a specific drug preference in ADHD.

It has been shown that many alcohol- or substance-dependent people start their dependence career with nicotine dependence (Fleming et al., 1989Go; Kandel et al., 1992Go; Torabi et al., 1993Go). In Lambert and Hartsough’s study on smoking, 46% of adolescents diagnosed with ADHD were smokers, compared with 26% in the control group (Lambert and Hartsough, 1998Go). In the same study, the age of of smoking was found to be 15.2 years for the ADHD group and 17.1 years for the control subjects. Although, in the present study, no difference in smoking prevalence was found between the ADHD (+) and the ADHD (–) groups, the age of onset of smoking was significantly lower in the ADHD (+) group. The high rates of smoking found in both groups partly reflects the high rates of smoking in Turkey.

Axis I and Axis II comorbidity
No group differences in comorbidity were seen. Antisocial personality disorder, sometimes found to facilitate the development of alcohol use disorders (Rada, 1980Go), was not specifically related to ADHD history in our small sample.

Legal problems
Some studies have suggested that children with ADHD have more problems with the law and have more traffic accidents in their youth and adulthood (Barkley et al., 1990Go). Barkley (1997)Go stated that impulsivity, stress intolerance, impatience and bursts of anger render ADHD subjects more prone to problems with the law. Our small sample bore out this hypothesis with respect to traffic accidents, but not in terms of fighting when drunk, being arrested or imprisonment.

Relapse
Studies have demonstrated that ADHD has a negative effect on the treatment of alcohol and substance use disorders (Wilens et al., 1998Go, 2000Go). Our study also found that childhood ADHD history was associated with accelerated relapse during the treatment of alcohol dependence.

Limitations of the study
In evaluating the findings of this study several limitations should be noted. First, the data reported in this study were derived almost totally from the self-reports of the subjects, and thus were prone to reporter biases. Secondly, substance use was not examined by biochemical, haematological or urinary tests. Thirdly, it should be kept in mind that the MAST provides a rather crude measure of dependence. Finally, the representativeness of the findings was limited by the small sample size, and its restriction to only male, not female, patients.

Conclusions
Alcohol-dependent subjects with childhood ADHD history not only tend to start problematic drinking early, but also appear to respond poorly to treatment. Although this study provided no information in this respect, it is hoped that early diagnosis and treatment of ADHD might contribute to efforts to prevent alcohol- and substance-related disorders.


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Table 3. Substance use and smoking in the ADHD (+) and ADHD (–) groups
 

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Table 4. Axis I and Axis II comorbidity rates in ADHD (+) and ADHD (–) groups
 

    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
* Author to whom correspondence should be addressed at: Ege Üniversitesi Tip Fakültesi Psikiyatri AD 35100 Bornova, Izmir, Turkey. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association, Washington, DC.

Barkley, R. A. (1997) ADHD and the Nature of Self Control. The Guilford Press, New York.

Barkley, R. A., Fischer, M., Edelbrock, C. S. and Smallish, L. (1990) The adolescent outcome of hyperactive children diagnosed by research criteria, I: an 8-year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry 29, 546–557.[ISI][Medline]

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Biederman, J., Wilens, T., Mick, E., Spencer, T. J. and Farone, S. V. (1995) Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder: Effects of ADHD and psychiatric comorbidity. American Journal of Psychiatry 152, 1652–1658.[Abstract]

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