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
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ABSTRACT |
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INTRODUCTION |
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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., 2000). 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., 1985
; Weiss et al., 1985
; Barkley et al., 1990
). Concurrence of ADHD and alcohol or substance dependence is more frequent than would be expected by chance (Tarter et al., 1977
; Kaminer, 1991
; Carroll and Rounsaville, 1993
). 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., 1995
). The percentage of alcohol or substance use disorders among pure ADHD subjects was reported to be 40% by Biederman et al. (1995)
, who concluded that ADHD on its own constituted a risk factor for the development of alcohol or substance use disorder. Tarter et al. (1977)
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)
reported that the percentage of childhood ADHD history was higher among alcohol-dependent subjects than among controls. Carroll and Rounsaville (1993)
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)
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.
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SUBJECTS AND METHODS |
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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). 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 Co
kunol et al. (1995)
. 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 710 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 clinics 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 2 test was used. Score data were analysed by Students t-test. Alpha levels of ≤0.05 were considered significant.
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RESULTS |
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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 5), 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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DISCUSSION |
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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, 1986; Horner and Scheibe, 1997
; Wilens et al., 1998
) 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., 1995). Biederman et al. (1997)
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., 1989; Kandel et al., 1992
; Torabi et al., 1993
). In Lambert and Hartsoughs study on smoking, 46% of adolescents diagnosed with ADHD were smokers, compared with 26% in the control group (Lambert and Hartsough, 1998
). 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, 1980), 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., 1990). Barkley (1997)
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., 1998, 2000
). 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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FOOTNOTES |
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