Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD

ADHD Symptomatology is Associated with Alcohol Use and Consequences via Drinking Norms

Background: Research suggests individuals with ADHD are at risk for alcohol use and related problems and are more susceptible to peer influence. Although previous research has focused on the relationship between alcohol use, related problems, and ADHD symptomatology, scant research has examined whether descriptive drinking norms (i.e., perception of others quantity of drinking) and level of alcohol use mediate this association. Objectives: Consequently, the current study tested a sequential mediation model to examine whether ADHD symptoms were associated with alcohol-related problems via drinking norms and level of alcohol use. Participants were 294 college students who completed an online survey regarding various health behaviors and mental health symptoms. Results: Path analyses were used to test the hypothesized model. Results revealed that the indirect effect from ADHD symptoms to alcohol-related problems as mediated by drinking norms and alcohol use was significant. Thus, higher ADHD symptoms were associated with greater drinking norms, which was in turn, associated with greater alcohol use, and in turn, associated with greater alcohol-related problems. Conclusions: ADHD symptoms and drinking norms may serve as risk factors for engaging in elevated alcohol use, and in turn, experiencing more alcohol-related problems. Interventions should target perceptions regarding peer alcohol use and alcohol-related problems for individuals with ADHD symptoms. Future research should explore the environment and social contexts in which individuals with ADHD symptoms are drinking in to further understand these associations.

High vs. Low Intensity Behavior Therapy Delivered to Adolescents with ADHD: Potential Adverse Long-Term Effects on Substance Use Outcomes

Individuals with ADHD are at risk for substance use initiation in adolescence and escalation to problematic use in adulthood. Little is known about the impact of psychosocial ADHD treatment on substance use. Based on existing theory, both therapeutic (i.e., through reducing symptoms and impairments) and iatrogenic effects (i.e., through improved social functioning) of psychosocial treatment for ADHD on adolescent substance use initiation are plausible. A primarily ethnic/racial minority sample (~ 95% Latinx or Black) of rising ninth grade students with ADHD (n = 106) were randomly assigned to receive high intensity (i.e., Summer Treatment Program-Adolescent, parent training, and school consultation) or lower intensity (parent training, organization skills training, and school consultation) intervention the summer before entering high school. Participants were followed four-years post-baseline and substance use was documented. Analyses tested treatment effects on substance use initiation (alcohol and/or marijuana) and mediators of main effects. After controlling for covariates, participants assigned to HI (37.5%) were significantly more likely than LI (18.6%) to initiate substance use by end of high school, indicating an iatrogenic effect of HI treatment. No significant mediators were detected. Post-hoc exploration of moderators suggested that youth with elevated Posttraumatic Stress Disorder (PTSD) symptoms may have experienced a benefit of HI treatment on substance use whereas youth without elevated PTSD symptoms experienced iatrogenic effects. Large, well-powered, samples should examine moderated mediational models to better understand who is most risk for iatrogenic effects of ADHD psychosocial treatment and why. Clinicians delivering psychosocial treatment to adolescents with ADHD should monitor for potential iatrogenic effects.

The Use of Novel Stimulants in ADHD Self-Medication: A Mixed Methods Analysis

BACKGROUND

Numerous individuals suffer from attentional issues, such as ADHD. While medication is considered the first-line treatment, it is unavailable to some. As a result, certain individuals are choosing to self-medicate with novel stimulants, a phenomenon that remains poorly understood. We aimed to investigate which NPSs are being used to self-medicate ADHD, evaluate their perceived effectiveness, and explore the experiences and motivations of those self-medicating.

METHODS

Data from respondents (n = 225) (mean age [SD] = 29.5 ± 9.6; male = 83%; female = 12%; non-binary = 5%) were collected via an online survey, with nine participants (mean age = 31.4; male = 5; female = 1; non-binary = 3) undertaking further semi-structured interviews and the data being investigated using a framework analysis.

RESULTS

The most-used NPSs were 4F-MPH and 2-FMA. Some individuals perceived self-medication to be more effective than conventional treatment (p < 0.001). A framework analysis identified the following themes surrounding novel stimulant self-medication: (1) the use of NPS stimulants as a stopgap between treatments; (2) poor access to ADHD treatment; (3) a lack of openness and confidence in psychiatrists and healthcare providers.

CONCLUSION

Novel stimulants are being used when access to ADHD treatment is poor. Interventions should aim to reduce long treatment wait times and issues surrounding geographical access. Careful consideration should be given before denying stimulant medication to individuals with co-occurring substance use and psychiatric comorbidity. Individuals desire a more patient-centred ADHD treatment with broader pharmacotherapies.

The role of distress tolerance and delay of gratification in the health risk behaviors of females with and without ADHD

OBJECTIVE

This study examined the independent and joint effects of ADHD status, distress tolerance, and delay of gratification on the propensity to engage in health risk behaviors (drug use, alcohol use, disordered eating).

PARTICIPANTS/METHODS

Participants included 115 female college students (41.7% with ADHD) who completed online questionnaires.

RESULTS

College students with a prior diagnosis of ADHD reported significantly lower distress tolerance, decreased delay of gratification, more drug and alcohol use, and more disordered eating in comparison to those without ADHD. Main effects for delay of gratification in predicting uncontrolled and emotional eating and two significant moderation analyses emerged. For individuals with ADHD, poorer distress tolerance was associated with more drug use.

CONCLUSION

Results highlight the potential to target distress tolerance to reduce engagement in drug use among female college students with ADHD, and to target the ability to delay gratification to reduce risk for disordered eating among all college students.

Alcohol and Cannabis Use by Adolescents with Special Educational Needs: A Systematic Review Focused on Students with Emotional and Behavioral Disorders

Aim: As most substance use prevention programs are offered at school, it is important to explore which group of students might be at increased risk. Both researchers and educators have often maintained that students with special educational needs due to emotional and behavioral disorders (SENs-EBD) are particularly vulnerable. Hence, the aim of the current systematic review was to examine the alcohol and cannabis use by students with SENs-EBD in comparison to students without SENs or other types of SENs. Methods: Adhering to the PRISMA guidelines, the review was registered on PROSPERO (CRD42023375799) and search terms were entered in Web of Science, Scopus, ERIC, and PubMed in December 2022. Publications were required to report on empirical quantitative studies (primary data) that assessed alcohol and/or cannabis use by adolescent students with SENs-EBD and a comparison group, and be published in English-language journal articles, conference papers, or book chapters from 2000 onwards. The QuADS tool was used for quality assessment. Results: Based on these criteria, six articles (sample sizes N = 61 to N = 122,180) were included for the thematic narrative synthesis. The studies revealed that the percentage of students with SENs-EBD consuming alcohol and cannabis was higher compared to students who did not have SENs or attended mainstream schools. Conclusion: The small number of heterogeneous studies, with limitations concerning the sample size, missing effect sizes, and influence of control variables, demonstrates the need for more research. The systematic review provides guidance for such future research endeavors, as well as preliminary notions for practical implications.

Attention-deficit/hyperactivity disorder combined subtype exacerbates opioid use disorder consequences: Mediation by impulsive phenotypes

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is highly prevalent and associated with opioid use disorder (OUD). Yet, little is known about the mechanisms by which ADHD (which is a heterogeneous construct/diagnosis) might alter the trajectory of OUD outcomes in persons who use heroin.

AIM

We examined whether ADHD subtypes are related to heroin-use consequences and the extent to which the effects of ADHD on lifetime heroin-use consequences are mediated by two impulsivity factors that may be partly independent of ADHD: foreshortened time perspective and drug-use impulsivity.

METHODS

Individuals who reported regular heroin use (N=250) were screened using the Assessment of Hyperactivity and Attention (AHA), Impulsive Relapse Questionnaire (IRQ), Stanford Time Perception Inventory (STPI), and a comprehensive assessment of lifetime and current substance use and substance-related consequences. This secondary analysis examined whether ADHD or intermediate phenotypes predicted heroin-use consequences.

RESULTS

Relative to participants whose AHA scores indicated lifetime absence of ADHD (n=88), those with scores indicating persistent ADHD (childhood and adult, n=62) endorsed significantly more total lifetime heroin-use consequences despite comparable heroin-use severity. Likewise, there was a significant indirect effect of the combined ADHD subtype in childhood on lifetime heroin-use consequences. This effect was mediated by STPI scores indicating less future (and more hedonism in the present) temporal orientation and by IRQ scores indicating less capacity for delaying drug use.

CONCLUSION

The combined ADHD subtype is significantly associated with lifetime heroin-use consequences, and this effect is mediated through higher drug-use impulsivity (less capacity for delay) and lower future temporal orientation.

High Versus Low Intensity Summer Adolescent ADHD Treatment Effects on Internalizing, Social, and Self-Esteem Problems

The current study aims to evaluate the effectiveness of a high-intensity (HI) versus a low-intensity (LI) skills-based summer intervention delivered to adolescents with ADHD by school staff in improving depressive symptoms, anxiety symptoms, social problems, and self-esteem. Participants were 325 ethnically diverse rising sixth and ninth graders with ADHD randomized to an HI versus an LI intervention (n = 218) or recruited into an untreated comparison group (n = 107). Group x time and group x grade x time one-year outcome trajectories were compared using linear mixed models. Across the transitional year (sixth or ninth grade), adolescents in the HI group were found to experience significantly greater decreases in depressive symptoms (p = .022, d = .25) compared to the LI group. There was no significant impact of the HI intervention (vs. LI) on anxiety symptoms (p = .070, d = .29), social problems (p = .054, d = .34), or self-esteem (p = .837, d = 0.21); however, secondary analyses of the non-randomized untreated comparison group indicated a significant effect of HI versus the untreated comparison group on social problems (p = .009, d = 43). These significant treatment effects suggest that comprehensive academic and organizational skills interventions for adolescents with ADHD may have a secondary impact of relieving adolescent depression for teens with this comorbidity. Given mixed evidence for the efficacy of the HI intervention on social skills, future work should further evaluate this effect.

Secondary analyses of sex differences in attention improvements across three clinical trials of a digital therapeutic in children, adolescents, and adults with ADHD

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) remains underdiagnosed and undertreated in girls. Inattentive symptoms, often predominant in girls with ADHD, represent a key driver of impairment and often persist into adulthood. AKL-T01 is a regulated digital therapeutic targeting inattention. We examined potential sex differences in the efficacy of AKL-T01 in three separate trials for 1) children, 2) adolescents, and 3) adults.

METHODS

We conducted secondary analyses of clinical outcomes by sex in three AKL-T01 randomized clinical trials in ADHD (n1 = 180 children 30.6% female, M(SD) age = 9.71 (1.32); n2 = 146 adolescents; 41.1% female, M(SD) age = 14.34 (1.26); n3 = 153 adults; 69.9% female, M(SD) age = 39.86 (12.84)). Active treatment participants used AKL-T01 for 25 min/day over 4-6 weeks. Primary outcomes included change in attention on the Test of Variables of Attention (TOVA) and symptom change on the clinician-rated ADHD Rating Scale (ADHD-RS). To evaluate study hypotheses, we conducted a series of robust linear regressions of TOVA and ADHD-RS change scores by sex, adjusting for baseline scores.

RESULTS

In children, girls demonstrated greater improvement in objective attention relative to boys following AKL-T01 (TOVA Attentional Composite Score; Cohen's d = .36 and Reaction Time Mean Half; Cohen's d = .54), but no significant sex differences in ADHD rating scale change. We did not observe significant sex differences in outcomes in the adolescent or adult trials. Limitations include binary sex categorization and slight study design variation across the three samples.

CONCLUSION

AKL-T01 might notably improve attentional functioning in girls with ADHD relative to boys. Objective attention measures may be particularly important in the assessment of attentional improvement in childhood, given known gender biases in ADHD symptom reporting. We emphasize the importance of considering sex and gender-specific factors in ADHD treatment evaluation.

TRIAL REGISTRATIONS

STARS ADHD CHILD: ClinicalTrials.gov ID NCT03649074; STARS ADHD ADOLESCENT: ClinicalTrials.gov ID NCT04897074; STARS ADHD ADULT: ClinicalTrials.gov ID NCT05183919.

The prevalence of cannabis use disorder in attention-deficit hyperactivity disorder: A clinical epidemiological meta-analysis

Studies have shown that individuals with attention-deficit hyperactivity disorder (ADHD) pose an increased risk for developing substance use disorders. Increased cannabis product accessibility and recent legislative changes have led to increased cannabis consumption, thereby increasing the risk of cannabis use disorder (CUD). The present meta-analysis explored the lifetime and current prevalence of CUD in ADHD. A systematic review was conducted using the following databases: PubMed, PsycINFO and Web of Science. A total of 14 articles were included and used to estimate the aggregate lifetime and current prevalence of CUD in ADHD alongside risk ratios comparing increased risk of CUD in ADHD versus control samples. Mixed and random-effects models indicated that lifetime and current prevalence rates of CUD in ADHD populations were 26.9% and 19.2%, respectively (although prediction intervals ranged from 12.4% to 48.8% and 5.5%-39.1%, respectively). Analysis of the risk ratios indicated that those with ADHD were at 2.85- and 2.91-times greater risk of a lifetime or current diagnosis of CUD, respectively, than those in the general population. Our findings support the need for additional research on the prevalence of CUD in those with ADHD, as well as the inclusion of CUD screening in the treatment of ADHD.

Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that exhibits striking sex differences in symptoms, prevalence, and associated problems across development. Etiological factors and mechanisms underlying these sex differences remain one of the most understudied aspects of this disorder. The current paper seeks to provide a novel theoretical framework for understanding this phenomenon by reviewing evidence that females with ADHD may experience a "double whammy" of organizational and activational pubertal hormonal effects. We propose a novel theory of activational effects of cyclical circulating ovarian hormones on ADHD with increasing risk at times of rapid declines in estrogen. These declines may decrease executive function and trait control at two points of the cycle characterized by biphasic affective risk: (1) increases in approach/risk-taking behaviors at mid-cycle (periovulatory) and (2) increases in avoidance/negative affect perimenstrually. Low estrogen and control may then interact with increases in positive and negative affect, respectively, to increase hyperactivity-impulsivity symptoms post-ovulation and inattention symptoms perimenstrually. These interactions may be exacerbated by organizational pubertal effects on relatively overdeveloped limbic circuitry and adolescent-specific social pressures magnified in females with ADHD.

An examination of the effects of ADHD symptoms and sex on the relation between cannabis protective behavioral strategies and cannabis consequences

The risk for cannabis-related problems is elevated among young adults with attention-deficit/hyperactivity disorder (ADHD) symptoms. It is unknown whether the use of cannabis protective behavioral strategies (PBS) mitigates this risk for college students with ADHD. Prior research finds that college students who use alcohol and report high levels of ADHD symptoms particularly benefit from employing alcohol PBS, and these relations are strongest for male students. Thus, this study examined the moderating effects of ADHD symptoms and sex assigned at birth on the relation between cannabis PBS use and cannabis-related problems among college students who use cannabis. Participants were 384 college students (66.9% female, 57.8% white non-Hispanic, Mage = 19.29) from 12 United States universities who reported past-month cannabis use. Participants completed measures of demographics, ADHD symptoms, past-month cannabis frequency and related problems, and cannabis PBS use via an online survey. There was a significant interaction of ADHD hyperactive/impulsive symptoms, PBS use, and sex on cannabis-related problems, controlling for cannabis use frequency. The strength of the negative association between PBS use and problems depended on level of ADHD symptoms for females, but not for males. However, there were no interactive effects for ADHD inattentive symptoms. These results supplement the literature base on relations between PBS use and ADHD symptoms in college students, extending support for their use to cannabis users. Importantly, promoting PBS use to female college students who are high in hyperactive/impulsive ADHD symptoms is recommended.

Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood

Importance

Possible associations between stimulant treatment of attention-deficit/hyperactivity disorder (ADHD) and subsequent substance use remain debated and clinically relevant.

Objective

To assess the association of stimulant treatment of ADHD with subsequent substance use using the Multimodal Treatment Study of ADHD (MTA), which provides a unique opportunity to test this association while addressing methodologic complexities (principally, multiple dynamic confounding variables).

Design, Setting, and Participants

MTA was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years. Analysis took place between April 2018 and February 2023.

Exposure

Stimulant treatment of ADHD was measured prospectively from baseline for 16 years (10 assessments) initially using parent report followed by young adult report.

Main Outcomes and Measures

Frequency of heavy drinking, marijuana use, daily cigarette smoking, and other substance use were confidentially self-reported with a standardized substance use questionnaire.

Results

A total of 579 children (mean [SD] age at baseline, 8.5 [0.8] years; 465 [80%] male) were analyzed. Generalized multilevel linear models showed no evidence that current (B [SE] range, -0.62 [0.55] to 0.34 [0.47]) or prior stimulant treatment (B [SE] range, -0.06 [0.26] to 0.70 [0.37]) or their interaction (B [SE] range, -0.49 [0.70] to 0.86 [0.68]) were associated with substance use after adjusting for developmental trends in substance use and age. Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment (B [SE] range, -0.003 [0.01] to 0.04 [0.02]) or continuous, uninterrupted stimulant treatment (B [SE] range, -0.25 [0.33] to -0.03 [0.10]) were associated with adulthood substance use. Findings were the same for substance use disorder as outcome.

Conclusions and Relevance

This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD. These findings do not appear to result from other factors that might drive treatment over time and findings held even after considering opposing age-related trends in stimulant treatment and substance use.

History of Childhood/Adolescence Referral to Speciality Care or Treatment in Adult Patients with Attention-Deficit/Hyperactivity Disorder: Mutual Relations with Clinical Presentation, Psychiatric Comorbidity and Emotional Dysregulation

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that only rarely remits in adulthood. While several studies underlined differences between child and adult ADHD, the relationship between adult clinical presentation and early referral/treatment has been rarely investigated. In our study, 100 adults with ADHD were recruited and subdivided according to a history of referral to speciality care or treatment with methylphenidate (MPH) during childhood/adolescence. The early referral was associated with a history of disruptive behaviors during childhood/adolescence. Current ADHD symptoms were more pronounced in patients first referred during childhood/adolescence but never treated with MPH. Early MPH treatment was associated with lower rates of mood disorders and lower severity of emotional dysregulation at the time of assessment. Negative emotionality mediated the relationship between MPH treatment and mood disorders comorbidity. ADHD patients first referred during childhood/adolescence are characterized by more externalizing features than those first referred in adulthood. MPH treatment during the developmental age may have a role in preventing mood disorders in patients with ADHD, possibly by reducing emotional dysregulation.

The relative reinforcing efficacy of nicotine in an adolescent rat model of attention-deficit hyperactivity disorder

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is an independent risk factor for tobacco use disorder. Individuals with ADHD are more likely to begin smoking at a younger age, become a daily smoker sooner, smoke more cigarettes per day, and exhibit greater nicotine dependence than individuals without ADHD. It is unclear whether these findings are due to the reinforcing efficacy of nicotine per se being greater among individuals with ADHD. The purpose of the present study was to examine this issue using an animal model of ADHD, the spontaneously hypertensive rat (SHR) strain.

Methods

Adolescent SHR and Wistar (control) rats were given access to a typically reinforcing nicotine unit dose (30 μg/kg), a threshold reinforcing nicotine dose (4 μg/kg), or saline under an FR 1 (week 1) and FR 2 (week 2) schedule during 23 h sessions to examine acquisition of self-administration. Behavioral economic demand elasticity was then evaluated at the 30 μg/kg dose through an FR escalation procedure.

Results

At the 30 μg/kg dose, SHR rats exhibited a lower average response rate, lower mean active to inactive lever discrimination ratio, and lower proportion of rats acquiring self-administration compared to control rats. During demand assessment, SHR rats showed no significant difference from Wistars in demand intensity (Q0) or elasticity (α; i.e., reinforcing efficacy). In addition, no strain difference in acquisition measures were observed at the 4 μg/kg dose.

Discussion

These findings suggest that the increased risk of tobacco use disorder in adolescents with ADHD may not be attributable to a greater reinforcing efficacy of nicotine, and that other aspects of tobacco smoking (e.g., non-nicotine constituents, sensory factors) may play a more important role. A policy implication of these findings is that a nicotine standard to reduce initiation of tobacco use among adolescents in the general population may also be effective among those with ADHD.

Long-term safety of methylphenidate in children and adolescents with ADHD: 2-year outcomes of the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study

BACKGROUND

Methylphenidate is the most frequently prescribed medication for the treatment of ADHD in children and adolescents in many countries. Although many randomised controlled trials support short-term efficacy, tolerability, and safety, data on long-term safety and tolerability are scarce. The aim of this study was to investigate the safety of methylphenidate over a 2-year period in relation to growth and development, psychiatric health, neurological health, and cardiovascular function in children and adolescents.

METHODS

We conducted a naturalistic, longitudinal, controlled study as part of the ADDUCE research programme in 27 European child and adolescent mental health centres in the UK, Germany, Switzerland, Italy, and Hungary. Participants aged 6-17 years were recruited into three cohorts: medication-naive ADHD patients who intended to start methylphenidate treatment (methylphenidate group), medication-naive ADHD patients who did not intend to start any ADHD medication (no-methylphenidate group), and a control group without ADHD. Children with ADHD diagnosed by a qualified clinician according to the DSM-IV criteria and, in the control group, children who scored less than 1·5 on average on the Swanson, Nolan, and Pelham IV rating scale for ADHD items, and whose hyperactivity score on the parent-rated Strengths and Difficulties Questionnaire was within the normal range (<6) were eligible for inclusion. Participants were excluded if they had previously taken any ADHD medications but remained eligible if they had previously taken or were currently taking other psychotropic drugs. The primary outcome was height velocity (height velocity SD score; estimated from at least two consecutive height measurements, and normalised with reference to the mean and SD of a population of the same age and sex).

FINDINGS

Between Feb 01, 2012, and Jan 31, 2016, 1410 participants were enrolled (756 in methylphenidate group, 391 in no-methylphenidate group, and 263 in control group). 1070 (76·3%) participants were male, 332 (23·7%) were female, and for eight gender was unknown. The average age for the cohort was 9·28 years (SD 2·78; IQR 7-11). 1312 (93·0%) of 1410 participants were White. The methylphenidate and no-methylphenidate groups differed in ADHD symptom severity and other characteristics. After controlling for the effects of these variables using propensity scores, there was little evidence of an effect on growth (24 months height velocity SD score difference -0·07 (95% CI -0·18 to 0·04; p=0·20) or increased risk of psychiatric or neurological adverse events in the methylphenidate group compared with the no-methylphenidate group. Pulse rate and systolic and diastolic blood pressure were higher in the methylphenidate group compared with the no-methylphenidate group after 24 months of treatment. No serious adverse events were reported during the study.

INTERPRETATION

Our results suggest that long-term treatment with methylphenidate for 2 years is safe. There was no evidence to support the hypothesis that methylphenidate treatment leads to reductions in growth. Methylphenidate-related pulse and blood pressure changes, although relatively small, require regular monitoring.

FUNDING

EU Seventh Framework Programme.

Risk behaviors in substance use disorder in a sample of Egyptian female patients with or without symptoms of attention-deficit hyperactivity disorder

Background

Risk-taking behaviors are associated with attention-deficit hyperactivity disorder (ADHD) and substance use disorder (SUD). Individuals with both diagnoses have been reported to have an earlier onset, a longer course, and greater severity, with more relapses and greater difficulty remaining abstinent.

The current study was assessing females seeking treatment for SUDs for the presence of comorbid ADHD, to investigate the association between severity of SUD and co-occurring ADHD symptoms and to examine related risk behaviors. Therefore, thirty female patients were enrolled, and demographic data was collected. Participants were interviewed by SCID I, addiction severity index, Arabic-translated and validated version of the adult ADHD Self-Report Scale Barratt Impulsiveness Scale Version 11, and Arabic version of the Adult Scale of Hostility and Aggression.

Results

Thirty female patients were included in the study, and 33.3% had extreme severity, on the addiction severity index scale. Fifteen patients had ADHD symptoms; 33.3% had high likely scores, according to Adult ADHD Self-Reported Scale (ASRS). There is a significant difference regarding the age of onset of substance use and smoking (P = 0.029), first sexual activity (P = 0.002), number of sexual partners (P = 0.009), impairment in employment, and family and social relationships items (P = 0.024, P = 0.028, respectively) in SUD patients with ADHD symptoms than in SUD patients without ADHD symptoms.

Conclusion

Female patients diagnosed with adult ADHD have an earlier age of smoking and substance use, having first sexual activity at younger age, and having more sexual partners with more employment, family, and social relationship problems.

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.

An Examination of the Role of Sluggish Cognitive Tempo as a Moderator of the Relationship Between ADHD and Nicotine Use

OBJECTIVE

ADHD is a neurodevelopmental disorder characterized by executive dysfunction and functional impairments including nicotine consumption. Sluggish cognitive tempo (SCT) has been associated with ADHD and posited as an independent construct. The present study hypothesized that SCT would moderate the relationships between ADHD and nicotine-related behaviors.

METHOD

Participants (n = 309) were recruited using Mechanical Turk and completed measures of ADHD symptoms, SCT, and smoking history.

RESULTS

ADHD was associated with age of initiation of smoking and more severe withdrawal symptoms for both combustible and electronic cigarettes. SCT significantly moderated the relationship between ADHD and withdrawal symptom severity (both electronic and combustible cigarettes).

CONCLUSION

The results of the present study suggest that SCT plays an important role in the complex relationship between ADHD and smoking withdrawal. Future research should further explore the construct of SCT to better understand its role in psychopathology and intervention strategies.

An Exploratory Investigation of Childhood Sexual Abuse and Other Theory-Driven Predictors of Sex Work Among Women with and without Childhood ADHD

Limited research has identified prospective risk factors for young-adult sex work or examined overlapping predictors concurrently. We investigated childhood sexual abuse (CSA), along with other theory-driven predictors of sex work, among a well-characterized sample of girls with and without childhood diagnoses of attention/deficit-hyperactivity disorder (ADHD).

METHODS

Participants were a racially and socioeconomically diverse sample of 140 girls with rigorously diagnosed ADHD (47 Inattentive [ADHD-I], 93 Combined [ADHD-C]), and 88 age- and ethnicity-matched comparison girls, all followed longitudinally into adulthood. Self-report data on young-adult occupations revealed a subsample of 7 participants reporting engagement in "sex work" or "prostitution." Logistic regressions tested whether CSA, measured both dichotomously and by discrete age ranges, predicted later sex work, accounting for other risk factors.

RESULTS

A lifetime history of CSA was positively associated with sex work in initial analyses (β = 1.51, p = .045), but not after adjusting for additional risk factors. When examined by age ranges, only CSA occurring between ages 9-15 significantly predicted sex work (β = 2.84, p = .043), even after adjusting for additional risk factors. Childhood ADHD-C also emerged as a significant predictor (β = 4.94, p = .015). ADHD-related medication and years of education were protective factors only when CSA was considered dichotomously.

CONCLUSIONS

Findings from this exploratory study underscore the need for longitudinal research that (a) considers the developmental timing of CSA and (b) accounts for impulsivity and inattention as risk factors for sex work among young-adult women. Implications for clinical practice are briefly discussed.

Substance-Related Problems in Adolescents with ADHD-Diagnoses: The Importance of Self-Reported Conduct Problems

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a known risk factor for substance-related problems (SRP) during adolescence, but the nature of this relationship and the importance of co-occurring conduct problems are not fully understood.

METHODS

Data stem from a linked dataset between a large population-based survey conducted in 2012 of Norwegian adolescents aged 16 to 19, and registry-based data from specialized child and adolescent mental health services (n = 9,411).

RESULTS

Adolescents with "ADHD + high conduct problems" had increased risk of SRP (odds ratios = 2.37-10.14). Adolescents with "ADHD only" had very similar risk of SRP as adolescents from the general population with low symptoms of conduct problems. Relative to boys, girls with "ADHD + high conduct problems" appeared to have somewhat higher risk for SRP.

CONCLUSION

The present study suggests that the risk for SRP among adolescent with ADHD is largely driven by co-existing conduct problems.

Adult attention-deficit hyperactivity disorder among patients with substance use disorders

Background

Attention-deficit/hyperactivity disorder (ADHD) is a childhood neurodevelopmental disorder that persists into adulthood. ADHD is a well-known risk factor for substance use disorder (SUD). However, the actual contribution of comorbidity is largely unknown. The current study investigated the prevalence of ADHD in a sample of abstinent patients compared to healthy controls.

Compared to 51 healthy controls, 51 patients seeking medical treatment for SUD were abstinent from any substance for at least 1 month, interviewed by the use of the ICD-10 symptom checklist, the Social Classification Scale, the Addiction Severity Index, Conners adult ADHD Rating Scales Self-Report (CAARS-S:L), and the Kiddie-Sads-Present and Lifetime Version (K-SADS-PL).

Results

Using CAARS-S:L, the ADHD index showed that 9 subjects (17.6%) were diagnosed with adult ADHD. Using K-SADS-PL, 8 of the participants (15.7%) were found to have an adult ADHD diagnosis. Lower scores of the ADHD index are related to increased patients’ age, while increased scores of the ADHD index are related to more alcohol-related problems of the patients. The strongest predicting factors of increased ADHD index were drug problems and legal status.

Conclusions

The current study provides evidence of an increased diagnosis of adult ADHD in patients with substance use disorder, regardless of the type of substance abuse.

Childhood Irritability: Predictive Validity and Mediators of Adolescent Psychopathology

Despite its transdiagnostic significance, there is modest evidence with respect to the predictive validity of childhood irritability, especially across developmental periods; similarly, little is known about explanatory factors underlying these predictions. This study had two goals: (1) to test the predictive validity of childhood irritability with respect to adolescent internalizing and externalizing problems, controlling for baseline ADHD and related psychopathology and (2) to test theoretically-derived family (i.e., parenting behavior, parenting stress) and social (i.e., peer status, social skills) constructs as explanatory factors of adolescent psychopathology. Two hundred thirty ethnically diverse (51.5% White) 5-10-year-old youth (32% female) with (n = 121) and without (n = 110) ADHD completed three separate laboratory-based assessments across six to seven years. Temporally-ordered predictors, putative mediators, and psychopathology outcomes were assessed using multiple informants (i.e., parent, teacher, youth) and methods (i.e., structured interviews, normed rating scales). Controlling for demographic factors, clinical correlates, and baseline psychopathology, childhood irritability uniquely predicted adolescent externalizing problems, but not internalizing problems. Next, analyses revealed that low social skills partially explained predictions of adolescent internalizing problems. However, family or social factors did not underlie predictions of adolescent externalizing problems. These preliminary findings support the predictive validity of childhood irritability with respect to early adolescent externalizing problems and implicate low social skills as a potentially unique mediator of internalizing outcomes. Intervention-induced improvements in social skills may minimize emergent psychopathology initiated by significant childhood irritability.

Chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use

Background: The dopamine receptor D4 [DRD4] has been reported to be associated with substance use. Yet, the roles that health conditions and behaviors may play in such association are understudied.Objective: This longitudinal study investigated the potential mediation effects of chronic pain and delinquency in adolescence on the association between the DRD4 2-repeat allele and substance use in adulthood. Sex, witnessing violence, and experiencing violence were also examined as potential moderators for the mediation pathways.Methods: We used the restricted and candidate gene data from the National Longitudinal Study of Adolescent to Adult Health (Waves I-IV) to conduct secondary analysis (N = 8,671; 47% male). A two-step approach was adopted to examine the mediation effects regarding four substance use outcomes in adulthood: number of lifetime alcohol use disorder symptoms, lifetime regular smoker status, past-month smoking, and lifetime "pain killer" misuse. The moderation effects were investigated using stratification and permutation.Results: The DRD4 2-repeat allele was associated with all adulthood substance use outcomes through adolescent chronic pain and delinquency (AORs/IRR range 1.08-3.78; all ps<0.01). The association between delinquency and smoking was higher among females. The association between delinquency and substance use was lower among the participants who witnessed violence in adolescence.Conclusions: This study identified modifiable mediators underlying the association between the DRD4 2-repeat allele and substance use behaviors, concluding that chronic pain and delinquency partially explain the effect of the DRD4 gene polymorphism on adult substance use.

Differentiating Preschool Children with Conduct Problems and Callous-Unemotional Behaviors through Emotion Regulation and Executive Functioning

Callous-unemotional (CU) traits are important characteristics for identifying severe patterns of conduct problems (CP). The current study focused on (a) identifying subgroups of young children displaying a combination of CP and CU behaviors and (b) examining the extent to which executive functioning (EF) and emotion regulation (ER) are associated with CU behaviors. Participants included 249 preschoolers (N = 249, 78% boys, Mage = 4.95 years; 81% Latino/Hispanic) referred to treatment because of externalizing behavior problems. CU behaviors and CP were measured via a combination of teacher/parent rating scales. A multimethod approach was used to measure EF and ER including parent/teacher rating scales, neuropsychological, and observational tasks. Poorer ER as rated by parents/teachers and observed was associated with greater levels of CU behaviors. Latent profile analyses identified three subgroups of children displaying (a) low CU/low CP, (b) moderate CU/moderate CP, and (c) high CU/high CP. Children in the high CU/high-CP group were rated as having significantly poorer rated ER compared to all other groups and poorer observed ER compared to the low-CU/low-CP group. Exploratory analyses found that children in the high-CU/high-CP group displayed marginally lower levels of rated ER but significantly better EF performance on standardized neuropsychological tasks compared to children in a low-CU/high-CP group.Children with higher levels of reported CU behaviors and CP display poorer ER yet may display relatively better EF performance compared to children with lower levels of CU behaviors and CP.

Review: Adult Outcome as Seen Through Controlled Prospective Follow-up Studies of Children With Attention-Deficit/Hyperactivity Disorder Followed Into Adulthood

OBJECTIVE

To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA).

METHOD

All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes.

RESULTS

The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders.

CONCLUSION

Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

Smoking-Specific Risk Factors in Early Adulthood That Mediate Risk of Daily Smoking by Age 29 for Children with ADHD

OBJECTIVE

To test whether smoking-specific risk factors in early adulthood mediate prediction to daily smoking from childhood ADHD.

METHODS

Participants were 237 with and 164 without childhood ADHD. A smoking risk profile score comprising smoking-specific factors measured between ages 18 to 25 (e.g., craving severity) and age of initiation was tested as mediator of the association between childhood ADHD and age 29 daily smoking.

RESULTS

Childhood ADHD predicted age 29 smoking (β = -.15, p = .019), 35% of ADHD versus 17% of nonADHD, and the profile score (β = -.07, p = .004), which in turn mediated prediction to age 29 daily smoking (β = -.03; p = .007). When tested individually, three profile variables (# cigarettes/day, difficulty concentrating during abstinence, and nicotine dependence) were significant mediators (ps = 0.005-0.038), above and beyond early adult smoking, ADHD persistence, and delinquency.

CONCLUSIONS

These behavioral smoking characteristics help explain later daily cigarette smoking for adults with ADHD histories and may need to be targeted in intervention.

Prenatal exposure to organophosphate pesticides and risk-taking behaviors in early adulthood

INTRODUCTION

Previous studies show evidence for associations of prenatal exposure to organophosphate (OP) pesticides with poorer childhood neurodevelopment. As children grow older, poorer cognition, executive function, and school performance can give rise to risk-taking behaviors, including substance abuse, delinquency, and violent acts. We investigated whether prenatal OP exposure was associated with these risk-taking behaviors in adolescence and young adulthood in a Mexican American cohort.

METHODS

We measured urinary dialkyl phosphates (DAPs), non-specific metabolites of OPs, twice (13 and 26 weeks gestation) in pregnant women recruited in 1999-2000 in the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) study, a birth cohort set in a primarily Latino agricultural community in the Salinas Valley, California. We followed up children throughout their childhood and adolescence; at the 18-year visit, adolescent youth (n = 315) completed a computer-based questionnaire which included questions about substance use, risky sexual activity, risky driving, and delinquency and police encounters. We used multivariable models to estimate associations of prenatal total DAPs with these risk-taking behaviors.

RESULTS

The prevalence of risk-taking behaviors in CHAMACOS youth ranged from 8.9% for smoking or vaping nicotine to 70.2% for committing a delinquent act. Associations of total prenatal DAPs (geometric mean = 132.4 nmol/L) with risk-taking behavior were generally null and imprecise. Isolated findings included a higher risk for smoking or vaping nicotine within the past 30 days (relative risk [RR] per 10-fold increase in prenatal DAPs = 1.89, 95% CI: 1.00, 3.56) and driving without a license (RR = 1.74, 95% CI: 1.25, 2.42). There were no consistent differences by sex or childhood adversity.

DISCUSSION

We did not find clear or consistent evidence for associations of prenatal OP exposure with risk-taking behaviors in adolescence/early adulthood in the CHAMACOS population. Our small sample size may have prevented us from detecting potentially subtle associations of early life OP exposure with these risk-taking behaviors.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

Understanding ADHD in Black Adolescents in Urban Schools: A Qualitative Examination of Factors that Influence ADHD Presentation, Coping Strategies, and Access to Care

The high school years are a challenging developmental period for adolescents with attention-deficit/hyperactivity disorder (ADHD), their families, and those who work with them in the school system. Moreover, racially minoritized families and schools in low-resource, urban settings often experience additional adverse experiences that can make access to evidence-based mental health care particularly difficult. This qualitative investigation into the experiences of Black high school students with ADHD, their caregivers, teachers, and school mental health providers (SMHPs) aimed to understand this community's experiences with ADHD across development and to explore the barriers/facilitators to adequate services. Through focus group interviews with stakeholders (i.e., 6 adolescents with a diagnosis of ADHD, 5 caregivers of adolescents with ADHD, 6 teachers, 5 school mental health providers), themes emerged related to (1) developmental changes observed in ADHD presentation in high school students and (2) contextual factors (including barriers/facilitators to optimal school and home functioning). These themes led to the development of an ecological model that show various contextual factors influencing the experiences of Black adolescents with ADHD in under-resourced urban public high schools (e.g., adolescents' coping strategies, caregiver involvement, teacher burden or lack of ADHD-knowledge, socioeconomic status, access to care). This qualitative study represents the first step of a treatment development project assessing the implementation of a depression prevention intervention for Black adolescents with ADHD in urban public-school settings. Clinical implications (e.g., coordination of care between home and schools, increasing attention to social determinants of health, ensuring culturally competent discussion of ADHD and its treatment) are discussed.

Economic burden of attention-deficit/hyperactivity disorder among children and adolescents in the United States: a societal perspective

OBJECTIVE

To provide a comprehensive evaluation of the economic burden associated with attention-deficit/hyperactivity disorder (ADHD) among children and adolescents from a US societal perspective.

MATERIALS AND METHODS

Direct healthcare costs of children (5-11 years) and adolescents (12-17 years) with ADHD were obtained using claims data from the IBM MarketScan Research Databases (01/01/2017-12/31/2018). Direct non-healthcare and indirect costs were estimated based on literature and government publications. Each cost component was estimated using a prevalence-based approach, with per-patient costs extrapolated to the national level.

RESULTS

The total annual societal excess costs associated with ADHD were estimated at $19.4 billion among children ($6,799 per child) and $13.8 billion among adolescents ($8,349 per adolescent). Education costs contributed to approximately half of the total excess costs in both populations ($11.6 billion [59.9%] in children; $6.7 billion [48.8%] in adolescents). Other major contributors to the overall burden were direct healthcare costs ($5.0 billion [25.9%] in children; $4.0 billion [29.0%] in adolescents) and caregiving costs ($2.7 billion [14.1%] in children; $1.6 billion [11.5%] in adolescents).

LIMITATIONS

Cost estimates were calculated based on available literature and/or governmental publications due to the absence of a single data source for all costs associated with ADHD. Thus, the quality of cost estimates is limited by the accuracy of available data as well as the study populations and methodologies used by different studies.

CONCLUSION

ADHD in children and adolescents is associated with a substantial economic burden that is largely driven by education costs, followed by direct healthcare costs and caregiver costs. Improved intervention strategies and policies may reduce the clinical and economic burden of ADHD in these populations.

Persistent Deficits in Self-Regulation as a Mediator between Childhood Attention-Deficit/Hyperactivity Disorder Symptoms and Substance Use Disorders

The link between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) has been largely demonstrated. Some scholars have hypothesized that self-regulation mechanisms might play a key role in explaining this association. Objective(s): The current study tested the hypothesis that retrospective childhood ADHD symptoms might lead to more severe SUDs and this association should be mediated by current self-ratings of behavioral disinhibition, inattention, and emotional dysregulation among 204 treatment-seeking adults (male: 67.3%; female: 32.7%) with a primary diagnosis of alcohol use disorder and other SUDs. Methods: The mediational model was estimated through self-report measures of childhood ADHD symptoms (independent variable; WURS), current self-regulation mechanisms (mediators)-behavioral disinhibition (BIS-11 motor subscale), difficulties with attention regulation (MAAS) and emotion regulation (DERS)-and severity of SUDs (dependent variable; SPQ alcohol, illicit and prescribed drugs). Results: The analysis showed that alterations in the self-regulation system fully mediated the association between the severity of childhood ADHD symptoms and SUDs in adulthood. Behavioral disinhibition and difficulties in attention regulation were the most representative alterations in self-regulation processes that explained this association. Conclusions: These findings suggest it is useful to implement several therapeutic approaches (e.g. behavioral, mindfulness-based, and pharmacological) to increase the self-regulation abilities of children and adolescents with ADHD in order to reduce the probability of SUD onset in adulthood. However, future longitudinal neuroimaging and neuropsychological studies are needed to further support the role of self-regulation mechanisms in explaining the prospective association between childhood ADHD symptoms and SUDs in adulthood.

Behavioral and mental health problems in adolescents with ADHD: Exploring the role of family resilience

BACKGROUND

Family resilience and its role in behavioral and mental health problems has not been well documented among U.S. adolescents, especially those with ADHD.

METHODS

Using data from the 2016 and 2017 National Survey of Children's Health (NSCH), we examined associations between family resilience connection index (FRCI) and conduct problems, depression, anxiety, and substance abuse in adolescents with ADHD aged 11-17 (n=4,169). Data were analyzed using multivariate logistic regression and chi-square tests.

RESULTS

Adolescents with ADHD who had a lower FRCI score were more likely to have conduct problems (OR:1.64, CI:1.13-2.38) and depression (OR: 3.08, CI: 2.12-4.49). There were small differences between adjusted and unadjusted odds after controlling for adverse childhood experience and other covariates.

LIMITATION

We could not assert prediction or causation, only associations among variables, due to the cross-sectional design of the 2016-2017 NSCH; however, a major advantage of the NSCH is that it includes a nationally representative sample of children and allows inferences to be made for understanding of the adolescents with ADHD in the U.S.

CONCLUSION

Findings suggest that family resilience may serve as a protective factor that leads to decreasing conduct problems, despite experiencing adversity in childhood. Targeting family resilience, in terms of teaching families ways to cope with adversities such as: a child's diagnosis of ADHD; behavioral problems, and/or other adverse experiences in children's environments, has great potential to reduce adolescents' conduct and mental health problems.

Lifetime depressive and current social anxiety are associated with problematic internet use in adolescents with ADHD: a cross-sectional study

AIM

To evaluate the relationships between problematic internet use (PIU) and psychiatric comorbid disorders and internet use habits in a clinical sample of adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

This cross-sectional study included 95 adolescents with ADHD. Problematic behaviors and symptoms related to internet use were evaluated via Young's Internet Addiction Scale (YIAS), and subjects with a YIAS score of ≥50 were categorized as PIU while those with a score of <50 were defined as normal internet use (NIU). The two groups were compared with respect to demographics and psychometric tests. While psychiatric disorders were examined by a semistructured instrument, self-report and parent-report scales were used to assess other individual and clinical characteristics of participants.

RESULTS

33.7% (n = 32) of the participants were determined to have PIU. There was no gender (p = .058) or age (p = .426) difference between the PIU and NIU groups. Current presence of social phobia (p = .035) and history of major depressive disorder (p = .006) were more frequent in the PIU group than the NIU group. Multivariable regression analysis revealed that PIU was independently associated with online gaming (OR: 2.375, 95% CI: 1.532-3.681), e-mail use (OR: 1.864, 95% CI: 1.170-2.971), social networking (OR: 1.834, 95% CI: 1.156-2.910), and Social Phobia Scale for Children and Adolescents (SPSCA) score (OR: 1.058, 95% CI: 1.020-1.098).

CONCLUSION

PIU may be common among adolescents with ADHD. The severity of social phobia and particular online activities (playing online games, e-mailing, social networking) may be associated with a higher risk of PIU in adolescents with ADHD.

Attention-Deficit/Hyperactivity Disorder Symptoms and Community Violence Exposure in Russian Adolescents

A large body of research has shown that exposure to community violence is common for many children across the world. However, less is known about exposure in particular subgroups such as those children with developmental disorders. To address this research gap, the aim of this study was to examine community violence exposure (CVE) in adolescents with attention-deficit/hyperactivity disorder (ADHD) symptoms and the role of gender in this association. Data were analyzed from 2,782 adolescents aged 13 to 17 years from Arkhangelsk, Russia that were collected during the Social and Health Assessment (SAHA). ADHD status was assessed with the hyperactivity/inattention scale of the Strengths and Difficulties Questionnaire (SDQ). Information was obtained on past-year witnessing and violence victimization in the community. Results showed that CVE was more prevalent in children with ADHD symptoms. Specifically, 75.1% of children with ADHD symptoms had been exposed to any violence versus 62.3% in the non-ADHD group (χ² = 18.65, p < .001). Multivariate analyses of covariance (MANCOVAs) revealed that CVE was significantly higher for adolescents with ADHD symptoms for both witnessing and victimization, while exposure was significantly higher for ADHD boys compared with girls. The findings of this study suggest that CVE may be elevated in adolescents with higher ADHD symptoms. Given that CVE has been associated with a variety of negative social and psychological outcomes in typically developing children, an important task for future research is to determine what factors are associated with CVE in adolescents with ADHD symptoms including those relating to such phenomena as comorbid psychopathology, the family, and peer relations, so that interventions can be designed and implemented to reduce CVE and its detrimental effects in this population.

Persistent attention-deficit/hyperactivity disorder predicts socially oriented, but not physical/physiologically oriented, alcohol problems in early adulthood

BACKGROUND

Although individuals with histories of childhood attention-deficit/hyperactivity disorder (ADHD) report more alcohol-related problems in adulthood than those without ADHD, it is unknown whether there are group differences in certain types of alcohol problems. We tested whether the nature of alcohol problems differed for individuals with and without childhood ADHD, as well as adulthood-persistent ADHD, to facilitate a personalized medicine approach for alcohol problems in this high-risk group.

METHODS

Data were drawn from a prospective, observational study. Children diagnosed with ADHD and demographically similar individuals without childhood ADHD were followed prospectively through young adulthood (N = 453; 87.6% male). ADHD symptom persistence was assessed using self-reports and parent reports. Alcohol problems and heavy drinking were assessed repeatedly from 18-30 years old to construct lifetime measures.

RESULTS

Full-sample confirmatory factor analyses identified 5 alcohol problem "types:" interpersonal problems/risky behaviors, occupational/academic impairment, impaired control/treatment seeking, tolerance/withdrawal, and drinking to blackout. Latent class analyses of items within each type yielded the best fit for 3-class solutions for all sets of items except blackout drinking, for which 2 classes emerged. Children with ADHD were more likely than those without ADHD to belong to high-risk latent classes for interpersonal problems/risky behaviors, occupational/academic problems, and impaired control (the high-risk class that indexed treatment-seeking behavior). These effects were driven by individuals whose ADHD symptoms persisted into adulthood. Few group differences emerged for tolerance/withdrawal and blackout drinking, except that individuals with only childhood ADHD (no persistence) were more likely to belong to the low-risk groups than those with adulthood-persistent ADHD and without ADHD.

CONCLUSIONS

Individuals with ADHD histories whose symptoms persist into adulthood may be more likely to experience socially oriented alcohol problems and impaired control/treatment seeking than individuals without an ADHD history and those with childhood ADHD only. Tailored alcohol prevention and treatment programs may benefit this high-risk population.

Sex-specific associations between subcortical morphometry in childhood and adult alcohol consumption: A 17-year follow-up study

Men and women tend to differ in the age of first alcohol consumption, transition into disordered drinking, and the prevalence of alcohol use disorder. Here, we use a unique longitudinal dataset to test for potentially predispositonal sex-biases in brain organization prior to initial alcohol exposure. Our study combines measures of subcortical morphometry gathered in alcohol naive individuals during childhood (mean age: 9.43 years, SD = 2.06) with self-report measures of alcohol use in the same individuals an average of 17 years later (N = 81, 46 males, 35 females). We observe that pediatric amygdala and hippocampus volume both show sex-biased relationships with adult drinking. Specifically, females show a stronger association between subcortical volumetric reductions in childhood and peak drinking in adulthood as compared to males. Detailed analysis of subcortical shape localizes these effects to the rostro-medial hippocampus and basolateral amygdala subnuclei. In contrast, we did not observe sex-specific associations between striatal anatomy and peak alcohol consumption. These results are consistent with a model in which organization of the amygdala and hippocampus in childhood is more relevant for subsequent patterns of peak alcohol use in females as compared to males. Differential neuroanatomical precursors of alcohol use in males and females could provide a potential developmental basis for well recognized sex-differences in alcohol use behaviors.. Thus, our findings not only indicate that brain correlates of human alcohol consumption are manifest long before alcohol initiation, but that some of these correlates are not equivalent between males and females.

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.

Relationship between cannabis use and psychotic experiences in college students

BACKGROUND

Emerging data suggest cannabis use is a component cause of psychotic disorders; however, the sequence of processes accounting for this association is poorly understood. Some clues have come from studies in laboratory settings showing that acute cannabis intoxication is associated with subclinical hallucinations and delusional thinking, i.e., "psychotic experiences". Although psychotic experiences are relatively common, those that are severe and distressing are linked to an increased risk of developing a psychotic disorder. This study aimed to investigate the association between the frequency of cannabis use and psychotic experiences in young adults.

METHODS

1034 U.S. college students completed questionnaires to assess: cannabis use in the past week, delusional ideation (Peters Delusions Inventory), hallucinations (Launay-Slade Hallucinations Scale-Extended), and depression (Beck Depression Inventory).

RESULTS

Participants reporting higher rates of weekly cannabis use were more likely to report hallucinatory experiences and delusional ideation. The relationship between cannabis use and hallucinatory experiences, but not the relationship between cannabis use and delusional ideation, remained significant after controlling for levels of depression. Moreover, those who reported greater amounts of cannabis use had more distressing delusional ideas, that were held with more conviction.

CONCLUSIONS

Cannabis use is linked to the presence of subclinical hallucinations and delusional ideation in U.S. college students.

ASRS Questionnaire and Tobacco Use: Not Just a Cigarette. A Screening Study in an Italian Young Adult Sample

Young adults exhibit greater sensitivity than adults to nicotine reinforcement, and Attention Deficit Hyperactivity Disorder (ADHD) increases the risk for early-onset smoking. We investigated the correlation between ADHD Self-Report Scale (ASRS) scores and smoking, evaluated the prevalence of ADHD symptomatology (not diagnoses) in smokers and non-smokers and its comorbidity with benzodiazepine and gambling addictions. A total of 389 young adults from 14 schools in Northern Italy fill out a survey and the Adult ADHD Self-Report Scale (ASRS). A total of 15.2% of subjects tested positive at the ASRS, which correlated with smoking; moreover, smokers had twice the probability of testing positive at the ASRS. ADHD symptomatology, especially when comorbid with tobacco abuse, is an important condition to monitor because early nicotine exposure could be a gateway for other addictive behaviors.

Trajectories of Emotional and Conduct Problems and Their Association With Early High School Achievement and Engagement for Adolescents With ADHD

Objective: This study aimed to (a) identify longitudinal trajectories of emotional and conduct problems from middle childhood to early adolescence in a sample of 130 adolescents diagnosed with ADHD and (b) examine trajectories in relation to early adolescent academic achievement and engagement. Method: Group-based trajectory models (GBTMs) were constructed from the parent-rated strengths and difficulties questionnaire (SDQ) subscales of emotional and conduct problems at three time points, mean ages 10.7 years, 11.6 years, and 13.7 years. Associations between trajectories and adolescent academic achievement and engagement were examined using multivariate regression. Results: Four distinct trajectories were identified within each domain. High-persistent problem trajectories in each domain were associated with poorer achievement and lower school engagement compared with adolescents following persistent-low problem trajectories. Conclusion: Findings highlight the importance of early assessment and management of comorbid emotional and conduct problems for children with ADHD as they predict school difficulties during early high school. (J. of Att. Dis. XXXX; XX(X) XX-XX).

Decision-Making Deficits in ADHD Are Not Related to Risk Seeking But to Suboptimal Decision-Making: Meta-Analytical and Novel Experimental Evidence

Objective: ADHD is related to decision-making deficits in real-life (e.g., substance abuse) and on experimental tasks (increased preference for risky options). In most tasks, risk and expected value are confounded (risky options have lowest expected value), making it impossible to disentangle risky from suboptimal (i.e., not choosing highest expected value) decision-making. We differentiated between risky and suboptimal decision-making in ADHD in two studies. Method and Results: First, on a multilevel meta-regression analysis (k = 48, n_ADHD = 1,144, n_Control = 1,108), ADHD and controls differed if the risky option was suboptimal (ADHD choosing more risky/suboptimal), whereas groups performed similar if the risky option was not suboptimal. Second, an empirical study showed that adults with ADHD (n = 40) made more suboptimal, but not more risky choices than controls (n = 40). Conclusion: These results contribute to a growing body of evidence that decision-making deficits in ADHD are driven by suboptimal decision-making and not by risk seeking.

Children's Knowledge of Cannabis and Other Substances in States with Different Cannabis Use Regulations

Background: Public acceptance of cannabis continues to increase across the US, yet there has been little research on how cannabis legalization affects young children. The present study compared knowledge of cannabis and other substances among children living in states with different cannabis laws and examined whether the association between such substance knowledge and externalizing behavior varies by state cannabis regulations. Methods: Participants were from the Adolescent Brain Cognitive Development^SM Study (ABCD Study®) at the baseline assessment (N = 11,875, ages 9-11, collected from 2016 to 2018). Chi-square difference tests were used to compare nested models testing group differences in knowledge of substances and the association between externalizing disorder/behavior and substance knowledge as a function of state legality of cannabis use (recreational, medical, low THC/CBD, none). Results: Children living in states with more permissive cannabis laws had a greater knowledge of cannabis and reported more alcohol experimentation. In contrast, knowledge regarding alcohol, tobacco, and other illicit drugs was not greater in children from states with more permissive cannabis laws. Externalizing disorder/behavior was not significantly associated with cannabis knowledge in any group and not significantly different across groups. The association between externalizing disorder/behavior and illicit drug knowledge was significant only in states with the recreational and medical use laws but did not differ significantly across groups. Conclusion: Children living in environments with more permissive cannabis regulations have greater knowledge of cannabis, but not other substances, and report more experimentation with alcohol.

Initial Engagement in Oral Sex and Sexual Intercourse Among Adolescent Girls With and Without Childhood Attention-Deficit/Hyperactivity Disorder

We investigated initial engagement in oral sex and sexual intercourse, as well as number of sexual partners, among a prospectively followed sample of adolescent girls with and without a thorough childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD). Participants were adolescent girls (ages 12-19) followed longitudinally as part of a study of ADHD in females. A diverse sample of 140 girls with clinician-diagnosed ADHD (47 inattentive, 93 combined) and 88 age- and ethnicity-matched comparison girls were initially recruited and invited to partake in research summer programs. We utilized data on initial engagement in oral sex, sexual intercourse, and number of sexual partners, collected during follow-up interviews conducted 5 and 10 years after baseline participation. Girls with a childhood diagnosis of ADHD engaged in oral sex at a significantly younger age and reported nearly twice as many oral sex partners than their typically developing peers. Post hoc tests revealed that group differences were driven largely by girls with the combined presentation of ADHD (i.e., those with childhood histories of both inattention and hyperactivity/impulsivity). No significant differences emerged with respect to age of initial sexual intercourse or number of male sexual intercourse partners. In sum, adolescent girls with ADHD, particularly those with the combined presentation, were more likely to engage in oral sexual activity at a young age and with a greater number of both male and female partners. Findings highlight the need for longitudinal research that quantifies and distinguishes between various forms of sexual behavior and later reproductive and mental health outcomes.

ADHD Symptoms and Sex Moderate the Relation Between Protective Behavioral Strategies and Alcohol Use Among Treatment-Mandated College Students

College students with attention deficit/hyperactivity disorder are likely to engage in alcohol use and experience alcohol-related problems. Use of protective behavioral strategies is related to fewer alcohol-related consequences. However, this association has not been sufficiently examined in relation to attention deficit/hyperactivity disorder symptoms, which could alter the likelihood of utilizing protective behavioral strategies. This study examined whether attention deficit/hyperactivity disorder symptoms moderate the relationship between protective behavioral strategies and alcohol use, and whether this differs by sex. Participants were 125 treatment-mandated college students (58.6% male; M_age = 19.50 years) who completed measures of attention deficit/hyperactivity disorder symptoms, protective behavioral strategies, and past-2-week drinking. There was a significant 3-way interaction such that drinking was highest when protective behavioral strategy use was low and hyperactivity/impulsivity symptoms were high, but only for women. There was also a significant protective behavioral strategy by inattention interaction, as students with high inattention and low protective behavioral strategy use consumed the most drinks. Interventions to enhance use of protective behavioral strategies may effectively decrease alcohol use for college students with attention deficit/hyperactivity disorder symptoms, particularly women.

Childhood ADHD and Involvement in Early Pregnancy: Mechanisms of Risk

Objective: ADHD is associated with risky sexual behavior and early pregnancy, but few studies have examined mechanisms of risk linking childhood ADHD to early pregnancy. The present study utilized data from the Multimodal Treatment Study of ADHD to examine potential mechanisms that may account for the association between childhood ADHD and becoming pregnant or causing a pregnancy by age 18. Method: Participants were 579 children with ADHD and 289 comparison peers followed over 16 years. Results: Relative to the comparison group, those with childhood ADHD were at more than two times increased risk of early pregnancy. Univariately, persistence of ADHD symptoms, delinquency/substance use, and academic performance/achievement during adolescence each mediated the association between childhood ADHD and early pregnancy. When considered together, only delinquency/substance use remained a significant mediator of this relationship. Conclusion: Findings point toward specific targets of intervention for youth with ADHD to prevent early pregnancy.

Machine-Learning prediction of comorbid substance use disorders in ADHD youth using Swedish registry data

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) have a high risk for substance use disorders (SUDs). Early identification of at-risk youth would help allocate scarce resources for prevention programs.

METHODS

Psychiatric and somatic diagnoses, family history of these disorders, measures of socioeconomic distress, and information about birth complications were obtained from the national registers in Sweden for 19,787 children with ADHD born between 1989 and 1993. We trained (a) a cross-sectional random forest (RF) model using data available by age 17 to predict SUD diagnosis between ages 18 and 19; and (b) a longitudinal recurrent neural network (RNN) model with the Long Short-Term Memory (LSTM) architecture to predict new diagnoses at each age.

RESULTS

The area under the receiver operating characteristic curve (AUC) was 0.73(95%CI 0.70-0.76) for the random forest model (RF). Removing prior diagnosis from the predictors, the RF model was still able to achieve significant AUCs when predicting all SUD diagnoses (0.69, 95%CI 0.66-0.72) or new diagnoses (0.67, 95%CI: 0.64, 0.71) during age 18-19. For the model predicting new diagnoses, model calibration was good with a low Brier score of 0.086. Longitudinal LSTM model was able to predict later SUD risks at as early as 2 years age, 10 years before the earliest diagnosis. The average AUC from longitudinal models predicting new diagnoses 1, 2, 5 and 10 years in the future was 0.63.

CONCLUSIONS

Population registry data can be used to predict at-risk comorbid SUDs in individuals with ADHD. Such predictions can be made many years prior to age of the onset, and their SUD risks can be monitored using longitudinal models over years during child development. Nevertheless, more work is needed to create prediction models based on electronic health records or linked population registers that are sufficiently accurate for use in the clinic.

Four-Year Follow-Up of High versus Low Intensity Summer Treatment for Adolescents with ADHD

OBJECTIVE

Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown.

METHOD

We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes.

RESULTS

Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs.

CONCLUSIONS

Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).

Integrating Tobacco Prevention Skills into an Evidence-Based Intervention for Adolescents with ADHD: Results from a Pilot Efficacy Randomized Controlled Trial

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at high risk for tobacco use, but tobacco use prevention strategies are not regularly incorporated into evidence-based ADHD interventions. We conducted a pilot randomized-controlled trial to determine the feasibility of integrating tobacco use prevention skills into a behavioral treatment for ADHD and to provide preliminary efficacy data comparing a combined (ADHD + tobacco) intervention (N = 40) to an ADHD only intervention (N = 23) on tobacco risk outcomes. Sixty-three adolescents (72% male; 13-17 years) with ADHD and their caregivers were randomly assigned to condition and families were masked to condition. Parent and adolescent ratings were collected at baseline, immediate post-intervention, and at 3- and 9-month follow-up assessments. The combined intervention was (1) implemented with high fidelity (94%), (2) well received by parents and adolescents as evidenced by high levels of treatment attendance (82%) and satisfaction with the intervention, and (3) associated with parent- and adolescent-reported reductions in tobacco use risk. Relative to the ADHD intervention, the combined intervention buffered against increases in tobacco risk, including reduced intentions to smoke and maladaptive social normative beliefs, and increased parental control, family cohesion, and family communication about substance use. Effect sizes at post-treatment were in the small to moderate range. Overall, this study provides preliminary support for a parent-adolescent behavioral treatment supplemented with family-based tobacco prevention strategies. This approach targets families already in treatment for ADHD, reducing barriers that occur when families attend multi-session prevention programs in addition to ADHD treatment.

Beers with Peers: Childhood ADHD and Risk for Correlated Change in Perceived Peer and Personal Alcohol Use Across Young Adulthood

BACKGROUND

ADHD poses risk for problematic alcohol use through adulthood. Perceived peer alcohol use, one of the strongest correlates of individuals' own alcohol use, is especially salient for adolescents with ADHD. The extent to which this risk extends into young adulthood is unknown, as well as how change in these constructs is associated throughout young adulthood.

METHODS

In the Pittsburgh ADHD Longitudinal Study, 358 individuals with childhood-diagnosed ADHD and 239 without were prospectively followed from ages 18 to 29. Piecewise, bivariate longitudinal growth modeling was used to examine the change in both peer alcohol use and individuals' heavy drinking (binge-drinking frequency), their between-person associations, and differences by ADHD group. The addition of structured residuals probed within-person year-to-year change in peer and personal alcohol use and their prospective associations.

RESULTS

Perceived peer alcohol use and individuals' heavy drinking frequencies changed together over time concurrently-from ages 18 to 21 (piece 1) and 21 to 29 (piece 2). Prospectively, individuals who increased the most in heavy drinking from ages 18 to 21 reported more friends using alcohol at age 29, regardless of ADHD history. Within-person increases in personal alcohol use likewise predicted increased perceived peer use the subsequent year within each age group (piece), regardless of ADHD history. However, while decreasing perceived peer use from ages 21 to 29 was related to more frequent heavy drinking at age 29 for those without ADHD, increasing perceived peer use from ages 18 to 21 predicted more frequent heavy drinking at age 29 for those with ADHD.

CONCLUSIONS

Young adult heavy drinking changes in tandem with perceived peer alcohol use across individuals and predicts selection of alcohol-using peers from year to year within individuals, further into adulthood than previously documented. Findings suggest the centrality of relationships with alcohol-consuming friends in relation to one's heavy drinking, especially for young adults with ADHD histories, through the twenties.