Psychostimulant treatment and risk for substance abuse among young adults with a history of attention-deficit/hyperactivity disorder: a population-based, birth cohort study

Methylphenidate use and restorative treatment needs in young adults with attention deficit hyperactivity disorder

OBJECTIVE

To assess the effect and dose-response of methylphenidate (MP) use on the restorative treatment needs in young adults with attention deficit hyperactivity disorder.

PARTICIPANTS AND METHODS

This retrospective study comprises a cohort of military recruits aged 18-25 who served for 12 to 48 months between 2005 and 2017. The medical records of 213 604 participants were assessed of which: 6875 participants with ADHD who received treatment with MP, 6729 participants with ADHD who had no prescriptions for MP, and 200 000 healthy participants. The outcome was restorative treatment needs, which served as an indicator of caries: having at least one prescription for restorative treatment during the study period.

RESULTS

Frequency of prescription for restorative treatment among the treated, the untreated and the control groups was 24%, 22%, and 17%, respectively (p < .0001). On multivariate analysis, the dose-response association between MP use and the odds of having at least one restorative treatment was confirmed (OR = 1.006 for each additional 1 gr of MP; 95% CI [1.004:1.009]) CONCLUSIONS: Participants with ADHD who receive chronic treatment with MP have higher restorative treatment needs than participants with untreated ADHD and healthy participants. Our results show that chronic MP medication among young adults leads to an elevated need for restorative treatment and implies a significant impact on oral health (OH).

Is age of onset and duration of stimulant therapy for ADHD associated with cocaine, methamphetamine, and prescription stimulant misuse?

BACKGROUND

To assess whether age of onset and duration of stimulant therapy for attention-deficit/hyperactivity disorder (ADHD) are associated with cocaine, methamphetamine, and prescription stimulant misuse during adolescence.

METHODS

Nationally representative samples of US 10th and 12th grade students (N = 150,395) from the Monitoring the Future study were surveyed via self-administered questionnaires from 16 annual surveys (2005-2020).

RESULTS

An estimated 8.2% of youth received stimulant therapy for ADHD during their lifetime (n = 10,937). More than one in 10 of all youth reported past-year prescription stimulant misuse (10.4%)-past-year cocaine (4.4%) and methamphetamine (2.0%) use were less prevalent. Youth who initiated early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years) did not have significantly increased adjusted odds of cocaine or methamphetamine use relative to population controls (ie, non-ADHD and unmedicated ADHD youth). Youth who initiated late stimulant therapy for ADHD (≥10 years old) and for short duration (<1 year) had significantly higher odds of past-year cocaine or prescription stimulant misuse in adolescence than those initiating early stimulant therapy for ADHD (≤9 years old) and for long duration (≥6 years). Youth who initiated late stimulant therapy for ADHD (≥10 years) for short duration (<1 year) had significantly higher odds of past-year cocaine, methamphetamine, and prescription stimulant misuse versus population controls during adolescence. No differences in past-year cocaine, methamphetamine, and prescription stimulant misuse were found between individuals who only used non-stimulant therapy for ADHD relative to youth who initiated early stimulant therapy (≤9 years old) and for long duration (≥6 years).

CONCLUSIONS

An inverse relationship was found between years of stimulant therapy and illicit and prescription stimulant misuse. Adolescents with later initiation and/or shorter duration of stimulant treatment for ADHD should be monitored for potential illicit and prescription stimulant misuse.

Effects of adolescent methylphenidate administration on methamphetamine conditioned place preference in an animal model of attention-deficit/hyperactivity disorder: Examination of potential sex differences

BACKGROUND

Individuals with attention-deficit/hyperactivity disorder (ADHD) are more likely to be diagnosed with a substance use disorder; however, the effects of long-term psychostimulant treatment on addiction are mixed. Preclinical studies are useful for further elucidating the relationship between ADHD and addiction-like behaviors, but these studies have focused on male subjects only. The goal of the current study was to determine if early-life administration of methylphenidate (MPH) augments methamphetamine (METH) conditioned place preference (CPP) and/or potentiates reinstatement of CPP in both male and female rats.

METHODS

Male and female spontaneously hypertensive rats (SHRs) and Wistar-Kyoto rats (WKYs) received either MPH (1.5mg/kg; p.o.) or vehicle (1.0ml/kg) during adolescence (postnatal day [PND] ~29-57). Two weeks after cessation of MPH treatment, rats were tested for METH CPP (1.0mg/kg or 2.0mg/kg; s.c.). Rats were then given extinction sessions. Once rats met extinction criteria, they were tested for reinstatement of CPP following a priming injection of METH (0.25mg/kg; s.c.).

RESULTS

All groups developed METH CPP, except vehicle-treated SHR males and vehicle-treated WKY females conditioned with the higher dose of METH (2.0mg/kg). Female SHRs treated with MPH showed greater reinstatement of METH CPP compared to female SHRs treated with vehicle. Adolescent MPH treatment did not augment the locomotor-stimulant effects of METH in adulthood.

CONCLUSIONS

These results demonstrate the importance of considering biological sex when prescribing psychostimulant medications for ADHD as long-term MPH administration may increase the risk of continued drug use in females with ADHD following a period of abstinence.

Amphetamine disrupts dopamine axon growth in adolescence by a sex-specific mechanism in mice

Initiating drug use during adolescence increases the risk of developing addiction or other psychopathologies later in life, with long-term outcomes varying according to sex and exact timing of use. The cellular and molecular underpinnings explaining this differential sensitivity to detrimental drug effects remain unexplained. The Netrin-1/DCC guidance cue system segregates cortical and limbic dopamine pathways in adolescence. Here we show that amphetamine, by dysregulating Netrin-1/DCC signaling, triggers ectopic growth of mesolimbic dopamine axons to the prefrontal cortex, only in early-adolescent male mice, underlying a male-specific vulnerability to enduring cognitive deficits. In adolescent females, compensatory changes in Netrin-1 protect against the deleterious consequences of amphetamine on dopamine connectivity and cognitive outcomes. Netrin-1/DCC signaling functions as a molecular switch which can be differentially regulated by the same drug experience as function of an individual's sex and adolescent age, and lead to divergent long-term outcomes associated with vulnerable or resilient phenotypes.

Neuroprotection in late life attention-deficit/hyperactivity disorder: A review of pharmacotherapy and phenotype across the lifespan

For decades, psychostimulants have been the gold standard pharmaceutical treatment for attention-deficit/hyperactivity disorder (ADHD). In the United States, an astounding 9% of all boys and 4% of girls will be prescribed stimulant drugs at some point during their childhood. Recent meta-analyses have revealed that individuals with ADHD have reduced brain volume loss later in life (>60 y.o.) compared to the normal aging brain, which suggests that either ADHD or its treatment may be neuroprotective. Crucially, these neuroprotective effects were significant in brain regions (e.g., hippocampus, amygdala) where severe volume loss is linked to cognitive impairment and Alzheimer's disease. Historically, the ADHD diagnosis and its pharmacotherapy came about nearly simultaneously, making it difficult to evaluate their effects in isolation. Certain evidence suggests that psychostimulants may normalize structural brain changes typically observed in the ADHD brain. If ADHD itself is neuroprotective, perhaps exercising the brain, then psychostimulants may not be recommended across the lifespan. Alternatively, if stimulant drugs are neuroprotective, then this class of medications may warrant further investigation for their therapeutic effects. Here, we take a bottom-up holistic approach to review the psychopharmacology of ADHD in the context of recent models of attention. We suggest that future studies are greatly needed to better appreciate the interactions amongst an ADHD diagnosis, stimulant treatment across the lifespan, and structure-function alterations in the aging brain.

ADHD and Substance Use Disorders in Young People: Considerations for Evaluation, Diagnosis, and Pharmacotherapy

Co-occurring ADHD and substance use disorder (SUD) is a common clinical presentation associated with significant impairment requiring careful evaluation, diagnosis, and treatment. Treatment with medication, along with cognitive behavioral therapy, is generally regarded as effective in addressing symptoms and impairments associated with both disorders. Options for pharmacotherapy include stimulant and nonstimulant therapies administered with careful monitoring of dosage and compliance to optimize efficacy. In high-risk groups such as college students and/or those with SUD, prescribers should address risks of stimulant misuse and diversion through patient and family education, medication monitoring, and other risk-reducing practices.

Finding the "Sweet Spot": Sharing the decision-making in ADHD treatment selection

BACKGROUND

Stimulants are often prescribed as first-line therapy for attention-deficit/hyperactivity disorder. Currently, there are many therapeutic options available for clinicians and families to consider when making the decision to use a medication. In practice, selection of a stimulant medication for ADHD is highly personalized and can be narrowed down to two major factors: finding the optimal duration of the medication effect, and then estimating a starting dose and subsequently "fine-tuning" the medication to the optimal dosage of the medication. With the possibility of titrating to an optimal stimulant dosage within one prescription of a liquid stimulant, prescribers can recruit the parent/caregiver to actively participate in managing the transition to medication, allowing for greater ownership and a sense of shared control over the process.

CASE PRESENTATION

The short case series offers a communication method by which clinicians can apply the principles of shared decision-making in helping the parent or caregiver of a newly diagnosed patient with ADHD make informed decisions about medication selection, and to obtain a greater sense of comfort with the new medication regimen.

CONCLUSIONS

Much has been published on the importance of clinicians and their patients fostering an environment of clear and unrestricted information-sharing. This short case series illustrates the effectiveness of this approach. Once parents are comfortable with the decision to start drug treatment for ADHD, it is incumbent upon the healthcare provider to ensure that an open channel of communication is maintained, and that parent/caregivers are encouraged to raise concerns as soon as possible.

The Impact of Pharmacotherapy of Childhood-Onset Psychiatric Disorders on the Development of Substance Use Disorders

Background and Objective: Child- and adolescent-onset psychopathology is known to increase the risk for developing substance use and substance use disorders (SUDs). While pharmacotherapy is effective in treating pediatric psychiatric disorders, the impact of medication on the ultimate risk to develop SUDs in these youth remains unclear. Methods: We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review of peer-reviewed literature published on PubMed through November 2021, examining pharmacological treatments of psychiatric disorders in adolescents and young adults and their effect on substance use, misuse, and use disorder development. Results: Our search terms yielded 21 studies examining the impact of pharmacotherapy and later SUD in attention-deficit/hyperactivity disorder (ADHD), two studies on Major Depressive Disorder, and three studies on psychotic disorders. The majority of these studies reported reductions in SUD (N = 14 sides) followed by no effects (N = 10) and enhanced rates of SUD (N = 2). Studies in ADHD also reported that earlier-onset and longer-duration treatment was associated with the largest risk reduction for later SUD. Conclusions: Overall, pharmacological treatments for psychiatric disorders appear to mitigate the development of SUD, especially when treatment is initiated early and for longer durations. More studies on the development of SUD linked to the effects of psychotherapy alone and in combination with medication, medication initiation and duration, adequacy of treatment, non-ADHD disorders, and psychiatric comorbidity are necessary.

Children With ADHD Are at Risk for a Broad Array of Adverse Adult Outcomes That Cross Functional Domains: Results From a Population-Based Birth Cohort Study

OBJECTIVE

To identify patterns ("classes") of outcomes for adults with and without childhood ADHD.

METHOD

Subjects were 232 childhood ADHD cases and 335 non-ADHD referents from a 1976 to 1982 birth cohort. We used latent class analyses to identify classes based on a broad array of adult psychosocial outcomes and determined the proportion of subjects with childhood ADHD within each class.

RESULTS

A three class solution provided optimal model fit; classes were termed "good," "intermediate," and "poor" functioning. Subjects with childhood ADHD comprised 62.8% of the "poor," 53.5% of the "intermediate," and 24.9% of the "good" functioning class. The "poor" functioning class was distinguished by increased likelihood of legal trouble and substance use disorders and included more individuals with childhood ADHD and psychiatric disorder than the "intermediate" class (45.5% vs. 30.6%).

CONCLUSION

Children with ADHD are at risk for adverse adult outcomes in multiple domains and co-morbid childhood psychiatric disorders increase risk.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Medical use and misuse of psychoactive prescription medications among US youth and young adults

OBJECTIVE

To investigate prevalence and correlates of medical use and misuse of psychoactive prescription medications among US youth and young adults.

DESIGN

Cross-sectional, self-reported surveys from the 2015-2018 National Survey of Drug Use and Health. Sampling was probabilistic and nationally representative.

SETTING

The target population included individuals from households, non-institutional group quarters (eg, college dormitories) and civilians living on military bases. Questionnaires were completed using computer-assisted self-interview methods.

PARTICIPANTS

Our analytical sample included youth and young adults aged 12-25 years (n=110 556). Psychoactive prescription medication misuse was a report by the respondent that they had used psychoactive prescription medications in the past year in any way not directed or prescribed for them. Medical use was defined as past-year use without a report of misuse. Because certain variables were assessed only among adults, our multivariable analysis to identify correlates of misuse was restricted to young adults aged 18-25 years (n=55 690).

RESULTS

Among US youth aged 12-17 years, 25.0% reported use of any psychoactive prescription medication assessed, and 5.7% reported past-year use of at least two psychoactive prescription medications. Among youth who used any psychoactive prescription medications, 20.9% (1.3 million) reported misuse; 3.4% were classified as having substance use disorder. Past-year use of each psychoactive prescription medication was: opioids (19.0%), stimulants (7.2%), tranquillisers (4.3%) and sedatives (2.2%). Among users of each psychoactive prescription medication, the estimated percentage reporting misuse was as follows: opioids (17.6%, 0.8 million), stimulants (24.2%, 0.4 million), tranquillisers (40.1%, 0.4 million) and sedatives (14.2%, 80 000). Among users of each psychoactive prescription medication, the estimated percentage having substance use disorder was as follows: opioids 2.6%, stimulants 3.0%, tranquillisers 7.0% and sedatives 3.6%. Analyses among young adults aged 18-25 years revealed that, compared with never users of non-prescription substances (including alcohol, tobacco, marijuana, cocaine, heroin), opioid misuse increased with: more recent use of non-prescription substances (adjusted prevalence ratios (APRs)=8.26, 2.75 and 2.41 for past ≤30-day, ≤12-month and >12-month use, respectively); and a higher number of substances used (APRs=1.69, 3.44, 6.82, 10.60 and 20.60 for 1, 2, 3, 4 and 5+ substances, respectively) (all p<0.05). Similar patterns were seen for stimulants, tranquillisers and sedatives.

CONCLUSIONS

It is important to monitor the diversity of medication misuse behaviours among youth and young adults, given their potential for abuse liability. Modifiable risk factors for prescription substance misuse, such as tobacco and other non-prescription substance use, underscore the need for comprehensive approaches towards health promotion among youth and young adults.

Neurodevelopmental Effects of Cannabis Use in Adolescents and Emerging Adults with ADHD: A Systematic Review

OBJECTIVE

Systematically review the scientific literature to characterize the effects of cannabis use on brain structure, function, and neurodevelopmental outcomes in adolescents and young adults with ADHD.

METHOD

Systematic review following PRISMA guidelines utilizing PubMed, Embase, PsycINFO, and Cochrane CENTRAL trials register from inception until 1 January 2020. Articles that examined the impact of cannabis use on youth with ADHD were included.

RESULTS

Eleven studies were identified that compared outcomes for individuals with ADHD who used cannabis or synthetic cannabinoids against those with ADHD who did not. Seven of these studies used neuroimaging techniques, including fMRI, structural MRI, and SPECT. Differential regions of activation were identified, including the right hippocampus and cerebellar vermis, and bilateral temporal lobes. Morphological differences were identified in the right precentral and postcentral gyri, left nucleus accumbens, right superior frontal and postcentral gyri. No study identified any additive or ADHD × cannabis use interaction on neuropsychological tasks of executive function. Two studies found adverse differential impacts of early-onset cannabis use in this population.

CONCLUSION

A dearth of evidence is available on the impact of cannabis use on the developing brain and functioning for individuals with ADHD, despite the elevated risk for substance use in this population. The limited, potentially underpowered evidence does not support the hypothesis that cannabis use has a deleterious impact on neuropsychological tasks in transitional age youth with ADHD. Larger and longer-term studies are needed, however, to better inform clinicians and patients as to the impacts of cannabis use in youth with ADHD.

Treatments for Adolescents With Comorbid ADHD and Substance Use Disorder: A Systematic Review

Objective: Comorbid ADHD and substance use disorder (SUD) presents frequently in adolescence, a developmental period that may promote the emergence of substance misuse among individuals with ADHD. Comorbid ADHD and SUD in adolescence results in significant and unique treatment challenges, necessitating examination into effective interventions. Method: This systematic review examined existing research into the treatment of comorbid adolescent ADHD and SUD. Results: Findings from a small number of pharmacological intervention studies suggest potential efficacy of extended-release stimulant and nonstimulant medications. Efficacy of psychotherapeutic interventions has not been systematically examined. Conclusion: Current research on treatments for comorbid ADHD and SUD in adolescence is limited. Future placebo-controlled clinical trials using large samples are needed to examine the efficacy of psychotherapeutic interventions, the heightened risk of prescription stimulant misuse, and the long-term maintenance of treatment gains in this population. Clinical guidelines for the treatment of comorbid ADHD and SUD are discussed.

Psychiatric Comorbidities Modify the Association Between Childhood ADHD and Risk for Suicidality: A Population-Based Longitudinal Study

OBJECTIVE

The objective of this study was to evaluate the effect of psychiatric comorbidities on the association between childhood ADHD and suicidality among adults.

METHOD

Subjects were recruited from a population-based birth cohort. Participating adult subjects with childhood ADHD and non-ADHD controls were administered a structured psychiatric interview to assess suicidality and psychiatric comorbidities. Associations were assessed using logistic regression.

RESULTS

Compared with controls, ADHD cases were significantly more likely to meet criteria for suicidality. Subjects with childhood ADHD who met criteria for generalized anxiety disorder had a higher than expected risk of suicidality with an observed odds ratio of 10.94 (95% confidence interval [4.97, 24.08]) compared with an expected odds ratio of 4.86, consistent with a synergistic interaction effect. Significant synergistic interactions were also observed for hypomanic episode and substance-related disorders.

CONCLUSION

Childhood ADHD is significantly associated with adult suicidal risk. Comorbidity between ADHD and some psychiatric disorders is associated with a higher suicidal risk than expected.

Stimulant treatment profiles predicting co-occurring substance use disorders in individuals with attention-deficit/hyperactivity disorder

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of developing substance use disorders (SUDs) and nicotine dependence (ND). It remains unclear whether and how stimulant treatment may affect this risk. We aimed to investigate how stimulant use profiles influence the risk of SUDs and ND, using a novel data-driven community detection analysis to construct different stimulant use profiles. Comprehensive lifetime stimulant prescription data and data on SUDs and ND were available for 303 subjects with ADHD and 219 controls, with a mean age 16.3 years. Community detection was used to define subgroups based on multiple indicators of treatment history, start age, treatment duration, total dose, maximum dose, variability, stop age. In stimulant-treated participants, three subgroups with distinct medication trajectories were distinguished (late-and-moderately dosed, n = 91; early-and-moderately dosed, n = 51; early-and-intensely dosed, n = 103). Compared to stimulant-naïve participants (n = 58), the early-and-intense treatment group had a significantly lower risk of SUDs and ND (HR = 0.28, and HR = 0.29, respectively), while the early-and-moderate group had a significantly lower risk of ND only (HR = 0.30). The late-and-moderate group was at a significantly higher risk of ND compared to the other two treatment groups (HR = 2.66 for early-and-moderate, HR = 2.78 for early-and-intense). Our findings show that in stimulant-treated adolescents with ADHD, long-term outcomes are associated with treatment characteristics, something that is often ignored when treated individuals are compared to untreated individuals.

Pharmacotherapeutic strategies for the treatment of attention-deficit hyperactivity (ADHD) disorder with comorbid substance-use disorder (SUD)

INTRODUCTION

Substance use disorder (SUD) is very common amongst patients with attention deficit hyperactivity disorder (ADHD). The two disorders share partially overlapping features and SUD in ADHD is characterized by an early age of onset, high likelihood of poly-substance use, increased risk of suicide attempts, more hospitalizations, and scarce treatment adherence.

AREAS COVERED

This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in patients with ADHD and SUD. The authors include open label and observational studies.

EXPERT OPINION

Stimulant and non-stimulant treatments should be used to aid ADHD symptomatology in patients with SUD. SUD seems to be less responsive, suggesting a relative independence of the two conditions. For this reason, the association of ADHD-specific drugs and SUD-treatments should be recommended in a large proportion of patients suffering from both disorders. The rate and the quality of ADHD response to specific pharmacological treatments is highly variable, depending on the dose and the duration of the treatment, the age of the patient, and the severity and the chronicity of addiction. Further research is necessary to explore the divergences in treatment response of different ADHD subtypes in different subtypes of SUD.

Effects of a mindfulness-based intervention (MYmind) for children with ADHD and their parents: protocol for a randomised controlled trial

INTRODUCTION

Mindfulness is one of the potential alternative interventions for children with attention-deficit hyperactivity disorder (ADHD). Some evidence suggests that mindfulness is related to changes in brain regions associated with ADHD. The potential benefits of mindfulness on children with ADHD, as well as the feasibility of this intervention approach, are warranted through prior local and foreign studies. This study aims to evaluate the effect of mindfulness-based group intervention for children with ADHD and their respective parents through a robust research design.

METHODS AND ANALYSIS

This study will adopt a randomised controlled trial design including 140 children aged 8-12 years with ADHD together with one of their parents (n=140). These families will be randomised into intervention group (n=70) who will be offered the MYmind programme delivered by trained healthcare professionals, and an active control group (n=70) who will be offered the CBT programme. The intervention includes 8 weekly 90 min group sessions for children with ADHD (aged 8-12 years) and their respective parents. The primary and secondary outcomes will include children's attention, ADHD-related symptoms, behaviours, executive function and mindfulness levels measured by validated objective measures and parent's reported instruments. Parents' parental stress, parenting styles, ADHD related symptoms, well-being, rumination level and mindfulness levels will also be measured. Analysis is by intention to treat. The effects of intervention will be evaluated by comparing outcomes between the two arms, as well as comparing outcomes within subject through comparing measurements at baseline (T0), immediately after the 8 week intervention (T1) and at 3 (T2) and 6 (T3) months postintervention.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Joint Chinese University of Hong Kong - New Territories East Cluster Clinical Research Ethics Committee (The Joint CUHK-NTEC CREC). Participants will be required to sign informed consent form from both parents and children. Findings will be reported in conferences and peer-reviewed publications in accordance with recommendations of Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

ChiCTR1800014741; Pre-results.

Risk of amphetamine use disorder and mortality among incident users of prescribed stimulant medications in the Veterans Administration

BACKGROUND AND AIMS

Non-medical use of prescribed stimulant medications is a growing concern. This study's aims were to ascertain the demographics of stimulant medication users compared with non-users, examine temporal trends of stimulant medication use and estimate risk factors for development of amphetamine use disorder (AUD) and mortality among new users of stimulant medications.

DESIGN

Cox proportional hazards regression in a retrospective cohort adjusted by baseline covariates.

SETTING

United States, national administrative database of the Veterans Affairs (VA) health-care system.

PARTICIPANTS

Adult incident users of stimulant medications (n = 78 829) from fiscal years (FY) 2001 to 2012.

MEASUREMENTS

Primary outcomes were time-to-event: (1) occurrence of AUD diagnosis and (2) death. Baseline covariates included demographic information, Food and Drug Administration (FDA)-approved indications for stimulant use, substance use disorders (SUD) and depression.

FINDINGS

Stimulant users compared with non-users were younger, more likely to be non-Hispanic white and female. Incident stimulant medication users increased threefold from FY2001-FY2012 and eightfold among adults aged 18-44 years. Nearly one in 10 incident users in FY2012 had a comorbid baseline SUD. Off-label use was common-nearly three of every five incident users in FY2012. Comorbid SUDs among incident stimulant medication users were risk factors for occurrence of AUD during follow-up, with adjusted hazard ratio (AHR) estimates ranging from 1.54 to 2.83 (Ps < 0.05). Increased mortality risk was observed with occurrence of AUD during follow-up [AHR = 1.55, 95% confidence interval (CI) = 1.13-2.14, P = 0.007], while on-label prescribing was protective against death (AHR = 0.686, 95% CI = 0.63-0.75, P < 0.0001).

CONCLUSIONS

In a US national cohort of adult incident stimulant medication users in the Veterans Affairs health-care system, measured from fiscal years 2001 to 2012, comorbid substance use disorders were common and were risk factors for development of an amphetamine use disorder (AUD). Increased mortality risk among incident users of stimulant medications was observed among both those who developed an AUD later and those whose use was defined as off-label.

Adults With Persistent ADHD: Gender and Psychiatric Comorbidities-A Population-Based Longitudinal Study

OBJECTIVE

The aim of the study was to evaluate associations between ADHD and comorbid psychiatric disorders among adults from a population-based birth cohort.

METHOD

Participants were recruited from all children born between 1976 and 1982 remaining in Rochester, Minnesota, after age 5. Participants with childhood ADHD ( n = 232; M age = 27.0 years; 72% men) and non-ADHD controls ( n = 335; M age = 28.6 years; 63% men) completed a structured interview (M.I.N.I. International Neuropsychiatric Interview) assessing current ADHD status and comorbid psychiatric disorders.

RESULTS

Among 232 with childhood ADHD, 68 (49 men, 19 women) had persistent adult ADHD. Compared with non-ADHD controls and non-persistent ADHD participants, adults with persistent ADHD were significantly more likely to have any or each of 12 psychiatric comorbidities. The associations retained significant or marginally significant when stratified by gender. Externalizing psychiatric disorders were more common in men (74%) and internalizing disorders in women (58%).

CONCLUSION

Persistent ADHD is associated with an increased risk of comorbid psychiatric disorders in adult men and women.

Attention Deficit Hyperactivity Disorder and Associated Cognitive Dysfunction in Pediatric Epilepsy

Attention deficit hyperactivity disorder (ADHD) is the most common neuropsychiatric comorbidity associated with childhood epilepsy, affecting about a third of children with epilepsy. In contrast, ADHD in the general population occurs in 4%-12% of school-aged children. The cause of this association remains unclear. It is likely that common mechanisms underlie the vulnerability for both executive deficits and epileptogenesis. There are characteristics unique to children with ADHD and epilepsy. The inattentive type of ADHD is more prevalent than the combined presentation in children with epilepsy, while the combined type is more common in the general population. Interestingly, there is an equal sex distribution of ADHD in patients with epilepsy, while in the general population, ADHD is 3-7 times more prevalent in boys. Specific features of ADHD seen in different epilepsy syndromes are frequently associated with executive deficits. Early screening of ADHD symptoms in children with epilepsy is essential, as timely interventions can improve academic and social function and outcomes. The mainstays of therapy include behavioral interventions and pharmacotherapy, with evidence demonstrating that stimulants are both safe and effective in children with ADHD and epilepsy.

Social contextual risk factors for stimulant use among adolescent American Indians

OBJECTIVE

Stimulants are the most common and efficacious treatment for Attention-Deficit Hyperactivity Disorder (ADHD). We examined the relationship between stimulant misuse and social factors that could be malleable to prevention among American Indian (AI) adolescents.

METHOD

Participants were AI students (N=3498) sampled from 33 schools in 11 states. Participants completed the American Drug and Alcohol Survey. A multilevel analytic approach was used to evaluate the effects of participant-level (level 1) variables (i.e., gender, grade, peer, school, family, stimulant prescribed by doctor) on lifetime and current simulant use to 'get high.'

RESULTS

Nearly 7% of our sample had been prescribed stimulants and nearly 6% of the sample reported using stimulants to get high. Age [OR=1.22; 95% CI=1.09, 1.36, p<0.001], perception of peer substance use [OR=1.19; 95% CI=1.14, 1.23, p<0.001], parental monitoring [OR=0.96; 95% CI=0.92, 1.99, p=0.04], and stimulants prescribed by a doctor [OR=8.79, 95% CI=5.86, 13.18, p<0.001] were associated with ever using stimulants to get high. Perception of peer substance use, [b=0.09, SE=0.02, p<0.001, 95%CI [0.05, 0.13], and having stimulants prescribed by a doctor, [b=0.58, SE=0.21, p=0.006, 95%CI [0.17, 0.99], were associated with frequency of past month use to get high. There was also a significant quadratic effect for parental monitoring, suggesting that low and high levels were associated with increased stimulant use.

CONCLUSIONS

Our results suggest a need for prevention efforts to be directed to AI youth who are prescribed stimulants.

Hippotherapy and neurofeedback training effect on the brain function and serum brain-derived neurotrophic factor level changes in children with attention-deficit or/and hyperactivity disorder

PURPOSE

The purpose of this study was to investigate the effect of hippotherapy and electroencephalography (EEG) neurofeedback on brain function and blood brain-derived neurotrophic factor (BDNF) level in children with attention-deficit or/and hyperactivity disorder (ADHD).

METHODS

Sixteen children with ADHD participated in this study and were randomly divided into 2 groups, a 1-time hippotherapy group (W1G, n = 8) and a 2-time hippotherapy group (W2G, n = 8). All the participants attended 8 weeks of hippotherapy program in the primary training, and then 7 children with ADHD attended 8 weeks of hippotherapy program combined with neurofeedback training in the secondary training. Blood BDNF levels were measured, and functional magnetic resonance imaging (fMRI) was performed. The EEG neurofeedback training program was used to train and measure psychological factors.

RESULTS

The combined effect of hippotherapy and neurofeedback on BDNF level showed a decreased tendency in W1G (pretraining, 1766.03 ± 362.54 pg/ml; posttraining, 1630.65 ± 276.70 pg/ml). However, the BDNF level of W2G showed an increased tendency (pretraining, 1968.28 ± 429.08 pg/ml; posttraining, 1976.28 ± 425.35 pg/ml). Moreover, combined training showed a significant group x repetition interaction in W1G (pretraining, 1436.57 ± 368.76 pg/ml; posttraining, 1525.23 ± 346.22 pg/ml; F = 3.870, p = 0.039). fMRI results showed that the left thalamus activity in both groups had a decreased tendency and a significantly lower change in W2G than in W1G (p < 0.05).

CONCLUSION

This study confirmed a significant increase in blood BDNF level after combined training, which may induce brain function improvement in children with ADHD.

Attention deficit hyperactivity disorder and substance abuse: An investigation in young Austrian males

BACKGROUND

Many studies have found an association between Substance Use Disorders (SUDs) and Attention Deficit Hyperactivity Disorder (ADHD) in children, adolescents and adults. We intended to determine whether substance abuse and SUDs are associated with former and current ADHD symptomatology in a non-clinical sample of 17 and 18 year old males.

METHOD

A representative sample of 3280 young men (6.8% of all males born in Austria in the respective year) was investigated during the examination for military service. We collected data on past (WURS) and current (ADHD symptom checklist) ADHD symptomatology, substance abuse, parental substance use and abuse and motives for substance use.

RESULTS

Measured by WURS, 10.1% had scored positive for past ADHD symptoms. 2.7% of all subjects stated that they have been treated for ADHD and 1.5% reported that they had at one point received pharmacological treatment for the condition. Abuse of alcohol, nicotine and illicit substances was significantly (p<.01) more frequent in subjects with ADHD syndrome. Perceived parental alcohol abuse increased the risk for ADHD in the offspring. Motives for substance use differed greatly between groups.

LIMITATIONS

The sample consists of men only. Subjects had to be fit enough to be enlisted military service, generating a possible bias towards healthier subjects. The cross-sectional design does not allow conclusions about the temporal relationships between ADHD symptoms and substance abuse.

CONCLUSION

Identification of vulnerability factors for comorbid ADHD and SUD in adolescence should be intensified. Preventive strategies ought to be established.

ADHD, Conduct Disorder, Substance Use Disorder, and Nonprescription Stimulant Use

OBJECTIVE

To assess whether the relationship of an ADHD diagnosis by adolescence to nonprescription stimulant use in adulthood is direct or indirect, via Conduct Disorder (CD) and/or Substance Use Disorder (SUD).

METHOD

Data were obtained from multiple waves of interviews and questionnaires completed by 551 community-based participants when they were between the mean ages of 14.1 and 36.6 years.

RESULTS

The results of the structural equation model (SEM) supported both a direct association between early ADHD and later nonprescription stimulant use ( B = .18, z = 2.74) and the relationship from ADHD to later nonprescription stimulant use ( B = .01, z = 1.72) via CD and SUD.

CONCLUSION

The longitudinal data supporting these paths suggest that efforts to prevent and treat the misuse of nonprescription stimulants may be more effective if attention is paid to those with a history of ADHD, as well as to those who also had CD and SUD.

Relations between mental health diagnoses, mental health treatment, and substance use in homeless youth

BACKGROUND

Youth experiencing homelessness have elevated rates of mental illness and substance use compared to the general population. However, the extent to which underlying mental health issues may contribute to substance use as a way to manage symptoms and whether mental health treatment may reduce risk for substance use is unclear. This paper investigated these relations in a community sample of homeless youth.

METHODS

Youth ages 13-24 (N=416) were interviewed as part of a community count and survey of homeless youth in Houston, Texas. A path analysis examined relations among lifetime diagnoses of ADHD, bipolar disorder, and depression; past-month marijuana, alcohol, and synthetic marijuana use, and hypothesized mediators of past-year mental health treatment and perceived unmet need for treatment.

RESULTS

Rates of prior mental disorder diagnoses were high, with extensive comorbidity across the three diagnoses (n=114, 27.3% had all three diagnoses). Relations varied by diagnoses and substances. ADHD was positively related to current marijuana use (β=0.55 (0.16), p<0.001), a relation that mental health treatment did not mediate. Depression was positively related to synthetic marijuana use through unmet need (β=0.25 (0.09), p=0.004) and to alcohol use through unmet need (β=0.20 (0.10), p=0.04) CONCLUSIONS: This study provides new information about relations between prior mental health diagnoses and substance use in homeless youth. Findings support the need to consider prior mental disorder diagnoses in relation to current substance use and to assess for whether youth perceive they have unmet needs for mental health treatment.

What can large population-based birth cohort study ask about past, present and future of children with disorders of development, learning and behaviour?

A large cohort consisting of all children born to mothers from community provides 'natural' selection into different exposures and is a powerful resource for epidemiological research. A large population-based birth cohort with detailed systematic information already recorded, as part of longitudinal medical care, historical and current school data, detailed birth certificate data and all three resources available for every member of the birth cohort, are extremely rare. Our population-based birth cohort consists of all children born between 1976 and 2000 to mothers residing in Olmsted County, Minnesota, at the time of child's birth (N=39 890). In this paper, we provide a comprehensive report of the method describing the identification, the characteristics and longitudinal follow-up of each child (and family members) from the birth cohort, wealth of complementary resources of data and study measures and designs (retrospective, combined retrospective/prospective). In the last decade or so, we obtained scientific and clinically needed answers for incidence rates, potential risk/protective factors, treatment, comorbidities, outcomes, cost/usage and potential biases (that are always assessed and clinically interpreted) of many developmental learning and behavioural disorders (DLBDs) including learning and attention-deficit/hyperactivity disorders, intellectual disability, speech-language impairment and autism spectrum disorder. Many current and future questions related to DLBDs are remaining to be answered. The Olmsted County Birth Cohort (OCBC) is an example of a comprehensive, contemporary epidemiological research model for the development of similar research infrastructures, and its current and future results are important for replication and comparison with other population-based retrospective and prospective birth cohort studies.

Adolescents' Prescription Stimulant Use and Adult Functional Outcomes: A National Prospective Study

OBJECTIVE

To assess the prospective 17-year relationship between the medical and nonmedical use of prescription stimulants during adolescence (age 18 years) and educational attainment and substance use disorder (SUD) symptoms in adulthood (age 35 years).

METHOD

A survey was self-administered by nationally representative probability samples of US high school seniors from the Monitoring the Future study; 8,362 of these individuals were followed longitudinally from adolescence (age 18, high school senior years 1976-1996) to adulthood (age 35, 1993-2013).

RESULTS

An estimated 8.1% reported medical use of prescription stimulants, and 16.7% reported nonmedical use of prescription stimulants by age 18 years. Approximately 43% of adolescent medical users of prescription stimulants had also engaged in nonmedical use of prescription stimulants during adolescence. Among past-year adolescent nonmedical users of prescription stimulants, 97.3% had used at least one other substance during the past year. Medical users of prescription stimulants without any history of nonmedical use during adolescence did not differ significantly from population controls (i.e., non-attention-deficit/hyperactivity disorder [ADHD] and non-stimulant-medicated ADHD during adolescence) in educational attainment and SUD symptoms in adulthood. In contrast, adolescent nonmedical users of prescription stimulants (with or without medical use) had lower educational attainment and more SUD symptoms in adulthood, compared to population controls and medical users of prescription stimulants without nonmedical use during adolescence.

CONCLUSION

Nonmedical use of prescription stimulants is common among adolescents prescribed these medications. The findings indicate youth should be carefully monitored for nonmedical use because this behavior is associated with lower educational attainment and more SUD symptoms in adulthood.

A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities

Attention-deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder that is often diagnosed during childhood, but has also increasingly been recognized to occur in adults. Importantly, up to 52% of children (including adolescents) and 87% of adults with ADHD also have a comorbid psychiatric disorder. The presence of a comorbid disorder has the potential to impact diagnosis and could affect treatment outcomes. Atomoxetine is a nonstimulant treatment for ADHD. Despite numerous published studies regarding efficacy of atomoxetine in the treatment of ADHD in patients with comorbid disorders, there is limited information about the impact of individual common comorbid disorders on the efficacy of atomoxetine for ADHD, especially with regard to adults. Moreover, a cumulative review and assessment of these studies has not been conducted. For this reason, we performed a literature review to find, identify, and cumulatively review clinical studies that examined the efficacy of atomoxetine in the treatment of patients with ADHD and comorbid psychiatric disorders. We found a total of 50 clinical studies (37 in children; 13 in adults) that examined the efficacy of atomoxetine in patients with ADHD and a comorbid disorder. The comorbidities that were studied in children or in adults included anxiety, depression, and substance use disorder. Overall, the presence of comorbidity did not adversely impact the efficacy of atomoxetine in treatment of ADHD symptoms in both patient populations. In the studies identified and assessed in this review, atomoxetine did not appear to exacerbate any of the comorbid conditions and could, therefore, be an important therapy choice for the treatment of ADHD in the presence of comorbid disorders.

Age and Cohort Patterns of Medical and Nonmedical Use of Controlled Medication Among Adolescents

OBJECTIVES

We identified peak annual incidence rates for medical and nonmedical use of prescription opioid analgesics, stimulants, sedatives, and anxiolytics (controlled medication), and explored cohort effects on age of initiation.

METHODS

Data were gathered retrospectively between 2009 and 2012 from Detroit area students (n = 5185). Modal age at the last assessment was 17 years. A meta-analytic approach produced age-, year-, and cohort-specific risk estimates of first-time use of controlled medication. Cox regression models examined cohort patterns in age of initiation for medical and nonmedical use with any of 4 classes of controlled medication (opioid analgesics, stimulants, sedatives, or anxiolytics).

RESULTS

Peak annual incidence rates were observed at age 16 years, when 11.3% started medical use, and 3.4% started using another person's prescription for a controlled medication (ie, engaged in nonmedical use). In the more recent birth cohort group (1996-2000), 82% of medical users and 76% of nonmedical users reported initiating such use by age 12 years. In contrast, in the less recent birth cohort group (1991-1995), 42% of medical users and 35% of nonmedical users initiated such use by age 12 years. Time to initiation was 2.6 times less in the more recent birth cohort group (medical use: adjusted hazard ratio [aHR] = 2.57 [95% confidence interval {CI} = 2.32-2.85]; nonmedical use: aHR = 2.57 [95% CI = 2.17-3.03]).

CONCLUSIONS

Peak annual incidence rates were observed at age 16 years for medical and nonmedical use. More recent cohorts reported initiating both types of use at younger ages. Earlier interventions may be needed to prevent adolescent nonmedical use of controlled medication.

Mediating and Moderating Role of Depression, Conduct Disorder or Attention-Deficit/Hyperactivity Disorder in Developing Adolescent Substance Use Disorders: A Population-Based Study

Objective

To evaluate the mediating/moderating effects of common internalizing /externalizing disorders on the association between ADHD and adolescent substance use disorders (SUD) in a population-based birth cohort.

Methods

Among 5718 children in the birth cohort, 343 ADHD incident cases and 712 matched controls were identified. Psychiatric diagnoses prior to age 19 were classified into DSM-IV categories. The association between ADHD and SUD was summarized (hazard ratios (HR), 95% CI). The effect of depression, CD/ODD, anxiety was evaluated separately.

Results

Assessment of the joint effects of ADHD and each psychiatric disorder did not support a moderating effect of these disorders on SUD on additive scale. However, the association between ADHD and SUD was partially explained by a mediating role of these psychiatric disorders.

Conclusion

For clinicians our results emphasize that depression (or CD/ODD) confers greater risk for SUD than ADHD alone. Early detection/treatment of SUD among adolescents with depression (or CD/ODD) is crucial regardless of ADHD.

Cognitive and emotional impairments in adults with attention-deficit/hyperactivity disorder and cocaine use

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is an important modulator of cognitive and social functioning in cocaine addiction but it is unclear whether ADHD symptoms and cocaine use display mutually aggravating interaction effects on cognition, social functioning, and depressive symptoms. Therefore, we investigated the interaction of cocaine use and adult ADHD on social and non-social cognition and depressive symptoms.

METHODS

Twenty-four cocaine users with (CU+ADHD) and 30 without ADHD (CU-ADHD), 29 cocaine-naïve ADHD patients, and 40 cocaine-naïve healthy controls underwent comprehensive neuropsychological testing including assessment of social cognition (cognitive/emotional empathy and Theory-of-Mind). Additionally, depressive symptoms were measured with the Beck Depression Inventory.

RESULTS

The effect size of global cognitive impairment was largest in CU+ADHD (d=1.22 vs. controls) followed by CU-ADHD (d=0.74), and cocaine-naïve ADHD patients (d=0.33). A similar pattern appeared regarding depressive symptoms (CU+ADHD: d=1.47; CU-ADHD: d=0.49, ADHD: d=0.34). In the measures of Theory-of-Mind (CU+ADHD: d=0.76; CU-ADHD: d=0.06, ADHD: d=0.01) and cognitive empathy (CU+ADHD: d=0.80; CU-ADHD: d=0.39, ADHD: d=-0.11) only CU+ADHD showed moderate to large impairments. Moreover, two-way analyses of covariance revealed a significant interaction effect of the factors ADHD and cocaine use on depressive symptoms (p<0.05) and Theory-of-Mind (p<0.05) but not on global cognitive performance (p=0.64).

CONCLUSIONS

When occurring together, cognitive impairments associated with both ADHD and cocaine use are largely additive, whereas both factors seem to mutually potentiate one another with respect to mood and mental perspective-taking disturbances. Given the high comorbidity between ADHD and cocaine use, longitudinal studies are needed to investigate the origin of these potentiated impairments.

Facebook Role Play Addiction - A Comorbidity with Multiple Compulsive-Impulsive Spectrum Disorders

Background Problematic Internet use (PIU) is an emerging entity with varied contents. Behavioral addictions have high comorbidity of attention deficit hyperactivity disorder and obsessive-compulsive spectrum disorders. Social networking site (SNS) addiction and role playing game (RPG) addiction are traditionally studied as separate entities. We present a case with excessive Internet use, with a particular focus on phenomenology and psychiatric comorbidities. Case presentation Fifteen-year-old girl with childhood onset attention deficit disorder, obsessive-compulsive disorder, adolescent onset trichotillomania, and disturbed family environment presented with excessive Facebook use. Main online activity was creating profiles in names of mainstream fictional characters and assuming their identity (background, linguistic attributes, etc.). This was a group activity with significant socialization in the virtual world. Craving, salience, withdrawal, mood modification, and conflict were clearly elucidated and significant social and occupational dysfunction was evident. Discussion This case highlights various vulnerability and sociofamilial factors contributing to behavioral addiction. It also highlights the presence of untreated comorbidities in such cases. The difference from contemporary RPGs and uniqueness of role playing on SNS is discussed. SNS role playing as a separate genre of PIU and its potential to reach epidemic proportions are discussed. Conclusions Individuals with temperamental vulnerability are likely to develop behavioral addictions. Identification and management of comorbid conditions are important. The content of PIU continues to evolve and needs further study.

Early exposure to stimulant medications and substance-related problems: The role of medical and nonmedical contexts

BACKGROUND

The age of onset (early vs. late) and context (medical vs. nonmedical) of exposure to stimulant medications for attention-deficit/hyperactivity disorder (ADHD) have been identified as important factors in the addictive potential of these controlled medications. This study examines the role of medical and nonmedical contexts in the association between early exposure to stimulant medications and substance use and substance-related problems among adolescents.

METHODS

A Web-based survey was self-administered by Detroit-area secondary school students (N=4755) between the 2009-10 and 2012-13 school years. The sample consisted of 51% females, 62% Whites, 32% African-Americans, and 6% from other racial categories.

RESULTS

During the study period, an estimated 11.7% of respondents were ever diagnosed with ADHD. Approximately 6.7% (n=322) of respondents indicated lifetime medical use of prescription stimulants while 2.6% (n=124) indicated lifetime nonmedical use. The odds of substance use and substance-related problems were significantly lower among those who initiated earlier medical use of stimulant medications relative to later medical initiation. In contrast, the odds of substance use and substance-related problems were significantly greater among those who initiated earlier nonmedical use of stimulant medications relative to later nonmedical initiation.

CONCLUSIONS

More than one in every ten adolescents in this epidemiologically-derived community-based sample was diagnosed with ADHD. This is the first investigation to demonstrate that context (medical vs. nonmedical) plays a critical role in the relationship between early exposure to stimulant medications and the subsequent risk of substance-related problems during adolescence within the same diverse youth sample.

Age of Onset, Duration, and Type of Medication Therapy for Attention-Deficit/Hyperactivity Disorder and Substance Use During Adolescence: A Multi-Cohort National Study

OBJECTIVE

To examine whether age of onset, duration, or type of medication therapy for attention-deficit/hyperactivity disorder (ADHD) is associated with substance use during adolescence.

METHOD

Nationally representative samples of high school seniors were surveyed via self-administered questionnaires. The sample consisted of 40,358 individuals from 10 independent cohorts (2005-2014) and represented a population that was 52% female, 62% white, 10% African American, 14% Hispanic, and 14% other race/ethnicity. Design-based logistic regression analyses were used to test the associations between age of onset, duration, and type of ADHD medication therapy and recent substance use, controlling for potential confounding factors.

RESULTS

Individuals who initiated stimulant medication therapy for ADHD later (aged 10-14 years and 15 years and older) and for shorter duration (2 years or less and 3-5 years) as well as those who reported only nonstimulant medication therapy for ADHD had significantly greater odds of substance use in adolescence relative to individuals who initiated stimulant medication therapy for ADHD earlier (aged 9 years or less) and for longer duration (6 or more years). The odds of substance use generally did not differ between population controls (youth without ADHD and unmedicated youth with ADHD) and individuals who initiated stimulant medication for ADHD early (aged 9 years or less) and for longer duration (aged 6 or more years).

CONCLUSION

Relative to later onset and shorter duration of stimulant treatment for ADHD, early onset and longer duration of stimulant treatment for ADHD was associated with a risk of substance use during adolescence that is lower than and similar to that in the general population.

The use of stimulants and atomoxetine in adults with comorbid ADHD and bipolar disorder

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) persists into adulthood in about 50% of the affected children, with high rates of comorbidity with bipolar disorder (BD). Stimulants and atomoxetine (ATX) are effective treatments for ADHD, but their use in adults with comorbid BD (ADHD-BD) has not been extensively studied and may be problematic.

AREAS COVERED

The aim of the paper is to summarize the available literature regarding the use of these medications in ADHD-BD adult patients. Results of randomized-controlled and open-label trials, case reports, and case series are reviewed. We also reviewed data relative to some specific issues of this comorbidity in adults, especially substance use disorder, malingering, and stimulants misuse.

EXPERT OPINION

ADHD-BD may be associated with more severe symptoms, course, and worst outcome of both conditions. The frequent coexistence with alcohol and substance abuse may further complicate treatment management. Stimulants are the most effective medications for ADHD, but their use may be contraindicated in the presence of a comorbid drug abuse or in patients that simulate or exaggerate ADHD symptoms in order to obtain stimulants for diversion or abuse. ATX may be effective in the treatment of ADHD symptoms in BD patients, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers. In the majority of the cases, a hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms. Although systematic trials on the use of stimulants and ATX in ADHD-BD comorbidity in adulthood are necessary, both treatments should be considered possible options to be carefully evaluated once the patient has been stabilized.

Peak ages of risk for starting nonmedical use of prescription stimulants

BACKGROUND

To produce population-level, year- and age-specific risk estimates of first time nonmedical use of prescription stimulants among young people in the United States.

METHODS

Data are from the National Surveys on Drug Use and Health 2004-2012; a nationally representative probability sample survey administered each year. Subpopulations included youths aged 12 to 21 years (n=240,160) who had not used prescription stimulants nonmedically prior to their year of survey assessment. A meta-analytic approach was used to produce population-level age-, year-, and cohort-specific risk estimates of first time nonmedical use of prescription stimulants.

RESULTS

Peak risk of starting nonmedical use of prescription stimulants was concentrated between ages 16 and 19 years, when an estimated 0.7% to 0.8% of young people reported nonmedical use of these medicines for the first time in the past twelve months. Smaller risk estimates ranging from 0.1% to 0.6% were observed at ages 12 to 15 years and 20 to 21 years. Compared with males, females were more likely to have started nonmedical use of prescription stimulants (odds ratio=1.35; 95% CI, 1.13-1.62), particularly between the ages of 14 and 19. Females showed a peak annual incidence rate of 1% at age 18, while males the same age showed an incidence rate of 0.5%.

CONCLUSIONS

Peak annual incidence rates for nonmedical use of prescription stimulants were observed between the ages of 16 and 19 years. There is reason to initiate interventions during the earlier adolescent years to prevent youths from starting nonmedical use of prescription stimulants.

Using factor analytic models to examine the association between attention-deficit/hyperactivity disorder symptoms and health-related outcomes in a representative population survey

The objective of the study was to examine the factor structure of attention-deficit/hyperactivity disorder (ADHD) symptoms in a representative population survey of adults and the association of these factors with health outcomes. Hierarchical and correlated factor analysis models were compared, and regression analyses with these models were used to determine the associations with psychological distress and substance use problems. A total of 1449 adults 18-65 years of age participated in a cross-sectional survey over the phone. ADHD symptom data came from an ADHD screener (10 items), and health outcomes were assessed using a questionnaire measuring psychological distress and two measures of substance use problems. The hierarchical general factor models with specific factors best represented the structure of ADHD in this representative population survey. The general factor and residual inattention factor were significantly associated with psychological distress, and the general factor was associated with substance use problems. From the correlated factor models, the inattention factor was associated with psychological distress and the hyperactivity factor was related to substance use problems. The hierarchical and correlated factor models explained similar levels of variance in outcomes. The results replicate previous studies indicating that a model of ADHD symptoms with a unitary dimension and separable dimensions of residual inattention and hyperactivity/impulsivity demonstrates a better fit than correlated factor models. The ADHD general factor was consistently significantly related to outcomes.

Attention-deficit/hyperactivity disorder in relation to addictive behaviors: a moderated-mediation analysis of personality-risk factors and sex

INTRODUCTION

Research has shown that those with attention-deficit/hyperactivity disorder (ADHD) have an increased risk for addiction disorders like alcoholism and substance abuse. What is less clear is the mechanism(s) whereby ADHD gives rise to increased engagement in addictive behaviors, and whether there are sex differences in the ADHD-addiction propensity. Both ADHD and addictions have also been associated with personality traits such as impulsivity, reward seeking, anxiousness, and negative affect. In this study, we tested a moderator-mediation model, which predicted that both sex and ADHD-symptom status would make independent contributions to the variance in personality risk and in addictive behaviors, with males, and those with diagnosed ADHD, scoring higher on both dependent variables. Our model also predicted that the effect of sex and ADHD-symptom status on addictive behaviors would be via the mediating or intervening influence of personality-risk factors.

METHODS

A community-based sample of young men and women took part in the study. Among these individuals, 46 had received a lifetime diagnosis of ADHD. The non-diagnosed participants were dichotomized into a high-ADHD-symptom group (n = 83) and a low-symptom group (n = 84).

RESULTS

We found that a high-risk personality profile may, in part, account for the relationship between ADHD symptomatology and the use/abuse of a broad range of addictive behaviors. However, we found no sex differences in personality risk for addiction or in the use of addictive behaviors; nor did sex moderate the relationships we assessed.

CONCLUSION

While ADHD status showed a strong relationship with both dependent variables in the model, we found no difference between those who had been diagnosed with ADHD and treated with stimulants, and their high-symptom non-diagnosed/non-treated counterparts. These results add support to claims that the treatment of ADHD with stimulant medication neither protects nor fosters the risk for substance abuse disorders.

Misuse of Methylphenidate

This chapter reviews methylphenidate misuse, abuse, dependence, diversion, and malingering associated with its use as a prescription medication for attention-deficit/hyperactivity disorder and the nonmedical use linked to its stimulant effects. Methylphenidate-induced regional elevations in brain dopamine appear to be integral to both efficacy in attention-deficit/hyperactivity disorder and potential for abuse, raising potential concerns for drug safety and prescription drug diversion costs associated with nonmedical use. Regardless, methylphenidate is an important treatment option, and detecting malingering for the purpose of illicit access to methylphenidate for subsequent misuse or diversion is a difficult challenge. Also discussed are the effects of methylphenidate in patients with comorbid substance use disorder and the potential linkage of methylphenidate use with subsequent substance abuse. The current data suggest that methylphenidate misuse and diversion are common health-care problems with a stimulant prescription drug diversion prevalence of approximately 5-10 % of high school students and 5-35 % of college students. The effectiveness and speed of action of methylphenidate are deemed desirable to enhance attention and focus performance for activities such as studying for exams, but methylphenidate is also misused recreationally. These data suggest a need for close screening and therapeutic monitoring of methylphenidate use in the treatment of attention-deficit/hyperactivity disorder.

"Complex" attention-deficit hyperactivity disorder, more norm than exception? Diagnoses and comorbidities in a developmental clinic

OBJECTIVE

Current recommendations for evaluation and diagnosis of attention-deficit hyperactivity disorder (ADHD) are meant for primary care settings and may not adequately address the needs of children seen in subspecialty developmental-behavioral pediatric settings who may have higher rates of comorbid developmental, learning, and psychiatric disorders. The authors sought to characterize the diagnostic complexity of school-aged children diagnosed with ADHD after comprehensive multidisciplinary evaluation in a subspecialty developmental-behavioral pediatric clinic.

METHODS

The authors conducted a retrospective medical record review of 144 patients aged 7 to 11 years who were consecutively evaluated by an interdisciplinary team (developmental-behavioral pediatrician, psychologist, educator) in a school-age clinic within a developmental-behavioral pediatrics tertiary care center from January 1, 2009 to December 31, 2009.

RESULTS

After comprehensive evaluation, rates of ADHD diagnosis increased from 32.6% (n = 47) preevaluation to 54.2% (n = 78) postevaluation (p < .0001). Rates of learning disorders among children receiving a final diagnosis of ADHD increased from 2.6% (n = 2) preevaluation to 50% (n = 39) postevaluation. (p < .0001). Among children receiving a final diagnosis of ADHD, 73.1% (n = 57) were diagnosed with at least 1 comorbid psychiatric, developmental, or learning disorder.

CONCLUSIONS

Among school-aged children diagnosed with ADHD in a developmental-behavioral pediatric subspecialty setting, a comprehensive evaluation including developmental, neuropsychological, and educational assessments yielded high rates of comorbid psychiatric, developmental, and learning disorders. This supports the need to provide comprehensive interdisciplinary assessment for such children to ensure the identification and treatment of not only the core symptoms of ADHD but also the comorbidities that may otherwise go unrecognized and therefore not optimally treated.

The severity of attention deficit hyperactivity symptoms and its relationship with lifetime substance use and psychological variables among 10th grade students in Istanbul

AIM

The aim of this study was to determine the severity of attention deficit hyperactivity symptoms (ADHS) and related psychological and behavioral variables among 10th grade students in Istanbul/Turkey.

METHODS

Cross-sectional online self-report survey conducted in 45 schools in 15 districts Istanbul. The questionnaire included sections about demographic data and use of substances including tobacco, alcohol and drugs. Also ADHS, depression, anxiety, anger and sensation seeking subscales of Psychological Screening Test for Adolescents (PSTA) were used. The analyses were conducted based on the 4938 subjects.

RESULTS

Mean ADHS score was higher in females and among those with a lifetime use of tobacco, alcohol and drug, and having self-harming behavior and suicidal thoughts. ADHS score was correlated with depression, anxiety, anger and sensation seeking scores. In univariate covariance analysis (ANCOVA); depression, anxiety, anger, sensation seeking, lifetime alcohol use and suicidal thoughts predicted the severity of ADHS.

CONCLUSIONS

The findings suggest that, since ADHS is associated with depression, anxiety, anger, sensation seeking, lifetime alcohol use and suicidal thoughts among 10th grade students, clinicians should screen suicidality and comorbid psychiatric symptoms routinely in adolescents with ADHS.

Gene expression profiling in the striatum of amphetamine-treated spontaneously hypertensive rats which showed amphetamine conditioned place preference and self-administration

Attention-deficit/hyperactivity disorder (ADHD), the most commonly diagnosed neurobehavioral disorder of childhood, is usually treated with psychostimulants (e.g., amphetamine). Little is known about the neuronal and behavioral consequences of chronic amphetamine use or abuse in individuals with ADHD. Of all ADHD animal models, the spontaneously hypertensive rat (SHR) is the most validated and widely used. Here, we analyzed striatal transcriptomes in amphetamine-pretreated SHRs (5 mg/kg, i.p. for 7 days [twice daily]), which showed a conditioned place preference to and self-administration of amphetamine. Microarray analyses revealed increased mRNA expression of 55 genes (>1.65-fold increase), while 17 genes were downregulated (<0.6-fold) in the striatum of SHRs. The main functional categories overrepresented among the differentially expressed genes in the striatum include those involved in transcription (e.g., Cebpb, Per2), genes associated with angiogenesis (e.g., Kdr, Klf5), cell adhesion (e.g., Col11a1, Ctgf), apoptosis (e.g., Nfkbia, Perp) and neuronal development (e.g., Egr2, Nr4a3). In conclusion, we dissected the striatal transcriptional responses to the reinforcing effects of repeated amphetamine treatment in the SHR model of ADHD. Future studies should determine the influence of these altered transcripts on amphetamine reinforcement in amphetamine-treated SHRs, and the clinical relevance of the present findings with regard to amphetamine use/abuse in ADHD individuals.

Childhood ADHD and risk for substance dependence in adulthood: a longitudinal, population-based study

Background

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are known to be at significantly greater risk for the development of substance use disorders (SUD) compared to peers. Impulsivity, which could lead to higher levels of drug use, is a known symptom of ADHD and likely accounts, in part, for this relationship. Other factors, such as a biologically increased susceptibility to substance dependence (addiction), may also play a role.

Objective

This report further examines the relationships between childhood ADHD, adolescent- onset SUD, and substance abuse and substance dependence in adulthood.

Method

Individuals with childhood ADHD and non-ADHD controls from the same population-based birth cohort were invited to participate in a prospective outcome study. Participants completed a structured neuropsychiatric interview with modules for SUD and a psychosocial questionnaire. Information on adolescent SUD was obtained retrospectively, in a previous study, from medical and school records. Associations were summarized using odds ratios (OR) and 95% CIs estimated from logistic regression models adjusted for age and gender.

Results

A total of 232 ADHD cases and 335 non-ADHD controls participated (mean age, 27.0 and 28.6 years, respectively). ADHD cases were more likely than controls to have a SUD diagnosed in adolescence and were more likely to have alcohol (adjusted OR 14.38, 95% CI 1.49–138.88) and drug (adjusted OR 3.48, 95% CI 1.38–8.79) dependence in adulthood. The subgroup of participating ADHD cases who did not have SUD during adolescence were no more likely than controls to develop new onset alcohol dependence as adults, although they were significantly more likely to develop new onset drug dependence.

Conclusions

Our study found preliminary evidence that adults with childhood ADHD are more susceptible than peers to developing drug dependence, a disorder associated with neurological changes in the brain. The relationship between ADHD and alcohol dependence appears to be more complex.

Individual differences in novelty-seeking behavior in spontaneously hypertensive rats: Enhanced sensitivity to the reinforcing effect of methylphenidate in the high novelty-preferring subpopulation

BACKGROUND

High novelty seeking has been assumed to predict vulnerability to use addictive drugs. Notably, it is also a symptom associated with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to identify whether spontaneously hypertensive rats (SHRs), putative animal models of ADHD, display individual differences in novelty-seeking behavior, and whether high novelty-seeking SHRs show enhanced sensitivity to the reinforcing effect of methylphenidate, the most commonly prescribed stimulant ADHD medication.

METHODS

First, we established that SHRs show higher levels of novelty-seeking behavior than their normotensive control strain, Wistar Kyoto (WKY) rats. Novelty seeking was measured in two tests: open field test in a novel test arena, and novel object preference tests. Thereafter, SHRs were classified into high responders (HR) or low responders (LR), high novelty-preferring (HNP) or low novelty-preferring (LNP) rats, based on individual scores in the two behavioral assays. Methylphenidate self-administration was assessed thereafter.

RESULTS

SHRs showed higher levels of novelty-seeking behavior than WKY rats. HR/LR and HNP/LNP subgroups were identified. HR and LR rats showed comparable rates of methylphenidate self-administration. However, HNP SHRs worked more for methylphenidate infusions than their LNP counterparts.

CONCLUSIONS

We showed some evidence on inter-individual variations in novelty seeking in SHRs. Importantly, we demonstrated enhanced sensitivity of HNP SHRs to the reinforcing effect of methylphenidate, indicating a "drug-vulnerable" SHR subpopulation. These findings are important as they may provide basis for a potential screening tool to identify a subset of ADHD patients (i.e. high novelty seekers) who may be at risk for misusing/abusing methylphenidate.

Attention-deficit/hyperactivity disorder and substance abuse

Attention-deficit/hyperactivity disorder (ADHD) and substance use disorders are inextricably intertwined. Children with ADHD are more likely than peers to develop substance use disorders. Treatment with stimulants may reduce the risk of substance use disorders, but stimulants are a class of medication with significant abuse and diversion potential. The objectives of this clinical report were to present practical strategies for reducing the risk of substance use disorders in patients with ADHD and suggestions for safe stimulant prescribing.

Irish adolescents with ADHD and comorbid substance use disorder

Objectives:

To examine the literature for drug treatment of attention deficit hyperactivity disorder (ADHD) in adolescents with co-occurring substance use disorder (SUD), the challenges posed by this, and make recommendations taking into account current trend in Ireland.

Methods:

Articles published from 1992-2008 were identified using OVID-MEDLINE search using the search terms attention deficit hyperactivity disorder and substance use disorder. Studies cited include review articles, epidemiological studies, experimental researches, open and controlled trials of drugs in ADHD with comorbid SUD and clinical guidelines. No non-English language papers were included.

Results:

Thirty-six studies were examined. A number of the papers reported on the link between ADHD and SUD, that they frequently co-occur, and there is evidence that treating ADHD can reduce the risk of future SUD. Some of the studies reviewed demonstrated the safety and effectiveness of ADHD medication on the ADHD symptoms but less so on the SUD. Concerns around stimulant abuse and diversion are valid. Although there is no current evidence of frequent diversion of ADHD medications in Ireland, this practice is prevalent in the US. Consequently psychiatrists should remain vigilant to the possibility of such diversions and take measures to address them if identified.

Conclusions:

The available evidence suggests that medication is not hazardous in ADHD comorbid with SUD. Pharmacological treatment of ADHD, following consideration of potential risks and benefits, is justified in the presence of SUD. Both methylphenidate and atomoxetine can be used. Stabilisation of serious SUD before pharmacotherapy is preferable, and it is advisable to provide psychological treatment to address SUD in these patients.