ADHD, stimulant treatment in childhood and subsequent substance abuse in adulthood - a naturalistic long-term follow-up study

Attention Deficit Hyperactivity Disorder: A Risk Factor for Premature Discontinuation of Inpatient Opioid Withdrawal Treatment

Background: Substance use disorders present a tremendous challenge within contemporary healthcare systems. Specifically, in the domain of opioid use disorders (OUDs), several foundational elements are crucial for the efficacious management of afflicted individuals. Regrettably, the premature discontinuation of inpatient opioid withdrawal treatment is a prevalent phenomenon. This study aims to elucidate the prevalence of the premature termination of inpatient opioid withdrawal treatment among patients with comorbid ADHD. Methods: We conducted a comprehensive assessment of all participants currently undergoing inpatient opioid withdrawal treatment. Our assessment protocol included the administration of the ADHD Self-Report Scale (ADHD-SR) and the Wender Utah Rating Scale (WURS-k). Additionally, participants who met the thresholds on one or both questionnaires underwent further evaluation using the Diagnostic Interview for ADHD in Adults (DIVA-2.0). Results: The prevalence of individuals diagnosed with ADHD within the studied cohort was determined to be 29.3%. Among the subset of participants identified as ADHD-positive, a notable 54.5% prematurely ceased therapy. In contrast, among those identified as ADHD-negative, the premature discontinuation rate was substantially lower at 28.3%. Conclusions: In summary, the impact of ADHD as a comorbid condition on the efficacy of inpatient opioid withdrawal treatment has been underscored. By identifying comorbid ADHD early in the treatment process, tailored therapeutic approaches may help to maximize the effectiveness of interventions and may improve patient outcomes. This underscores the importance of proactive screening for ADHD as a psychiatric comorbidity in optimizing the management of individuals undergoing inpatient opioid withdrawal treatment.

The Association Between ADHD in Adolescence and Injury in Early Adulthood in Israel: A Nationwide Historical Cohort Study

OBJECTIVE

To examine the association between late adolescence ADHD and the risk of serious injury in early adulthood.

METHOD

A nationwide cohort study utilizing data from the Military Health Examinations Database for potential military recruits (age 16.5-18 years), cross-referenced with the Israeli National Trauma Registry (2008-2020). Individuals with and without ADHD (mild/severe) were compared for early adulthood injury risk using Cox models.

RESULTS

This study compared 76,403 participants with mild ADHD (18.76%) and 330,792 without (81.24%), alongside 2,835 severe ADHD participants (1.11%) versus 252,626 without (98.89%). Adjusted hazard ratios for injury-related hospitalization were 1.27 (95% CI [1.17, 1.37]) for mild ADHD and 1.40 (95% CI [1.09, 1.79]) for severe ADHD, compared to non-ADHD.

CONCLUSIONS

Adolescents with ADHD, regardless of severity, had a significantly higher risk of hospitalization due to injury that persists into early adulthood, underscoring the importance of recognizing ADHD as an injury risk and incorporating it into injury prevention strategies.

[Effect of Emotion Regulation on Anxiety/Depression Symptoms in Children With Attention-Deficit/Hyperactivity Disorder: The Mediating Role of Social Problems and the Moderating Role of Family Functioning]

Objective

To investigate the mediating effect of social problems in the effect pathway of emotional dysregulation influencing anxiety/depression emotions in children with attention-deficit/hyperactivity disorder (ADHD) and to explore the potential moderating effect of family functionality.

Methods

A total of 235 children diagnosed with ADHD were enrolled in the study. The paticipants' age ranged from 6 to 12. Emotion Regulation Checklist, Achenbach's Child Behavior Checklist (CBCL) Social Problems Subscale, CBCL Anxious/Depressed Subscale, and Family Assessment Device were used to evaluate the emotional regulation, social problems, anxiety/depression emotions, and family functionality of the participants. A moderated mediation model was employed to analyze whether social problems and family functionality mediate and moderate the relationship between emotional regulation and anxiety/depression emotions.

Results

Social problems partially mediated the impact of emotional dysregulation on anxiety/depression emotions in ADHD children, with the direct effect being 0.26 (95% confidence interval [CI]: [0.17, 0.36], P<0.001), the indirect effect being 0.13 (95% CI: [0.07, 0.19], P<0.001), and the mediating effect accounting for 33% of the total effect. Family functionality exhibited a positive moderating effect on the relationship between social problems and anxiety/depression emotions.

Conclusion

This study contributes to the understanding of complex factors influencing anxiety/depression in children with ADHD, providing reference for the further development of targeted interventions for children with ADHD and the improvement of prognosis.

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.

Adherence, frequency, and long-term follow-up of video game-based treatments in patients with attention-deficit/hyperactivity disorder: A systematic review

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder in children and adolescents. Recent studies show that video games have great potential for the treatment and rehabilitation of ADHD patients. The aim of the present review is to systematically review the scientific literature on the relationship between video games and ADHD, focusing on adherence to treatment, frequency of the intervention, and the long-term follow-up of video games in children and adolescents with ADHD.

METHODS

The preferred reporting items for systematic reviews and meta-analyses guidelines were adopted. The review protocol was registered in PROSPERO database. We searched in three databases, PubMed, Medline, and Web of Science to identify studies examining the association between video game interventions in ADHD patients.

RESULTS

A total of 18 empirical studies met the established inclusion criteria. The results showed that video games-based interventions can be used to improve ADHD symptoms and display high adherence to treatment. In addition, in the studies reviewed, the most common intervention frequency is 30 min three to five times per week. However, there is little evidence from studies with video games showing long-term effects in patients with ADHD.

CONCLUSION

Video games are useful and effective interventions that can complement traditional treatments in patients with ADHD.

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.

Attention deficit hyperactivity and oppositional defiant disorder symptoms in adolescence and risk of substance use disorders-A general population-based birth cohort study

BACKGROUND

Externalizing symptoms are associated with risk of future substance use disorder (SUD). Few longitudinal studies exist using general population-based samples which assess the spectrum of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms.

AIMS/OBJECTIVES

We aimed to study the associations between adolescent ADHD symptoms and subsequent SUD and additionally examine whether the risk of SUD is influenced by comorbid oppositional defiant disorder (ODD) symptoms.

METHODS

The Northern Finland Birth Cohort 1986 was linked to nationwide health care register data for incident SUD diagnoses until age 33 years (n = 6278, 49.5% male). ADHD/ODD-case status at age 16 years was defined using parent-rated ADHD indicated by Strengths and Weaknesses of ADHD symptoms and Normal Behaviors (SWAN) questionnaire with 95% percentile cut-off. To assess the impact of ODD comorbidity on SUD risk, participants were categorized into four groups based on their ADHD/ODD case status. Cox-regression analysis with hazard ratios (HRs) and 95% confidence intervals (CIs) were used to study associations between adolescent ADHD/ODD case statuses and subsequent SUD.

RESULTS

In all, 552 participants (8.8%) presented with ADHD case status at the age of 16 years, and 154/6278 (2.5%) were diagnosed with SUD during the follow-up. ADHD case status was associated with SUD during the follow-up (HR = 3.84, 95% CI 2.69-5.50). After adjustments for sex, family structure, and parental psychiatric disorder and early substance use the association with ADHD case status and SUD remained statistically significant (HR = 2.60, 95% CI 1.70-3.98). The risk of SUD remained elevated in individuals with ADHD case status irrespective of ODD symptoms.

CONCLUSIONS

ADHD in adolescence was associated with incident SUD in those with and without symptoms of ODD. The association of ADHD and SUD persisted even after adjustment for a wide range of potential confounds. This emphasizes the need to identify preventative strategies for adolescents with ADHD so as to improve health outcomes.

Machine learning in attention-deficit/hyperactivity disorder: new approaches toward understanding the neural mechanisms

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent and heterogeneous neurodevelopmental disorder in children and has a high chance of persisting in adulthood. The development of individualized, efficient, and reliable treatment strategies is limited by the lack of understanding of the underlying neural mechanisms. Diverging and inconsistent findings from existing studies suggest that ADHD may be simultaneously associated with multivariate factors across cognitive, genetic, and biological domains. Machine learning algorithms are more capable of detecting complex interactions between multiple variables than conventional statistical methods. Here we present a narrative review of the existing machine learning studies that have contributed to understanding mechanisms underlying ADHD with a focus on behavioral and neurocognitive problems, neurobiological measures including genetic data, structural magnetic resonance imaging (MRI), task-based and resting-state functional MRI (fMRI), electroencephalogram, and functional near-infrared spectroscopy, and prevention and treatment strategies. Implications of machine learning models in ADHD research are discussed. Although increasing evidence suggests that machine learning has potential in studying ADHD, extra precautions are still required when designing machine learning strategies considering the limitations of interpretability and generalization.

Meta-analysis of the efficacy of digital therapies in children with attention-deficit hyperactivity disorder

Background

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that commonly occurs in childhood. The aim of this meta-analysis was to summarize the available evidence for the efficacy of digital therapeutics in children and adolescents with ADHD.

Methods

We searched the MEDLINE, EMBASE, Cochrane Library (Cochrane Database of Systematic Reviews), and Web of Science (science and social science citation index) databases for relevant studies and used Stata 15.0 software to carry out the meta-analysis.

Results

A total of 31 studies involving 2169 participants (1665 boys and 504 girls) aged 4-17 years old were included in the final analysis. The meta-analysis results showed that digital interventions improved the symptoms of inattention with an effect value of -0.20 (95% confidence interval [CI] -0.36, -0.04) and decreased the continuous performance task (CPT) reaction time (effect, -0.40, 95% CI -0.73, -0.07) in ADHD patients. The score for impulsive hyperactivity was slightly decreased (effect, -0.07, 95% CI -0.23, 0.09). Moreover, executive function was improved (effect, 0.71, 95% CI 0.37, 1.04). The capability of working memory appeared to be increased (effect, 0.48, 95% CI 0.21, 0.76) between the two groups. Visual appraisal of the sensitivity analysis suggested the absence of heterogeneity, and no obvious publication bias was detected.

Discussion

Based on the existing literature evidence, we conclude that digital therapy can be a promising therapeutic strategy for ADHD patients.

Characteristics and outcomes of cases with methylphenidate abuse, dependence or withdrawal: an analysis of spontaneous reports in EudraVigilance

Methylphenidate (MPH) is a central nervous stimulant, which is mainly used in attention deficit hyperactivity disorder (ADHD) and narcolepsy. In recent years, rising MPH prescription volumes have drawn attention to possible misuse. We analyzed data on suspected MPH abuse, dependence or withdrawal reported to the EudraVigilance database (1996-2019), comparing case characteristics (e.g. age, indications and outcome). In 1531 cases from 35 countries (median: 29 years, 57.6% male), 42.3% had been diagnosed with ADHD and 8.0% with narcolepsy. Narcolepsy cases were older than ADHD cases (mean age: 47 vs. 22 years), and used co-medications more frequently (79.4 vs. 47.8%). Intravenous MPH administration was most common among individuals not diagnosed with ADHD or narcolepsy. A history of abuse, dependence or withdrawal of any substance was more often documented in fatal than in nonfatal cases (49.0 vs. 22.5%), whereas differences regarding the route of administration were less pronounced. Minors, who presumably received MPH for ADHD treatment, presented less frequently with serious outcomes than older cases or those without an approved indication. Prescribers should exercise caution in adult MPH users and should make a thorough co-medication assessment. Finally, more research on substance abuse in narcolepsy patients is required, which should include comorbidities and co-medication.

ADHD genetic burden associates with older epigenetic age: mediating roles of education, behavioral and sociodemographic factors among older adults

BACKGROUND

Shortened lifespans are associated with having Attention Deficit Hyperactivity Disorder (ADHD), which is likely mediated by related behavioral and sociodemographic factors that are also associated with accelerated physiological aging. Such factors include exhibiting more depressive symptoms, more cigarette smoking, higher body mass index, lower educational attainment, lower income in adulthood, and more challenges with cognitive processes compared to the general population. A higher polygenic score for ADHD (ADHD-PGS) is associated with having more characteristic features of ADHD. The degree to which (1) the ADHD-PGS associates with an epigenetic biomarker developed to predict accelerated aging and earlier mortality is unknown, as are whether (2) an association would be mediated by behavioral and sociodemographic correlates of ADHD, or (3) an association would be mediated first by educational attainment, then by behavioral and sociodemographic correlates. We evaluated these relationships in a population-based sample from the US Health and Retirement Study, among N = 2311 adults age 50 and older, of European-ancestry, with blood-based epigenetic and genetic data. The ADHD-PGS was calculated from a prior genomewide meta-analysis. Epigenome-wide DNA methylation levels that index biological aging and earlier age of mortality were quantified by a blood-based biomarker called GrimAge. We used a structural equation modeling approach to test associations with single and multi-mediation effects of behavioral and contextual indicators on GrimAge, adjusted for covariates.

RESULTS

The ADHD-PGS was significantly and directly associated with GrimAge when adjusting for covariates. In single mediation models, the effect of the ADHD-PGS on GrimAge was partially mediated via smoking, depressive symptoms, and education. In multi-mediation models, the effect of the ADHD-PGS on GrimAge was mediated first through education, then smoking, depressive symptoms, BMI, and income.

CONCLUSIONS

Findings have implications for geroscience research in elucidating lifecourse pathways through which ADHD genetic burden and symptoms can alter risks for accelerated aging and shortened lifespans, when indexed by an epigenetic biomarker. More education appears to play a central role in attenuating negative effects on epigenetic aging from behavioral and sociodemographic risk factors related to ADHD. We discuss implications for the potential behavioral and sociodemographic mediators that may attenuate negative biological system effects.

Challenges of Treating ADHD with Comorbid Substance Use Disorder: Considerations for the Clinician

Adults with attention deficit/hyperactivity disorder (ADHD) often present psychiatric comorbidities and, in particular, substance use disorder (SUD). ADHD-SUD comorbidity is characterized by greater severity of both disorders, earlier age of onset, higher likelihood of polydrug-abuse and suicidal behaviors, more hospitalizations, and lower treatment adherence. At the present stage, research focused on the pharmacological management of ADHD with comorbid SUD in both adolescents and adults is still lacking. Furthermore, while the short-term effects of stimulants are well studied, less is known about the chronic effects of these drugs on dopamine signaling. Current available evidence is consistent in reporting that high doses of stimulant medications in ADHD-SUD subjects have a mild to moderate efficacy on ADHD symptoms. Some data suggest that pharmacological treatment with stimulants may be beneficial for both ADHD symptoms and comorbid cocaine or amphetamine use. However, in the long run, stimulant medications may have a potential risk for misuse. For the absence of potential misuse, atomoxetine is often recommended for ADHD with comorbid cocaine or amphetamine use disorder. However, its efficacy in reducing addictive behavior is not demonstrated. In subjects with other subtypes of SUD, both atomoxetine and stimulant drugs seem to have scarce impact on addictive behavior, despite the improvement in ADHD symptomatology. In this population, ADHD treatment should be combined with SUD-specific strategies.

Identification and treatment of individuals with attention-deficit/hyperactivity disorder and substance use disorder: An expert consensus statement

Attention-deficit/hyperactivity disorder (ADHD) often co-occurs with substance use (SU) and/or substance use disorder (SUD). Individuals with concurrent ADHD and SU/SUD can have complex presentations that may complicate diagnosis and treatment. This can be further complicated by the context in which services are delivered. Also, when working with young people and adults with co-existing ADHD and SU/SUD, there is uncertainty among healthcare practitioners on how best to meet their needs. In February 2022, the United Kingdom ADHD Partnership hosted a meeting attended by multidisciplinary experts to address these issues. Following presentations providing attendees with an overview of the literature, group discussions were held synthesizing research evidence and clinical experience. Topics included: (1) A review of substances and reasons for use/misuse; (2) identification, assessment and treatment of illicit SU/SUD in young people and adults with ADHD presenting in community services; and (3) identification, assessment and treatment of ADHD in adults presenting in SU/SUD community and inpatient services. Dis-cussions highlighted inter-service barriers and fragmentation of care. It was concluded that a multimodal and multi-agency approach is needed. The consensus group generated a table of practice recommendations providing guidance on: identification and assessment; pharmacological and psychological treatment; and multi-agency interventions.

Functional Impairments Associated With ADHD in Adulthood and the Impact of Pharmacological Treatment

OBJECTIVE

Among untreated adults, functional impairments associated with ADHD are widespread and cumulative, and can include social, educational, and professional impairments, increased risk of accidents and mortality, and reduced quality of life. Here, we review the most prominent functional impairments in adults with ADHD and summarize evidence describing the potential role of medication in improving outcomes.

METHOD

Articles related to the search terms "ADHD," "adult," and functional impairments were identified through Google Scholar and PubMed and selected for inclusion based on four criteria: strength of evidence, relevance to current challenges in adult ADHD, impact on the field, and recency of the results.

RESULTS

We identified 179 papers to support the conclusions on the relationship between ADHD and functional impairments, and the impact of pharmacological therapy on functional impairments.

CONCLUSION

This narrative review provides evidence that pharmacological treatment can be effective in minimizing not only the symptoms of ADHD, but its functional consequences as well.

The Winding Road to Equal Care: Attitudes and Experiences of Prescribing ADHD Medication among Pediatric Psychiatrists: A Qualitative Study

Evidence is lacking on how to understand the reasons for variations, both in prevalence of ADHD and ADHD medication prescribing patterns in children and adolescents, within Region Skåne. These variations are not in line with current national clinical guidelines and seem to have increased over time. This qualitative interview study illuminates pediatric psychiatrists' attitudes toward ADHD and their experiences of prescribing ADHD medication. Eleven pediatric psychiatrists described the complex interplay of variables that they experienced while assessing a child, which had influence on their decision to prescribe medication. Being part of a local unit's culture influenced how ADHD medications were prescribed. They wished that the assessment of the child's symptoms was consistent with guidelines in every unit but noted that such alignment was not implemented. They pointed out that an ADHD diagnosis is dependent on the surrounding's motivation and capacity to adapt to the present state of the child. The participants described how they balanced clinical guidelines with demands from the family, as well as from society at large. Their personal attitudes and clinical experiences towards diagnosing and prescribing medications to children with ADHD influenced their decisions. The study adds information about how attitudes may lead to variation in diagnostics and therapy.

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.

Questionnaire-based computational screening of adult ADHD

BACKGROUND

ADHD is classically seen as a childhood disease, although it persists in one out of two cases in adults. The diagnosis is based on a long and multidisciplinary process, involving different health professionals, leading to an under-diagnosis of adult ADHD individuals. We therefore present a psychometric screening scale for the identification of adult ADHD which could be used both in clinical and experimental settings.

METHOD

We designed the scale from the DSM-5 and administered it to n = 110 control individuals and n = 110 ADHD individuals. The number of items was reduced using multiple regression procedures. We then performed factorial analyses and a machine learning assessment of the predictive power of the scale in comparison with other clinical scales measuring common ADHD comorbidities.

RESULTS

Internal consistency coefficients were calculated satisfactorily for TRAQ10, with Cronbach's alpha measured at .9. The 2-factor model tested was confirmed, a high correlation between the items and their belonging factor. Finally, a machine-learning analysis showed that classification algorithms could identify subjects' group membership with high accuracy, statistically superior to the performances obtained using comorbidity scales.

CONCLUSIONS

The scale showed sufficient performance for its use in clinical and experimental settings for hypothesis testing or screening purpose, although its generalizability is limited by the age and gender biases present in the data analyzed.

Alcohol Misuse among English Youth, Are Harms Attributable to Alcohol or to Underlying Disinhibitory Characteristics?

INTRODUCTION

Alcohol use by young people is associated with a range of psychological and physical harms. However, similar harms are also reported with disinhibitory conditions such as conduct problems that are said to precede and predispose to alcohol misuse. We explored whether alcohol use or indicators of underlying disinhibition predict psychological and physical harms in a cohort of young people.

METHODS

We used data from a randomised controlled intervention trial that identified young people who consumed alcohol (n = 756), mean age = 15.6 years, attending emergency departments (EDs) in England. Disinhibition was measured by the self-report Strengths and Difficulties Questionnaire hyperactivity and conduct problem items, and alcohol-related harms by questions from the ESPAD, a major European school survey. We conducted a mediation analysis with a primary outcome of frequency of engaging in alcohol-related harms 12 months after screening in ED, exploring for the mediating influence of alcohol consumed at six months. We included age, gender, allocated group and baseline consumption as covariates and adjusted for the multi-level nature of the study, where young people were nested within EDs.

RESULTS

Conduct problems and to a lesser extent hyperactivity predicted harms at twelve months. This effect was not mediated by alcohol consumed at 6 months.

CONCLUSIONS

Among young drinkers underlying behavioural attributes predict harm independently of alcohol use. This suggests that the harms associated with alcohol use are attributable more to underlying disinhibitory characteristics than the quantity of alcohol consumed.

Sex Differences in Substance Use, Prevalence, Pharmacological Therapy, and Mental Health in Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD)

Sex differences are poorly studied within the field of mental health, even though there is evidence of disparities (with respect to brain anatomy, activation patterns, and neurochemistry, etc.) that can significantly influence the etiology and course of mental disorders. The objective of this work was to review sex differences in adolescents (aged 13–18 years) diagnosed with ADHD (according to the DSM-IV, DSM-IV-TR and DSM-5 criteria) in terms of substance use disorder (SUD), prevalence, pharmacological therapy and mental health. We searched three academic databases (PubMed, Web of Science, and Scopus) and performed a narrative review of a total of 21 articles. The main conclusions of this research were (1) girls with ADHD are more at risk of substance use than boys, although there was no consensus on the prevalence of dual disorders; (2) girls are less frequently treated because of underdiagnosis and because they are more often inattentive and thereby show less disruptive behavior; (3) together with increased impairment in cognitive and executive functioning in girls, the aforementioned could be related to greater substance use and poorer functioning, especially in terms of more self-injurious behavior; and (4) early diagnosis and treatment of ADHD, especially in adolescent girls, is essential to prevent early substance use, the development of SUD, and suicidal behavior.

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.

Differences in alcohol and cannabis use amongst substance use disorder patients with and without comorbid attention-deficit/hyperactivity disorder

Background

Substance use disorders (SUDs) continue to be a public health problem. Attention-deficit/hyperactivity disorder (ADHD) is seen as a risk factor for SUD. Prevalence of alcohol and cannabis use amongst adults with SUD and comorbid ADHD impacts both disorders cognitively and behaviourally.

Aim

Our study aimed to compare alcohol and cannabis use between treatment-seeking SUD patients with ADHD and SUD patients without ADHD symptomatology.

Setting

Various rehabilitation centres, including the South African National Council on Alcoholism and Drug Dependence (SANCA) Centres, and Private and Provincial Government Substance Abuse Treatment Centres.

Methods

A cross-sectional study of adults on drug rehabilitation was conducted. Data on socio-demographic information and alcohol and cannabis use from 185 post-detox inpatients were collected. Diagnoses were based on DSM-IV criteria. Attention-deficit/hyperactivity disorder diagnosis was confirmed by the Diagnostic-Interview for ADHD in Adults (DIVA 2.0). SUD+ADHD (n = 52) and SUD-ADHD (n = 128) groups were compared on alcohol and cannabis use as a function of gender.

Results

No significant differences in the use of alcohol between the SUD+ADHD and SUD-ADHD groups were found. However, the SUD+ADHD group showed increased cannabis consumption. Especially, the SUD+ADHD females showed an earlier age of onset of cannabis use than the SUD-ADHD females and revealed that they use cannabis for a longer period compared with the SUD-ADHD females and SUD+ADHD and SUD-ADHD males.

Conclusion

The results revealed the relationship between ADHD and cannabis use, especially amongst females with ADHD and reinforce the need to consider ADHD in cannabis use SUD in clinical interventions.

Sensitization-based risk for substance abuse in vulnerable individuals with ADHD: Review and re-examination of evidence

Evidence of sensitization following stimulants administration in humans is just emerging, which prevents reaching more definitive conclusions in favor or against a purported protective role of stimulant treatments for ADHD for the development of substance use disorders. Existing evidence from both animal and human research suggest that stimulants produce neurophysiological changes in the brain reward system, some of which could be persistent. This could be relevant in choosing optimal treatments for young patients with ADHD who have additional clinical risk factors for substance abuse (e.g. conduct disorder (CD) and/or familial addictions). Here we stipulate that, while the majority of youth with ADHD greatly benefit from treatments with stimulants, there might be a subpopulation of individuals whose neurobiological profiles may confer risk for heightened vulnerability to the effects of stimulants on the responsiveness of the brain reward system. We propose that focused human research is needed to elucidate the unknown effects of prolonged stimulant exposure on the neurophysiology of the brain reward system in young patients with ADHD.

The lived experiences of adults with attention-deficit/hyperactivity disorder: A rapid review of qualitative evidence

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that frequently persists into adulthood, although research and diagnostic criteria are focused on how the condition presents in children. We aimed to review qualitative research on lived experiences of adults with ADHD to characterize potential ADHD symptomatology in adulthood and provide perspectives on how needs might be better met. We searched three databases for qualitative studies on ADHD. Studies (n = 35) in English that included data on the lived experiences of adults with ADHD were included. These studies covered experiences of receiving a diagnosis as an adult, symptomatology of adult ADHD, skills used to adapt to these symptoms, relationships between ADHD and substance use, patients' self-perceptions, and participants' experiences interacting with society. Many of the ADHD symptoms reported in these studies had overlap with other psychiatric conditions and may contribute to misdiagnosis and delays in diagnosis. Understanding symptomatology of ADHD in adults may inform future diagnostic criteria and guide interventions to improve quality of life.

Video games for the assessment and treatment of attention-deficit/hyperactivity disorder: a systematic review

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and serious disorder among children. Video games have shown potential for aiding in child healthcare. Video games could contribute to the assessment and management of ADHD, but there are no previous reviews on this topic. Here, we systematically review the evidence about video game-based assessment tools and interventions for children diagnosed with ADHD. This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered in PROSPERO database. We searched four databases-PubMed, PsycInfo, Embase and clinicaltrials.gov-to identify original studies exploring either video game-based interventions or video game-based assessment tools in children with ADHD. After initial screening, full text revision and study selection, 22 articles were finally included in the review. Most studies used PC as platform, with a minority using a video console, pad, or 3D device. Video game-based assessment tools were generally effective in discriminating ADHD cases from controls, and in discriminating between ADHD subtypes. Video game-based therapeutic interventions were well accepted and generally effective in improving cognitive areas and decreasing ADHD symptoms. Gamification and cognitive training could be the main mechanisms underlying the usefulness and effectiveness of video game-based assessment tools and interventions. Software optimization and greater collaboration between developers and healthcare professionals are some of the priorities for future research in this area.

Treatment of Adolescents with Concurrent Substance Use Disorder and Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Childhood attention-deficit/hyperactivity disorder (ADHD) is a risk factor for the development of substance abuse and substance use disorders (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment, and is associated with poor treatment outcomes. In this study, we provide a systematic review of controlled studies on the effectiveness of pharmacological, psychosocial, and complementary treatments of ADHD in adolescents with and without comorbid SUD. In addition, we review the longitudinal association between pharmacotherapy for childhood ADHD and the development of SUD in adolescence and early adulthood. We conducted a systematic review of the research literature published since 2000 using Medline, PsycINFO, and the Cochrane Database of Systematic Reviews databases to select randomized clinical trials, observational studies, and meta-analyses. The quality of the evidence from each study was rated using the SIGN grading system. Based on the limited evidence available, strong clinical recommendations are not justified, but provisionally, we conclude that stimulant treatment in children with ADHD may prevent the development of SUD in adolescence or young adulthood, that high-dose stimulant treatment could be an effective treatment for adolescents with ADHD and SUD comorbidity, that cognitive behavior therapy might have a small beneficial effect in these patients, and that alternative treatments are probably not effective. More studies are needed to draw definitive conclusions that will allow for strong clinical recommendations.

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.

Emotions or attention – what are predictors for the development of childhood psychopathology? A longitudinal study with pre- and elementary school children

Current debate has identified the factors emotion knowledge (EK) and attention as specific trajectories longitudinally influencing psychopathological development in childhood. The “Emotion Knowledge Hypothesis” assumes that children with great emotion skills have high self-regulating abilities that result in lower cognitive load and stronger attention capacities. Attention problems are thus perceived as a consequence of reduced EK. According to the competing “Attention Effect Hypothesis”, attention problems and EK deficits are associated because of impaired learning capacities due to attention problems. According to this hypothesis, attention problems are predictive of impaired EK. If those specific trajectories are disrupted, this might attenuate the development of later behavior problems. The present study tests those competing hypotheses replicating previous studies in this field to shed light on potential psychopathology trajectories. A total of 136 pre- and elementary school children as well as their teachers participated in this study. Children’s symptoms of inattention as well as their emotional competences were assessed 3 times over a 12-month period. We applied multilevel structural equation modelling and cross-lagged panel models for data analysis. Overall, we noted a drop in inattention scores and rise in emotional competences over the one-year course, indicating maturation effects. There was a significant but very small effect for attention scores predicting emotional competences. With respect to the question whether interventions should focus on the “Emotion Knowledge” or “Attention Effect” hypothesis, our findings imply that none of them has superiority over the other. Therefore, both emotion knowledge and attention are crucial for development, and that children with deficits in either domain should receive targeted interventions in order to disrupt potentially harmful developmental pathways.

Prevalence of criminal convictions in Norwegian adult ADHD outpatients and associations with ADHD symptom severity and emotional dysregulation

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) often co-occurs with antisocial behaviour. Several studies have shown high rates of ADHD among prisoners. However, the prevalence of crime among individuals with ADHD is less known. The aim of the present study was to estimate the prevalence of lifetime criminal conviction (CC) in a clinical sample of adults with ADHD, and the associations with the severity of ADHD and emotional dysregulation (ED).

METHODS

Patients were admitted to a private psychiatric outpatient clinic in Oslo between 2014 and 2018. Of the 656 patients diagnosed with ADHD, 629 (95.9%) agreed to participate in the study. CC was determined based on self-reporting of the lifetime history of criminal behaviour. ADHD was diagnosed according to the DSM-5 criteria, and ADHD severity was measured using the Adult ADHD Self-Report Scale (ASRS). ED was assessed by the eight-item version of Barkley's Current Behaviour Scale - Self-Report (CBS-SR).

RESULTS

The prevalence of self-reported CC in this clinical sample was 11.7% among women and 24.5% among men. CC was associated with hyperactive-impulsive severity (p < 0.001) and ED (p = 0.006).

CONCLUSIONS

The prevalence of self-reported lifetime criminal conviction was high for both genders. CC was associated with symptom severity of hyperactivity-impulsivity and emotional dysregulation. The findings suggest the need for greater research efforts on the avoidance of criminal activity in people with ADHD and targeted intervention for ADHD treatment and CC prevention.

Perceived social support in children and adolescents with ADHD

BACKGROUND

Social support is crucial to healthy development, serving as an important protective factor.

AIMS

This study is the first to evaluate the psychometric properties of the German version of the Child and Adolescent Social Support Scale (CASSS). We further investigated differences between children and adolescents with and without ADHD.

METHODS

Our total sample of N = 525 consisted of clinical participants diagnosed with ADHD (28.8 %) and healthy controls (71.2 %). We investigated item properties, factorial validity and reliability of the CASSS and performed a group comparison between patients with ADHD and healthy controls.

RESULTS

Factor analyses confirmed a four-factor structure corresponding to different sources of social support. All scales showed very good internal consistency. Results revealed that patients with ADHD perceived less overall support compared to the healthy controls.

CONCLUSIONS

The German version of the CASSS is a reliable and valid instrument for the assessment of perceived social support in children and adolescents. As children with ADHD perceived less social support in comparison to healthy controls, the identification and promotion of social skills should be an integral part of the treatment of ADHD.

Evidence for similar structural brain anomalies in youth and adult attention-deficit/hyperactivity disorder: a machine learning analysis

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children world-wide. Of these, two-thirds continue to have impairing symptoms of ADHD into adulthood. Although a large literature implicates structural brain differences of the disorder, it is not clear if adults with ADHD have similar neuroanatomical differences as those seen in children with recent reports from the large ENIGMA-ADHD consortium finding structural differences for children but not for adults. This paper uses deep learning neural network classification models to determine if there are neuroanatomical changes in the brains of children with ADHD that are also observed for adult ADHD, and vice versa. We found that structural MRI data can significantly separate ADHD from control participants for both children and adults. Consistent with the prior reports from ENIGMA-ADHD, prediction performance and effect sizes were better for the child than the adult samples. The model trained on adult samples significantly predicted ADHD in the child sample, suggesting that our model learned anatomical features that are common to ADHD in childhood and adulthood. These results support the continuity of ADHD's brain differences from childhood to adulthood. In addition, our work demonstrates a novel use of neural network classification models to test hypotheses about developmental continuity.

Causal modelling of variation in clinical practice and long-term outcomes of ADHD using Norwegian registry data: the ADHD controversy project

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is among the most common mental disorders in children and adolescents, and it is a strong risk factor for several adverse psychosocial outcomes over the lifespan. There are large between-country and within-country variations in diagnosis and medication rates. Due to ethical and practical considerations, a few studies have examined the effects of receiving a diagnosis, and there is a lack of research on effects of medication on long-term outcomes.Our project has four aims organised in four work packages: (WP1) To examine the prognosis of ADHD (with and without medication) compared with patients with other psychiatric diagnoses, patients in contact with public sector child and adolescent psychiatric outpatient clinics (without diagnosis) and the general population; (WP2) Examine within-country variation in ADHD diagnoses and medication rates by clinics' catchment area; and(WP3) Identify causal effects of being diagnosed with ADHD and (WP4) ADHD medication on long-term outcomes.

METHOD AND ANALYSIS

Our project links several nationwide Norwegian registries. The patient sample is all persons aged 5-18 years that were in contact with public sector child and adolescent psychiatric outpatient clinics in 2009-2011. Our comparative analysis of prognosis will be based on survival analysis and mixed-effects models. Our analysis of variation will apply mixed-effects models and generalised linear models. We have two identification strategies for the effect of being diagnosed with ADHD and of receiving medication on long-term outcomes. Both strategies rely on using preference-based instrumental variables, which in our project are based on provider preferences for ADHD diagnosis and medication.

ETHICS AND DISSEMINATION

The project is approved by the Regional Ethics Committee, Norway (REC number 2017/2150/REC south-east D). All papers will be published in open-access journals and results will be presented in national and international conferences.

TRIAL REGISTRATION NUMBERS

ISRCTN11573246 and ISRCTN11891971.

Assessment and treatment of substance use in adults with ADHD: a psychological approach

Over half of young people and adults diagnosed with Attention Deficit Hyperactivity Disorder [ADHD] also have substance use disorder [SUD]. Their use of substances may arise from an attempt to self-medicate and/or to cope with their difficulties. This manuscript reviews key research in the literature and identifies that traditional SUD psychological interventions are an effective treatment for those presenting with a dual diagnosis of ADHD and SUD. However, typically, this is only available to those presenting to specialist SUD services for treatment of harmful use and/or dependency. This misses an opportunity to intervene much earlier, before drug use escalates to these levels. The manuscript aims to provide practical guidance for healthcare practitioners, by detailing a psychological framework for earlier assessment and intervention of problematic drug use in young people and adults with ADHD. Specific techniques are outlined drawing on psychoeducation, motivational interviewing and cognitive behavioural therapy in a phased approach to address factors that motivate initial use of substances and those that maintain use.

Trajectories of healthcare utilization and costs of psychiatric and somatic multimorbidity in adults with childhood ADHD: a prospective register-based study

BACKGROUND

A better understanding of the trajectories and economic burden of psychiatric and somatic disorders (multimorbidity) in ADHD from childhood to adulthood is important for guiding more targeted areas for treatment of ADHD and prevention of multimorbidity, and for forecasting demands on the medical infrastructure. This study aimed to investigate patterns of healthcare utilization and costs of multimorbidity across young adulthood in individuals with a childhood ADHD diagnosis, and additionally in individuals who continue to have ADHD-related contact with health services (persisters) and those who do not (remitters).

METHODS

We prospectively followed a cohort (N = 445,790) born 1987-1990 from the ages of 18 to 26 years. Data on healthcare utilization were obtained from the Swedish National Patient Register (inpatient and outpatient care) and the Prescribed Drug Register (medication prescriptions).

RESULTS

Mean annual costs per capita from multimorbidity was €890 ($1,223) in individuals with a childhood ADHD diagnosis (persisters/remitters: €1,060[$1,456]/€609[$837]) and €304 ($418) in individuals without. Costs were largely driven by inpatient hospital admissions, mainly from drug abuse and injuries. Healthcare utilization and costs of psychiatric and somatic disorders at 18 years was significantly higher in individuals with childhood ADHD compared to those without. These group differences remained stable or increased across young adulthood for most outcomes and were generally larger in women than in men. ADHD remitters continued to show significantly greater healthcare utilization and costs compared to individuals without childhood ADHD, although their profiles were not as severe as ADHD persisters.

CONCLUSIONS

Childhood ADHD has long-term associations with both psychiatric and somatic disorders. Findings demonstrate the individual and societal burden of ADHD in adulthood and highlight the importance of continued support from childhood-adolescent to adult health services and early prevention of multimorbidity. Findings also point to specific targets for intervention that may be effective, such as drug abuse and injuries.

Genetic liability to ADHD and substance use disorders in individuals with ADHD

AIMS

1) To investigate whether genetic liability to attention-deficit/hyperactivity disorder (ADHD), indexed by polygenic risk scores for ADHD (PRS-ADHD), is associated with substance use disorders (SUD) in individuals with ADHD. 2) To investigate whether other individual- or family-related risk factors for SUD could mediate or confound this association.

DESIGN

Population-based cohort study SETTING AND PARTICIPANTS: ADHD cases in the iPSYCH sample (a Danish case-cohort sample of genotyped cases with specific mental disorders), born in Denmark between 1981 and 2003 (N = 13 116). Register-based information on hospital diagnoses of SUD was available until December 31, 2016.

MEASUREMENTS

We estimated odds ratios (ORs) with 95% confidence intervals (CIs) for any SUD as well as for different SUD types (alcohol, cannabis, and other illicit drugs) and severities (use, abuse, and addiction), with effect sizes corresponding to a comparison of the highest PRS-ADHD decile to the lowest.

FINDINGS

PRS-ADHD were associated with any SUD (OR = 1.30, 95% CI: 1.11-1.51). Estimates were similar across different types and severity levels of SUD. Other risk factors for SUD (male sex, age at ADHD diagnosis, comorbid conduct problems, and parental factors including SUD, mental disorders, and socio-economic status) were independently associated with increased risk of SUD. PRS-ADHD explained a minor proportion of the variance in SUD (0.2% on the liability scale) compared to the other risk factors. The association between PRS-ADHD and any SUD was slightly attenuated (OR = 1.21, 95% CI: 1.03-1.41) after adjusting for the other risk factors for SUD. Furthermore, associations were nominally higher in females than in males (ORfemales  = 1.59, 95% CI: 1.19-2.12, ORmales  = 1.18, 95% CI: 0.98-1.42).

CONCLUSIONS

A higher genetic liability to attention-deficit/hyperactivity disorder appears to be associated with higher risks of substance use disorders in individuals with attention-deficit/hyperactivity disorder.

Association of Psychiatric Comorbidity With the Risk of Premature Death Among Children and Adults With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

A previous register-based study reported elevated all-cause mortality in attention-deficit/hyperactivity disorder (ADHD), but cause-specific risks and the potential associations of psychiatric comorbidities remain unknown.

OBJECTIVES

To investigate the all-cause and cause-specific mortality risks in ADHD and to explore the potential role of psychiatric comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study used Swedish national registers to identify 2 675 615 individuals born in Sweden from January 1, 1983, through December 31, 2009, as the study population, among whom 86 670 individuals (3.2%) received a diagnosis of ADHD during follow-up. Follow-up was completed December 31, 2013, and data were analyzed from October 2018 through March 2019.

EXPOSURES

Attention-deficit/hyperactivity disorder identified by first clinical diagnosis or first prescription of ADHD medications as recorded in Swedish registers. Clinical diagnosis of psychiatric comorbidity was available in the National Patient Register.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortalities and hazard ratios (HRs) using Cox proportional hazards regression models.

RESULTS

In the overall cohort of 2 675 615 individuals, 1 374 790 (51.4%) were male (57 919 with an ADHD diagnosis) and 1 300 825 (48.6%) were female (28 751 with an ADHD diagnosis). Mean (SD) age at study entry was 6.4 (5.6) years. During follow-up, 424 individuals with ADHD and 6231 without ADHD died, resulting in mortality rates of 11.57 and 2.16 per 10 000 person-years, respectively. The association was stronger in adulthood (HR, 4.64; 95% CI, 4.11-5.25) compared with childhood (HR, 1.41; 95% CI, 0.97-2.04) and increased substantially with the number of psychiatric comorbidities with ADHD (HR for individuals with only ADHD, 1.41 [95% CI, 1.01-1.97]; HR for those with ≥4 comorbidities, 25.22 [95% CI, 19.60-32.46]). In adulthood, when adjusting for early-onset psychiatric comorbidity, the association between ADHD and risk of death due to natural causes was attenuated substantially and was no longer statistically significant (HR, 1.32; 95% CI, 0.94-1.85). When adjusting for later-onset psychiatric disorders, the association was attenuated to statistical nonsignificance for death due to suicide (HR, 1.13; 95% CI, 0.88-1.45) but remained statistically significant for death caused by unintentional injury (HR, 2.14; 95% CI, 1.71-2.68) or other external causes (HR, 1.75; 95% CI, 1.23-2.48).

CONCLUSIONS AND RELEVANCE

Psychiatric comorbidity appears to play an important role in all-cause and cause-specific mortality risks in ADHD. In adulthood, early-onset psychiatric comorbidity contributed primarily to the association with death due to natural causes, whereas later-onset psychiatric comorbidity mainly influenced death due to unnatural causes, including suicide and unintentional injury. These findings suggest that health care professionals should closely monitor specific psychiatric comorbidities in individuals with ADHD to identify high-risk groups for prevention efforts.

Cost effectiveness of optimal treatment of ADHD in Israel: a suggestion for national policy

OBJECTIVES

There are well known behavioral complications of ADHD at adulthood such as learning difficulties resulting in lower education attainments; increased rate of car and other accidents; substance abuse; misconduct and imprisonment. These complications can be prevented or alleviated by effective treatment. In this study we calculated the economic burden of ADHD among adults in Israel and the cost of diagnosing and treating ADHD from childhood to adulthood. We then obtained the cost-benefit ratio of the treatment.

METHODS

The data were calculated using accepted estimations of prevalence and cost for the Israeli population assuming a prevalence of 4% among adults which is based on the ADHD prevalence among school age children.

RESULTS

The estimated cost per person with ADHD due to lower education attainment, higher involvement in crime and car accidents and more drug abuse is 289,969 USD and the estimated cost for optimal treatment is 41,667 USD. Hence, the benefit cost ratio is 7.02 and, assuming only 50% success of treatment, it is 3.51, still a very high cost benefit ratio.

CONCLUSIONS

Since early diagnosis and appropriate treatment of ADHD is very effective in reducing the various symptoms and complications at adulthood thus enabling a better education and higher income, it seems important to diagnose and offer comprehensive treatment to children with ADHD. Moreover, it seems equally important to continue treatment at adulthood.

Sex differences in the intensity of cross-sensitization between methylphenidate and amphetamine in adolescent rats

Chronic use of psychostimulants such as methylphenidate (MPD) and amphetamine (Amph) leads to abuse and dependence. Cross-sensitization occurs when exposure to a drug causes a significant intensified response to a different drug as compared to the effect of the drug in subjects with no previous exposure. Cross-sensitization is used as an experimental correlate for a drug's potential to elicit dependence. The present study uses male and female adolescent rats to examine whether cross-sensitization occurs with MPD, a drug not traditionally considered to elicit dependence, and Amph, a drug considered to elicit dependence. The results showed that there is cross-sensitization with MPD to Amph in adolescent rats and that there is a significant difference in male and female responses. Cross-sensitization between MPD and Amph was observed in a linear dose dependent manner in males and in an inverted U-shape pattern in females. Males treated with the highest dose of 10.0 mg/kg MPD and females treated with the mid-dose of 2.5 mg/kg MPD showed the most robust cross-sensitization. Overall, adolescent female rodents had a greater intensity of response to MPD, Amph, and cross-sensitization between MPD and Amph. This study shows that there are significant sex differences in psychostimulant cross-sensitization in adolescence, indicating the maturity of the gonadal system is not the predominant reason for differences between male and female responses to psychostimulant drugs.

Long-term effects of stimulant exposure on cerebral blood flow response to methylphenidate and behavior in attention-deficit hyperactivity disorder

Stimulant prescription rates for attention deficit hyperactivity disorder (ADHD) are increasing, even though potential long-term effects on the developing brain have not been well-studied. A previous randomized clinical trial showed short-term age-dependent effects of stimulants on the DA system. We here assessed the long-term modifying effects of age-of-first-stimulant treatment on the human brain and behavior. 81 male adult ADHD patients were stratified into three groups: 1) early stimulant treatment (EST; <16 years of age) 2) late stimulant treatment (LST: ≥23 years of age) and 3) stimulant treatment naive (STN; no history of stimulant treatment). We used pharmacological magnetic resonance imaging (phMRI) to assess the cerebral blood flow (CBF) response to an oral methylphenidate challenge (MPH, 0.5 mg/kg), as an indirect measure of dopamine function in fronto-striatal areas. In addition, mood and anxiety scores, and recreational drug use were assessed. Baseline ACC CBF was lower in the EST than the STN group (p = 0.03), although CBF response to MPH was similar between the three groups (p = 0.23). ADHD symptom severity was higher in the STN group compared to the other groups (p < 0.01). In addition, the EST group reported more depressive symptoms (p = 0.04), but not anxiety (p = 0.26), and less recreational drug use (p = 0.04). In line with extensive pre-clinical data, our data suggest that early, but not late, stimulant treatment long-lastingly affects the human brain and behavior, possibly indicating fundamental changes in the dopamine system.

Stress, sensitive periods, and substance abuse

Research on the inter-relationship between drug abuse and social stress has primarily focused on the role of stress exposure during adulthood and more recently, adolescence. Adolescence is a time of heightened reward sensitivity, but it is also a time when earlier life experiences are expressed. Exposure to stress early in postnatal life is associated with an accelerated age of onset for drug use. Lifelong addiction is significantly greater if drug use is initiated during early adolescence. Understanding how developmental changes following stress exposure interact with sensitive periods to unfold over the course of maturation is integral to reducing their later impact on substance use. Arousal levels, gender/sex, inflammation, and the timing of stress exposure play a role in the vulnerability of these circuits. The current review focuses on how early postnatal stress impacts brain development during a sensitive period to increase externalizing and internalizing behaviors in adolescence that include social interactions (aggression; sexual activity), working memory impairment, and depression. How stress effects the developmental trajectories of brain circuits that are associated with addiction are discussed for both clinical and preclinical studies.

Discovery of the first genome-wide significant risk loci for attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a highly heritable childhood behavioral disorder affecting 5% of children and 2.5% of adults. Common genetic variants contribute substantially to ADHD susceptibility, but no variants have been robustly associated with ADHD. We report a genome-wide association meta-analysis of 20,183 individuals diagnosed with ADHD and 35,191 controls that identifies variants surpassing genome-wide significance in 12 independent loci, finding important new information about the underlying biology of ADHD. Associations are enriched in evolutionarily constrained genomic regions and loss-of-function intolerant genes and around brain-expressed regulatory marks. Analyses of three replication studies: a cohort of individuals diagnosed with ADHD, a self-reported ADHD sample and a meta-analysis of quantitative measures of ADHD symptoms in the population, support these findings while highlighting study-specific differences on genetic overlap with educational attainment. Strong concordance with GWAS of quantitative population measures of ADHD symptoms supports that clinical diagnosis of ADHD is an extreme expression of continuous heritable traits.

Discovery of the first genome-wide significant risk loci for attention deficit/hyperactivity disorder

Attention deficit/hyperactivity disorder (ADHD) is a highly heritable childhood behavioral disorder affecting 5% of children and 2.5% of adults. Common genetic variants contribute substantially to ADHD susceptibility, but no variants have been robustly associated with ADHD. We report a genome-wide association meta-analysis of 20,183 individuals diagnosed with ADHD and 35,191 controls that identifies variants surpassing genome-wide significance in 12 independent loci, finding important new information about the underlying biology of ADHD. Associations are enriched in evolutionarily constrained genomic regions and loss-of-function intolerant genes and around brain-expressed regulatory marks. Analyses of three replication studies: a cohort of individuals diagnosed with ADHD, a self-reported ADHD sample and a meta-analysis of quantitative measures of ADHD symptoms in the population, support these findings while highlighting study-specific differences on genetic overlap with educational attainment. Strong concordance with GWAS of quantitative population measures of ADHD symptoms supports that clinical diagnosis of ADHD is an extreme expression of continuous heritable traits.

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.

Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan

Attention-deficit/hyperactivity disorder (ADHD) is highly heritable and the most common neurodevelopmental disorder in childhood. In recent decades, it has been appreciated that in a substantial number of cases the disorder does not remit in puberty, but persists into adulthood. Both in childhood and adulthood, ADHD is characterised by substantial comorbidity including substance use, depression, anxiety, and accidents. However, course and symptoms of the disorder and the comorbidities may fluctuate and change over time, and even age of onset in childhood has recently been questioned. Available evidence to date is poor and largely inconsistent with regard to the predictors of persistence versus remittance. Likewise, the development of comorbid disorders cannot be foreseen early on, hampering preventive measures. These facts call for a lifespan perspective on ADHD from childhood to old age. In this selective review, we summarise current knowledge of the long-term course of ADHD, with an emphasis on clinical symptom and cognitive trajectories, treatment effects over the lifespan, and the development of comorbidities. Also, we summarise current knowledge and important unresolved issues on biological factors underlying different ADHD trajectories. We conclude that a severe lack of knowledge on lifespan aspects in ADHD still exists for nearly every aspect reviewed. We encourage large-scale research efforts to overcome those knowledge gaps through appropriately granular longitudinal studies.

Addressing Adolescents' and Young Adults' Substance Use Disorders

Adolescents and young adults (AYAs) have unique needs and important biopsychosocial differences when compared with older adults who use substances. As their brains continue to develop, youth are especially susceptible to the reinforcing effects of substances in the context of a still-developing capacity for executive control and decision making. In this article, the authors highlight key differences in the neurobiologic, epidemiologic, and relational aspects of substance use found in AYA. They also discuss how best to engage with youth who use substances and how prevention and intervention can be adapted for optimal effectiveness for this distinct and high-risk population.

Substance use through adolescence into early adulthood after childhood-diagnosed ADHD: findings from the MTA longitudinal study

BACKGROUND

Inconsistent findings exist regarding long-term substance use (SU) risk for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The observational follow-up of the Multimodal Treatment Study of Children with ADHD (MTA) provides an opportunity to assess long-term outcomes in a large, diverse sample.

METHODS

Five hundred forty-seven children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD and 258 classmates without ADHD (local normative comparison group; LNCG) completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25.

RESULTS

In adulthood, weekly marijuana use (32.8% ADHD vs. 21.3% LNCG) and daily cigarette smoking (35.9% vs. 17.5%) were more prevalent in the ADHD group than the LNCG. The cumulative record also revealed more early substance users in adolescence for ADHD (57.9%) than LNCG (41.9%), including younger first use of alcohol, cigarettes, marijuana, and illicit drugs. Alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early SU predicted quicker SU escalation and more SU in adulthood for both groups.

CONCLUSIONS

Frequent SU for young adults with childhood ADHD is accompanied by greater initial exposure at a young age and slightly faster progression. Early SU prevention and screening is critical before escalation to intractable levels.

The pharmacology of amphetamine and methylphenidate: Relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities

Psychostimulants, including amphetamines and methylphenidate, are first-line pharmacotherapies for individuals with attention-deficit/hyperactivity disorder (ADHD). This review aims to educate physicians regarding differences in pharmacology and mechanisms of action between amphetamine and methylphenidate, thus enhancing physician understanding of psychostimulants and their use in managing individuals with ADHD who may have comorbid psychiatric conditions. A systematic literature review of PubMed was conducted in April 2017, focusing on cellular- and brain system-level effects of amphetamine and methylphenidate. The primary pharmacologic effect of both amphetamine and methylphenidate is to increase central dopamine and norepinephrine activity, which impacts executive and attentional function. Amphetamine actions include dopamine and norepinephrine transporter inhibition, vesicular monoamine transporter 2 (VMAT-2) inhibition, and monoamine oxidase activity inhibition. Methylphenidate actions include dopamine and norepinephrine transporter inhibition, agonist activity at the serotonin type 1A receptor, and redistribution of the VMAT-2. There is also evidence for interactions with glutamate and opioid systems. Clinical implications of these actions in individuals with ADHD with comorbid depression, anxiety, substance use disorder, and sleep disturbances are discussed.

Is Cannabis Use Associated With the Worst Inpatient Outcomes in Attention Deficit Hyperactivity Disorder Adolescents?

Objective

To determine the impact of cannabis use disorder (CUD) on the inpatient outcomes of attention deficit hyperactivity disorder (ADHD) in adolescents

Background

Previous studies have evaluated the impact of CUD on the health-related quality of life in ADHD patients.

Methods

We used the nationwide inpatient sample (NIS) from the Healthcare Cost and Utilization Project (HCUP) from years 2010­–2014. We identified ADHD and cannabis use (CU) as the primary and the other diagnosis, respectively, using validated International Classification of Diseases, 9th Revision, and Clinical Modification (ICD­9–­CM) codes. We used the binomial logistic regression model to generate adjusted odds ratios (aOR).

Results

We analyzed a total of 11,232 ADHD adolescent hospital admissions from years 2010–2014; of these, 1.79% had CUD. The mean age of adolescents was 14.1 years (SD = 1.79). The prevalence of CUD was highest in ADHD adolescents of 15-18 years (73%) and common in the white race (71%). A higher proportion of ADHD with CUD was transferred to acute care hospitals and skilled/other nursing facilities (5.4% and 7.4% vs. 1.1% and 2.6%, respectively, p-value < 0.001). CUD increases the risk of inpatient charges > $12,247 (median) by 0.6 times (aOR = 1.835; p-value = 0.002) and increases the risk of inpatient stay > 5 days (median) by 0.7 times (aOR = 2.099; p-value < 0.001). The utilization of psychotropic medications was reduced by 0.8 times in ADHD with CUD adolescents by 0.8 times (aOR = 0.448; p-value = 0.017), and the implication of behavioral therapy in the management of ADHD with CUD adolescents was reduced by 0.9 times (aOR = 0.412; p-value = 0.048). Also, there is a 2.8 times higher risk of comorbid alcohol abuse in ADHD with CUD adolescents (aOR = 17.141; p-value < 0.001).

Conclusion

The increased risk of substance use is a long-term implication of ADHD in adolescents. It has been determined that comorbid CUD in patients with ADHD not only increases the risk of acute inpatient care but also prolongs the inpatient stay, thus increasing the healthcare cost. Surprisingly, comorbid CUD decreases the utilization of psychotropic medications and behavioral therapy in ADHD. Another major issue is the higher risk of comorbid alcohol abuse in ADHD with CUD adolescents. Further exploration with randomized controlled studies would be required to support and highlight the growing issue of cannabis use among adolescents with ADHD.