Attention-deficit/hyperactivity disorder subtypes and substance use and use disorders in NESARC
Introduction
Attention-deficit/hyperactivity disorder (ADHD), comprising of inattentive, and/or hyperactive–impulsive symptoms, is known to affect approximately 4.4% adults in the United States (Kessler et al., 2006). Substance use and substance use disorders (SUD) are prominent amongst the numerous comorbid psychopathologies related to ADHD (Biederman, 2004, Sobanski, 2006). A diagnosis of ADHD is known to significantly increase the risk of substance use or SUD independent of other psychiatric comorbidity (Wilens, Biederman, Mick, Faraone, & Spencer, 1997).
Results from large cross-sectional population-based studies on ADHD and SUD have been mixed. Glantz et al. (2009) using the National Comorbidity Survey Replication (NCS-R) reported an association between a lifetime diagnosis of ADHD and SUD. Similarly, a recent study of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) found a modest association between ADHD and SUD after controlling for psychiatric comorbidity and socio-demographic variables (Bernardi et al., 2012). However, Kessler et al. (2012) using the NCS Adolescent sample reported that adolescent ADHD was associated with subsequent onset of substance related disorders but to a lesser degree than other childhood disorders (e.g. conduct disorder).
In two meta-analyses of this literature, Lee, Humphreys, Flory, Liu, and Glass (2011) reported that ADHD was prospectively associated with substance use disorders as well as nicotine and illicit drug use (including marijuana), but not alcohol use. Likewise, Charach, Yeung, Climans, and Lillie (2011) reported robust associations between ADHD, nicotine, and alcohol use disorders. However, a majority of the extant research on ADHD, substance use and SUD use a composite diagnosis of ADHD. Studies on ADHD subtypes utilizing clinical samples have found the ADHD-C (Combined) subtype to show high rates of substance use disorders (Sprafkin et al., 2007, Wilens et al., 2009). However, the relationship between ADHD subtypes and substance involvement in the general population remains less well understood.
There is also growing evidence that symptoms of inattention and hyperactivity–impulsivity, even when not satisfying diagnostic thresholds, can influence the likelihood of co-occurring substance use/misuse. A study by Elkins, McGue, and Iacono (2007) found that hyperactive-impulsive symptoms were associated with initiation of substance use, onset of nicotine dependence, and cannabis use disorders while inattentive symptoms were not. Likewise, in a large Swedish registry, Chang, Lichtenstein, and Larsson (2012), found early onset substance use was associated with hyperactive–impulsive but not inattentive symptoms. In contrast, Pingault et al. (2013) found trajectories of inattention, but not hyperactivity, were associated with nicotine dependence in a longitudinal cohort of Canadian children. The use of such dimensional indices (e.g. inattentive or hyperactive-impulsive symptoms) is considered valuable even in clinical samples (Molina & Pelham, 2003) and warrant further study.
From the perspective of studying substance involvement, a significant shortcoming of the extant literature is the inability to distinguish the effects of ADHD on substance use versus SUD. For instance, is ADHD associated with starting to smoke, nicotine dependence or both? While there is some overlap in risk factors for initiation and dependence, others are distinct (Kendler et al., 1999, Neale et al., 2006). This distinction is helpful when examining subtypes as factors important to various stages of substance involvement; however, few studies have considered this approach.
Therefore, to contrast subtypes of ADHD, examine the role of non-diagnostic, dimensional (i.e. symptom count) indices of symptomatology, and to improve upon prior studies that have either collapsed across classes of drugs or not examined them in the context of prior substance use, this study leverages a large population based sample of 34,653 US adults (NESARC) to examine the relationship between ADHD subtypes and substance involvement using a categorical and dimensional approach. The main goals of this analysis were:
- a)
To examine the relationship between non-diagnostic but symptomatic ADHD as well as DSM-IV ADHD subtypes, substance use, and DSM-IV defined SUD.
- b)
To examine the relationship between inattentive and hyperactive–impulsive symptom counts, regardless of diagnosis, substance use, and DSM-IV defined SUD.
- c)
To examine (a) and (b) for SUD but only in those who have a history of substance use/exposure.
Section snippets
Sample
Data from the NESARC (waves 1 and 2) were used in these analyses (see Grant et al., 2005 for detailed information on data collection and adjustments). Interviews were conducted by the US Bureau of Census on behalf of the National Institute of Alcohol Abuse and Alcoholism (NIAAA) on non-institutionalized US citizens and non-citizens who were 18 years and older. Wave 1 included 43,093 participants, and data were collected on 34, 653 of these participants approximately 3 years later at Wave 2.
Prevalence of ADHD subtypes/subgroups
The majority of the sample (N = 32,623) did not satisfy the DSM-IV symptom criterion (Criterion A) to be classified into one of the three ADHD subtypes, however, 50.6% reported some symptoms (N = 17,009). The next largest was the ADHD-C group (N = 361) followed by the ADHD-I group (N = 325). The ADHD-HI group was the smallest (N = 279). Socio demographic characteristics of the sample are included in Table 1. The range of inattentive (mean = 0.90, weighted SD = 144.4) and hyperactive–impulsive (mean = 1.28,
Discussion
This study examines ADHD subtypes, dimensional measures of inattention and hyperactivity–impulsivity (i.e. symptoms counts) and their associations with substance use and SUD in a large representative sample. Importantly, the large sample size helped to examine the association between ADHD and individual SUD, including individual illicit drugs, while accounting for prior associations with substance use. Overall, the prevalence of substance use and SUD in the NESARC was representative of the U.S.
Conclusion
This study adds to the literature by showing that ADHD symptoms (inattentive and hyperactive impulsive) and DSM-IV ADHD subtypes are robustly related to substance use and SUD across a range of substances. Importantly our findings suggest that the presence of ADHD symptoms, even when not satisfying diagnostic criteria, is strongly associated with substance use and SUD. This is an important factor for consideration when tailoring intervention. Furthermore, the current study is the first to
Role of funding source
This research was funded by the National Institute of Drug Abuse (NIDA) grants T32DA007313 (DDA), K02DA32573, DA25886, and DA23668 (AA) and National Institute of Mental Health (NIMH) grant MH-080287 (AMR). AMR also receives grant funds from the McDonnell Center for Systems Neuroscience and the McDonnell Center for Cellular and Molecular Neurobiology. The content in this paper is the responsibility of the authors and does not represent the official views of the funding agencies.
Contributors
DDA and AA conceived the hypothesis, conducted the analyses, wrote the first draft and revised all versions of the manuscript. MTL and AMR provided feedback on phenotype coding, analysis and critically revised the manuscript.
Conflict of interests
None.
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