Gender Differences in Associations Between Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder

doi:10.1016/j.jaac.2015.12.010

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 55, Issue 3, March 2016, Pages 227-234.e4

https://doi.org/10.1016/j.jaac.2015.12.010 Get rights and content

Objective

To examine gender differences in the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), and to explore the impact of comorbid psychiatric conditions.

Method

This was a cohort study of all children born in Denmark in 1990 to 2003 (n = 729,560). By record linkage across nationwide registers, we merged data on birth characteristics, socioeconomic status, familial psychiatric history, and diagnoses of ADHD (N = 19,645), comorbidities, and SUD. Hazard ratios (HR) with 95% CIs were estimated by Cox regression and adjusted for a range of variables.

Results

ADHD increased the risk of alcohol abuse (HR_females = 1.72 [95% CI = 1.42–2.08], HR_males = 1.57 [1.37–1.79]), cannabis abuse (HR_females = 2.72 [2.12–3.47], HR_males = 2.24 [1.86–2.70]), and other illicit substance abuse (HR_females = 2.05 [1.54–2.73], HR_males = 2.42 [1.98–2.96]), compared to individuals without ADHD. In the overall estimates, no gender differences were found. Among individuals with ADHD without comorbidities, females had a higher SUD risk than males, as did females with ADHD and conduct disorder (CD). Comorbid CD, depression, bipolar disorder, and schizophrenia further increased the risk of SUD in ADHD, compared to non-ADHD. Autism spectrum disorder in males with ADHD lowered the SUD risk.

Conclusion

ADHD increased the risk of all SUD outcomes. Individuals with ADHD without comorbidities were also at increased risk, and some comorbid disorders further increased the risk. Females and males with ADHD had comparable risks of SUD, although females had higher risk of some SUDs than males. Females with ADHD may be perceived as less impaired than males, but they are at equally increased risk of SUD.

Section snippets

Data Sources and Study Population

This register-based, prospective cohort study used data derived from the Danish Civil Registration System (CRS),³⁴ the Danish Medical Birth Register (MBR),³⁵ the Integrated Database for Labour Market Research (IDA),³⁶ the Danish Psychiatric Central Research Register (DPCRR),³⁷ and the Danish National Patient Register (DNPR).³⁸ Using the CRS, we identified all children born in Denmark to Danish-born parents between 1990 and 2003 (n = 729,560) and identified their parents and siblings. All

Results

We identified 729,560 children born between 1990 and 2003. We excluded 16,167 children (2.2%) due to missing information on 1 or more covariates (n = 13,998), diagnosis of ADHD before the age of 3 years (n = 218), diagnosis of any kind of substance abuse before the age of 5 years (n = 152), or loss to follow-up due to death or emigration before entry to the study (n = 1,799), leaving us with a total of 713,393 children in the study cohort (51% males and 49% females). Included individuals

Discussion

This nationwide, prospective, population-based cohort study found that, compared to individuals without mental disorders, children and adolescents with ADHD (N = 19,645) had a 1.57- to 2.72-fold increased risk of different types of SUDs. Importantly, we found very few gender differences in the association between ADHD and SUD compared to those in individuals of the same gender without ADHD and when adjusting estimates for effects of potential confounders, including other psychiatric disorders.

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The prevalence of cannabis use disorder in attention-deficit hyperactivity disorder: A clinical epidemiological meta-analysis
2024, Journal of Psychiatric Research
Studies have shown that individuals with attention-deficit hyperactivity disorder (ADHD) pose an increased risk for developing substance use disorders. Increased cannabis product accessibility and recent legislative changes have led to increased cannabis consumption, thereby increasing the risk of cannabis use disorder (CUD). The present meta-analysis explored the lifetime and current prevalence of CUD in ADHD. A systematic review was conducted using the following databases: PubMed, PsycINFO and Web of Science. A total of 14 articles were included and used to estimate the aggregate lifetime and current prevalence of CUD in ADHD alongside risk ratios comparing increased risk of CUD in ADHD versus control samples. Mixed and random-effects models indicated that lifetime and current prevalence rates of CUD in ADHD populations were 26.9% and 19.2%, respectively (although prediction intervals ranged from 12.4% to 48.8% and 5.5%–39.1%, respectively). Analysis of the risk ratios indicated that those with ADHD were at 2.85- and 2.91-times greater risk of a lifetime or current diagnosis of CUD, respectively, than those in the general population. Our findings support the need for additional research on the prevalence of CUD in those with ADHD, as well as the inclusion of CUD screening in the treatment of ADHD.
Alcohol use disorders and ADHD
2021, Neuroscience and Biobehavioral Reviews
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.
Comorbidity of addictive problems: Assessment and treatment implications
2020, Adolescent Addiction: Epidemiology, Assessment, and Treatment
Comorbidity can be defined as the presence of more than one disorder in a person in a specific period of time and could be examined using the “current” or the “lifetime” approach. The frequent comorbidity between addictive problems and psychiatric disorders is the rule, not an exception. Comorbidity rates are higher in adolescents than in adults. Because most of the existing studies have found comorbidity between SUD and emotional disorders, conduct disorder, and ADHD, we focus on these specific comorbid patterns. Our review shows the negative impact of comorbidity on the course and outcome of addictive problems and the challenge it produces in assessing and treating adolescents with addictive problems and comorbid disorders. There are numerous areas that need further development in the assessment and treatment of adolescents with addictive problems and comorbid disorders, and progress will remain limited until comorbid disorders are adequately assessed and targeted in treatment.
Patterns of Psychiatric Comorbidity and Genetic Correlations Provide New Insights Into Differences Between Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder
2019, Biological Psychiatry
Citation Excerpt :
Individuals prescribed central stimulants for narcolepsy were excluded (see Supplement for details). Adults with ASD only (ASD) were defined as individuals with an ASD diagnosis (ICD-10 codes F84.0–1+F84.5+F84.8–9) (40,41) who were 18 years of age or older, were registered in the NPR during 2008 to 2015, and had no ADHD diagnosis. Adults (18 years of age or older) with both ADHD and ASD as defined above comprised the combined group (ADHD+ASD).
Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) share common genetic factors but seem to have specific patterns of psychiatric comorbidities. There are few systematic studies on adults; therefore, we compared psychiatric comorbidities in adults with these two neurodevelopmental disorders using population-based data and analyzed their genetic correlations to evaluate underlying factors.
Using data from Norwegian registries, we assessed patterns of psychiatric disorders in adults with ADHD (n = 38,636; 2.3%), ASD (n = 7528; 0.4%), and both diagnoses (n = 1467; 0.1%) compared with the remaining adult population (n = 1,653,575). We calculated their prevalence ratios (PRs) and differences using Poisson regression, also examining sex-specific relations. Genetic correlations (r_g) among ADHD, ASD, and the examined psychiatric disorders were calculated by linkage disequilibrium score regression, exploiting summary statistics from relevant genome-wide association studies.
For all psychiatric comorbidities, PRs differed between ADHD and ASD. Associations were strongest in individuals with ADHD and ADHD+ASD for most comorbidities, in both men and women. The relative prevalence increase of substance use disorder was three times larger in ADHD than in ASD (PR_ADHD, 6.2; 95% confidence interval [CI], 6.1–6.4; PR_ASD, 1.9; 95% CI, 1.7–2.2; p < .001); however, the opposite was true for schizophrenia (PR_ASD, 13.9; 95% CI, 12.7–15.2; PR_ADHD, 4.4; 95% CI, 4.1–4.7; p < .001). Genetic correlations supported these patterns but were significantly different between ADHD and ASD only for the substance use disorder proxies and personality traits (p < .006 for all).
Adults with ADHD, ASD, or both ADHD and ASD have specific patterns of psychiatric comorbidities. This may partly be explained by differences in underlying genetic factors.
Sex Differences in Comorbidity Patterns of Attention-Deficit/Hyperactivity Disorder
2019, Journal of the American Academy of Child and Adolescent Psychiatry
Citation Excerpt :
Previously, Biederman et al.31 reported sex differences in the association between ADHD and SUD in referred individuals, in whom the association was strongest in female individuals. This is consistent with our previous and present findings.20 However, the remaining sex differences found in the present study do not correlate.
To investigate sex differences in associations between attention-deficit/hyperactivity disorder (ADHD) and a spectrum of comorbid disorders.
The study population included all children born in Denmark from 1981 through 2013 (N = 1,665,729). Data were merged from Danish registers and information was obtained on birth characteristics, socioeconomic status, familial psychiatric history, and diagnoses of ADHD (n = 32,308) and comorbid disorders. To estimate absolute and relative risks of comorbid disorders, incidence rates and adjusted hazard ratios (HRs) with 95% CIs were calculated for female and male individuals. In addition, interactions between ADHD and sex in association with comorbid disorders were estimated as HR ratios (HRRs) in female and male individuals (95% CIs).
Individuals diagnosed with ADHD had significantly increased absolute and relative risks of all 12 comorbid psychiatric disorders investigated. ADHD-sex interactions were found for some comorbid disorders. Compared with male individuals, ADHD in female individuals showed a stronger association with autism spectrum disorder (HRR 1.86, 95% CI 1.62–2.14), oppositional defiant/conduct disorder (HRR 1.97, 95% CI 1.68–2.30), intellectual disability (HRR 1.79, 95% CI 1.54–2.09), personality disorders (HRR 1.23, 95% CI 1.06–1.43), schizophrenia (HRR 1.21, 95% CI 1.02–1.43), substance use disorders (HRR 1.21, 95% CI 1.07–1.38), and suicidal behavior (1.28, 95% CI 1.12–1.47). The remaining disorders showed no significant sex differences in association with ADHD.
This study indicates that the association between ADHD and several comorbid disorders is stronger in female than in male individuals. These important findings add to the literature on sex differences in ADHD and suggest that female individuals diagnosed with ADHD are a more vulnerable group of patients.
No evidence of associations between genetic liability for schizophrenia and development of cannabis use disorder
2021, Psychological Medicine

View all citing articles on Scopus

: This article can be used to obtain continuing medical education (CME) at www.jaacap.org.

: This study was funded by a grant from the Lundbeck Foundation.

: Dr. Petersen served as the statistical expert for this research.

: The authors are grateful for the supporting funding for this study from the Lundbeck Foundation.

: Disclosure: Dr. Dalsgaard has served as a consultant to the Danish Health and Medicines Authority. Dr. Petersen and Mss. Ottosen and Larsen report no biomedical financial interests or potential conflicts of interest.

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New researchGender Differences in Associations Between Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder

Objective

Method

Results

Conclusion

Section snippets

Data Sources and Study Population

Results

Discussion

J Am Acad Child Adolesc Psychiatry

Drug Alcohol Depend

Eur Neuropsychopharmacol

Addict Behav

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Drug Alcohol Depend

J Am Acad Child Adolesc Psychiatry

Clin Psychol Rev

Eur Psychiatry

Lancet

Neurosci Biobehav Rev

Neurosci Biobehav Rev

J Health Econ

Eur Psychiatry

J Substance Abuse Treat

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

Schizophr. Res

J Am Acad Child Adolesc Psychiatry

Schizophr. Res

Lancet Psychiatry

Econ Lett

Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study

JAMA

Attention deficit hyperactivity disorder (ADHD) among illicit psychostimulant users: a hidden disorder?

Addiction

Comorbidity of attention-deficit hyperactivity and psychoactive substance use disorders

Hosp Community Psychiatry

Personality characteristics of adults with autism spectrum disorders or attention deficit hyperactivity disorder with and without substance use disorders

J Nerv Ment Dis

Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study

Am J Psychiatry

New research
Gender Differences in Associations Between Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder