AOD Use and Attention Deficit/Hyperactivity Disorder

Timothy E. Wilens, M.D.

Children with attention deficit/hyperactivity disorder (ADHD) often continue to exhibit significant impairment in academic, occupational, and social functioning throughout adulthood. In addition, children with ADHD are at increased risk for developing alcoholism and other drug addictions, especially if alcoholism or ADHD exists in other family members. Alcohol and other drug (AOD) abuse may develop earlier in life (i.e., in midadolescence) when ADHD is accompanied by certain behavioral or mood disorders. The nature of the link between ADHD and AOD use disorder is unknown, although the association may be mediated by the co-occurring disorders just mentioned. In addition, ADHD-related AOD abuse may develop initially as an attempt to alleviate symptoms of mental distress associated with chronic failure, feelings of inadequacy, and conflict with parents and peers. Therapeutic intervention should incorporate both addiction and mental health treatment, including appropriate use of psychiatric medications. KEY WORDS: attention deficit disorder; hyperactive behavior; child; AODD (alcohol and other drug use disorder); comorbidity; drug therapy; disease course; AODD recovery; self administration of drugs; biochemical mechanism; adulthood; AOD prevention; psychosocial treatment method; literature review

ince the beginning of the century, The presence of ADHD is an programs for both disorders at earlier terms such as “hyperactive” have important risk factor for the develop- stages of their development. Sbeen used to define a hetero- ment of alcoholism and other disorders This article explores the co-occur- geneous group of restless and inattentive associated with the use of alcohol and rence (i.e., comorbidity) of ADHD children who display learning difficul- other drugs (AODs).1 In addition, AOD and AODD and suggests possible ties. Many such children exhibit the use disorders (AODDs) tend to appear mechanisms that may underlie their condition now known as attention earlier and to progress more rapidly in association. A discussion of ADHD deficit/hyperactivity disorder (ADHD). persons with ADHD. Alcoholics with treatment focuses on the use of medi- Children with ADHD may run about ADHD also are less likely than those cations that can alleviate symptoms of aimlessly, fidget and squirm when without ADHD to remain in alcoholism ADHD, thereby potentially affecting seated, and talk excessively. They treatment programs or to achieve the subsequent development of AODD. are often irritable, impatient, and moderation or abstinence (Tarter and impulsive. Additional symptoms Edwards 1988). The identification of TIMOTHY E. WILENS, M.D., is director may include difficulty concentrating, specific risk factors for AODD in per- of Substance Abuse Services in the forgetfulness, daydreaming, and easy sons with ADHD may permit more Clinical Research Program in Pediatric distractibility. The disorder may per- targeted prevention and treatment Psychopharmacology at Massachusetts sist into adulthood, accompanied by General Hospital and an associate significant academic, occupational, 1AOD disorders considered here include addiction professor of psychiatry at Harvard and social impairment. (i.e., dependence) and abuse. Medical School, Boston, Massachusetts.

Vol. 22, No. 2, 1998 127 Attention Studies have identified comorbid those without, ADHD (mean age 19 Deficit/Hyperactivity ADHD in 25 to 30 percent of certain versus 22) (Wilens et al. 1997). In Disorder adolescents with AODD. However, addition, adults with AODD exhibit the subjects of the studies were repeat increased severity of AOD use prob- The fourth revision of the Diagnostic criminal offenders and patients in res- lems when ADHD is also present and Statistical Manual of Mental idential settings who were undergoing (Carroll and Rounsaville 1993). The Disorders (DSM–IV) (American treatment for psychiatric and addictive presence of ADHD appears to accel- Psychiatric Association [APA] 1994) disorders (Wilens et al. 1996). Con- erate the transition from AOD abuse presents criteria for establishing a sequently, the applicability of those to dependence (Wilens et al. 1998) diagnosis of ADHD. According to results to the general population is and increases the risk for developing DSM–IV, behavioral symptoms of uncertain. Among adults with AODD, a drug use disorder among subjects ADHD are divided into the categories rates of ADHD range from 15 to 25 already abusing alcohol (Biederman et of “inattention” and “hyperactivity- percent (Wilens et al. 1996).3 Con- al. in press). impulsivity.” Most patients (i.e., 75 versely, approximately 50 percent of ADHD also affects the rate of percent) exhibit combined symptoms adults with ADHD exhibit AOD recovery from AODD. In one study, of inattention and hyperactivity- abuse or dependence (Wilens et al. adults with ADHD took more than impulsivity. Between 15 and 20 percent 1996). Data suggest that the risk of twice as long as subjects without of patients with ADHD exhibit only AODD developing at any time over ADHD to recover from comorbid symptoms of inattention, and between the life span of an adult with ADHD AODD (144 versus 60 months, respec- 5 and 10 percent exhibit hyperactivity- is twice that of adults without ADHD tively). In addition, AODD lasted impulsivity but not inattention (for a (52 percent versus 27 percent, respec- more than 3 years longer in the subjects review, see Biederman 1998). tively) (Biederman et al. 1995). with ADHD (Wilens et al. 1998). Additional DSM–IV criteria help Evidence from family studies confirms distinguish ADHD from other disor- an association between co-occurring ders or normal temperamental traits. ADHD and AODD. Elevated rates of Possible Mechanisms For example, the symptoms must be alcoholism are consistently found in Linking ADHD and AODD pervasive (e.g., occurring both at parents of youth with ADHD (Wilens home and at work or in school) and et al. 1996). Conversely, child and The underlying mechanisms that link persistent (e.g., not a transient reaction adolescent offspring of alcoholics, ADHD to AODD remain unknown to stress) and must cause significant compared with children of nonalcoholics, but may involve complex interactions impairment in social, academic, or exhibit lower attention spans; higher among biological and psychological occupational functioning (APA 1994).2 levels of impulsivity, aggressiveness, factors. Two possible contributory ADHD affects from 6 to 9 percent and hyperactivity; and elevated rates factors of particular significance to of children and adolescents and up to of ADHD (Wilens et al. 1996). Those risk evaluation and treatment strategy 5 percent of adults (Biederman 1998). data support the hypothesis that both are comorbidity with additional psychi- Data suggest that childhood ADHD disorders are familial and probably atric disorders and the use of AODs persists into adolescence in approximately genetically transmitted. to self-medicate psychological distress. 75 percent of the patients and into The interpretation of family studies adulthood in approximately 50 percent is complicated by the possible influence of the patients (Biederman 1998). The of prenatal exposure to AODs. For Comorbid Psychiatric disorder may remit spontaneously in example, the offspring of alcohol- and Disorders adolescence, although some symp- cocaine-dependent mothers are at toms, especially attention-related increased risk for psychiatric abnormal- Certain psychiatric conditions frequently problems, may persist into adulthood. ities, including ADHD (Wilens et al. co-occur in youth with combined 1996). Family genetic data in those stud- ADHD and AODD (Wilens et al. ies are generally insufficient to determine 1996). Among those conditions are Extent of Comorbidity the relative contributions of AOD bipolar disorder and conduct disorder. of ADHD and AODD exposure; parental psychopathology; Juvenile bipolar disorder is characterized and the interaction of genetic and by irritability and mood swings. Con- ADHD and AODD occur together environmental factors, such as the effects duct disorder is characterized by a in the same person, either simultane- of poverty and poor prenatal care. persistent pattern of aggressive behavior, ously or sequentially, more often than would be expected by chance (Wilens 2The term “ADHD” as used in this article also et al. 1996). Symptoms of ADHD Course and Remission refers to previous definitions of the disorder. appear years before the development 3By comparison, between 10 and 30 percent of of AODD, often as early as infancy AODD appears at an earlier age adults in the United States exhibit alcohol use (APA 1994). among adults with, compared with disorders (Kessler et al. 1997).

128 Alcohol Health & Research World AOD USE AND ATTENTION DEFICIT/HYPERACTIVITYRunningDISORDER Heads

criminality, or violation of social use (e.g., agitation associated with tially addictive drugs (Hechtman norms (APA 1994). Childhood withdrawal) (Riggs 1998). 1985). In one study, patients with ADHD is associated with the devel- The treatment of ADHD and ADHD who were untreated and opment of AODD in adolescence AODD must be considered simulta- those who had poorer responses to independent of other comorbid neously; however, if the addiction is psychostimulants exhibited more psychiatric conditions. However, the active, it must be treated immediately illegal AOD use than did patients presence of conduct disorder or bipo- (Riggs 1998). Depending on the treated successfully (Loney et al. 1981). lar disorder confers a risk for an even severity and duration of the AODD, However, patients with ADHD and younger onset of AODD (i.e., at age patients may require treatment in a their families should be instructed 16 or younger) independent of ADHD residential facility. Psychosocial thera- not to give psychostimulants to per- (Wilens et al. 1997; Biederman et al. pies aimed at co-occurring ADHD sons to whom they are not prescribed 1997). Although anxiety and depressive and AODD may be combined with (DEA 1995). disorders may co-occur with ADHD, patient and family education, atten- Additional medications used to they do not appear to confer additive dance at self-help groups (e.g., Alcoholics treat ADHD include various antide- risk for the development of AODD Anonymous), and the use of appropriate pressants (e.g., bupropion [Wellbutrin®], during adolescence in ADHD youth medications (i.e., pharmacotherapy) imipramine [Tofranil® and others], (Biederman et al. 1997). (Riggs 1998). and venlafaxine [Effexor®]) and certain medications commonly prescribed Pharmacotherapy to treat high blood pressure (e.g., Self-Medication clonidine [Catapres®]) (Spencer et al. Medications play an important role in 1996). The choice of such medica- Evidence suggests that some use of the long-term treatment of ADHD. tions depends in part on potential AODs represents in part an attempt The influence of such treatment on adverse interactions with AODs that to ameliorate psychiatric symptoms the subsequent development of the patient may be using. During and their associated subjective states AODD remains unclear and may the course of pharmacotherapy, the of distress (Khantzian 1997). The depend in part on the severity of the clinician should frequently monitor academic underachievement and underlying condition. Nevertheless, compliance with treatment, perform behavioral problems associated with results of preliminary studies suggest random urine analyses to detect AOD ADHD may result in conflicts with that certain medications can alleviate adults and peers, chronic failure, and ADHD symptoms in adolescents and use, and coordinate treatment with demoralization. It is plausible that adults while reducing co-occurring other caregivers. some people with ADHD may AOD use or cravings (Levin et al. 1997; develop AODD in response to the Riggs 1998). emotional effects of social, occupational, The most commonly used medica- Conclusions and emotional impairment and accom- tions for treating ADHD are the panying poor self-image. Consistent psychostimulants, a class of medications Research supports a relationship with this theory, adolescents with that promote increased ability to con- between ADHD and AODD, with ADHD report using AODs for mood centrate, wakefulness, and alertness. symptoms of ADHD appearing many adjustment rather than to achieve a Psychostimulants prescribed for ADHD years before the earliest onset of AOD “high” (Biederman et al. 1995; Wilens include amphetamine (Dexedrine®, abuse. AODDs that begin in adoles- et al. 1996). methylphenidate (Ritalin®), and pemo- cence run a more severe course than line (Cylert®) (Riggs 1998). Children those that appear in adulthood. with ADHD treated with those medica- Therefore, prevention and early treat- Treatment Considerations tions may exhibit increased ability to ment strategies should be directed at pay attention in class as well as improved children with ADHD before AOD Treatment of patients with comorbid academic and social performance. use problems develop and become ADHD and AODD should be based Psychostimulants themselves are chronic (Wilens et al. 1997). More on a thorough evaluation of relevant subject to abuse. Of the three psycho- studies that follow disease develop- psychiatric, social, cognitive, educa- stimulants just mentioned, pemoline ment over the life span are needed to tional, and family factors, along with has the lowest potential for abuse, distinguish the relative contributions a history of the patient’s AOD use followed by methylphenidate and of causal factors linking these disor- and treatment. The clinician should amphetamine (Riggs 1998; Drug ders and to identify youth at increased rule out medical and neurological Enforcement Administration [DEA] risk for ADHD–AODD comorbidity. conditions whose symptoms may 1995). The use of psychostimulants This type of research may lead to overlap with ADHD (e.g., the rest- as prescribed for ADHD does not more effective treatments, including lessness and emotional lability of promote subsequent misuse of stimu- pharmacotherapies, for both types of hyperthyroidism) or result from AOD lants themselves or of other poten- disorders (Biederman 1998).

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BIEDERMAN, J.; WILENS, T.; MICK, E.; FARAONE, KHANTZIAN, E.J. The self-medication hypothesis WILENS, T.E.; BIEDERMAN, J.; AND SPENCER, T. S.; WEBER, W.; CURTIS, S.; THORNELL, A.; of substance use disorders: A reconsideration and Attention deficit hyperactivity disorder and the PFISTER, K.; JETTON, J.; AND SORIANO, J. Is recent applications. Harvard Review of Psychiatry psychoactive substance use disorders. In: Jaffee, ADHD a risk for psychoactive substance use dis- 4:231–244, 1997. S., ed. Pediatric Substance Use Disorders: Child order? Findings from a four year follow-up study. Psychiatric Clinics of North America. Philadelphia: LEVIN, F.R.; EVANS, S.M.; MCDOWELL, D.; AND Saunders, 1996. pp. 73–91. Journal of the American Academy of Child and KLEBER, H.D. Methylphenidate treatment for Adolescent Psychiatry 36:21–29, 1997. cocaine abusers with adult attention-deficit/ WILENS, T.E.; BIEDERMAN, J.; MICK, E.; FARAONE, S.V.; AND SPENCER, T. Attention deficit hyperac- hyperactivity disorder: A pilot study. Journal of BIEDERMAN, J.; WILENS, T.; MICK, E.; FARAONE, tivity disorder (ADHD) is associated with early S.V.; AND SPENCER, T. Attention deficit hyperac- Clinical Psychiatry 58:1–21, 1997. onset substance use disorders. Journal of Nervous tivity disorder influences the path to substance LONEY, J.; KRAMER, J.; AND MILICH, R. The and Mental Disease 185:475–482, 1997. use disorders. Biological Psychiatry, in press. hyperactive child grows up: Predictors of symptoms, WILENS, T.; BIEDERMAN, J.; AND MICK, E. CARROLL, K.M., AND ROUNSAVILLE, B.J. History delinquency and achievement at followup. In: Does ADHD affect the course of substance abuse? and significance of childhood attention deficit Gadow, K., and Loney, J., eds. Psychosocial Aspects Findings from a sample of adults with and with- disorder in treatment-seeking cocaine abusers. of Drug Treatment for Hyperactivity. Boulder, CO: out ADHD. American Journal on Addictions Comprehensive Psychiatry 34:75–82, 1993. Westview Press, 1981. pp. 381–415. 7:156–163, 1998. Second Edition of the AOD Thesaurus Now Available

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