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CORK Bibliography: Substance Use and Attention Deficit/Hyperactivity Disorder

47 citations. January 2010 to present

Prepared: September 2011

Advokat C. What are the cognitive effects of stimulant medications? Emphasis on adults with attention-deficit/hyperactivity disorder (ADHD. (review). Neuroscience and Biobehavioral Reviews 34(8): 1256-1266, 2010. (104 refs.)

The relevant literature concerning cognitive effects of amphetamine and methylphenidate, was reviewed, with an emphasis on research conducted in adults diagnosed with attention-deficit/hyperactivity disorder. As first-line treatment for ADHD, stimulant drugs are well-known to improve attention and concentration. Yet, there is increasing evidence that (as with children and adolescents), they do not promote learning and academic achievement in adult college students with ADHD. A review of neuropsychological studies indicates that, although response latencies are reduced, performance of ADHD adults on tests of 'distractibility' and 'planning' is also not consistently improved by stimulants. Studies in non-ADHD adults suggest that stimulants do not promote acquisition of new information, might improve retention of previously acquired information, and facilitate memory consolidation, but may actually impair performance of tasks that require adaptation, flexibility and planning. It is still not clear if improvement only occurs when there is a baseline deficit. Stimulants may influence cognition by their effects on physiological arousal. Regardless, the evidence does not support the conclusion that stimulants are cognitive 'enhancers.

Aldridge AP; Kroutil LA; Cowell AJ; Reeves DB; Van Brunt DL. Medication costs to private insurers of diversion of medications for attention-deficit hyperactivity disorder. PharmacoEconomics 29(7): 621-635, 2011. (38 refs.)

Background: The diversion of prescription stimulants for misuse, particularly those used in the treatment of attention-deficit hyperactivity disorder (ADHD), is potentially a significant problem for public health and for healthcare funding and delivery. Most prior research on the diversion of prescription stimulants for misuse, particularly those used in the treatment of ADHD, has focused on the 'end users' of diverted medications rather than the suppliers. Furthermore, little is known about the direct costs of diversion for third-party insurance payers in the US. Objectives: The objectives of this study were to estimate the prevalence in the US of people whose private insurance paid costs for ADHD prescriptions that they gave or sold to another person (diversion), and to estimate medication costs of diversion to private insurers. Methods: Estimates are from a cross-sectional survey of respondents from two Internet survey panels targeting individuals aged 18-49 years in the civilian, noninstitutionalized US population, principally for those who filled prescriptions for ADHD medications in the past 30 days that were covered by private health insurance. Analysis weights were post-stratified to control totals from the Current Population Survey and National Health Interview Survey. Weighted prevalence rates and standard errors for diversion are reported, as are the costs of diverted pills using drug prices reported in the 2008 Thomson Reuters RED BOOK (TM). Sensitivity analyses were conducted that varied the cost assumptions for medications. Results: Among individuals aged 18-49 years whose private insurance paid some costs for ADHD medications in the past 30 days, 16.6% diverted medications from these prescriptions. Men aged 18-49 years for whom private insurance paid some costs of ADHD drugs in the past 30 days were more than twice as likely as their female counterparts to divert medications from these prescriptions (22.5% vs 9.1%; p = 0.03). After a pro-rated co-payment share was subtracted, the estimated value of diverted medications in a 30-day period was $US8.0 million. Lower- and upper-bound estimates were $US6.9 million to $US17 million, for a range of $US83 million to $US204 million annually. Overall, diversion accounted for about 3.6% of the total costs that private insurers paid for ADHD medications (range: 3.5-4.5%). The percentages varied by medication category, although relative differences were sensitive to inclusion of a pro-rated co-payment. A higher percentage of the costs of extended-release (XR) medications was lost to diversion compared with that for immediate-release (IR) medications. Conclusions: Costs of ADHD medications paid for by private insurers that were lost to diversion were small relative to the total estimated medication costs and relative to total estimated healthcare costs for treating ADHD. Nevertheless, there may be significant cost savings for insurers if diversion can be reduced, particularly for XR medications. These findings represent a first step to informing policies to reduce diversion both in the interest of public health and for direct and indirect cost savings to insurers.

Arria AM; Garnier-Dykstra LM; Caldeira KM; Vincent KB; O'Grady KE; Wish ED. Persistent nonmedical use of prescription stimulants among college students: Possible association with ADHD symptoms. Journal of Attention Disorders 15(5): 347-356, 2011. (30 refs.)

Objective: To investigate the possible association between untreated ADHD symptoms (as measured by the Adult ADHD Self-Report Scale) and persistent nonmedical use of prescription stimulants. Method: Multinomial regression modeling was used to compare ADHD symptoms among three groups of college students enrolled in a longitudinal study over 4 years: (1) persistent nonmedical users of prescription stimulants, (2) persistent users of marijuana who did not use prescription stimulants nonmedically, and (3) consistent nonusers of drugs. Results: ADHD symptoms were associated with being a persistent nonmedical user of prescription stimulants after adjustment for race/ethnicity, sex, socioeconomic status, and other illicit drug use. No associations were observed between ADHD symptoms and being a persistent marijuana user or nonuser. Conclusion: ADHD symptoms, and in particular inattention symptoms, appeared to be associated with nonmedical use of prescription stimulants.

Bandiera FC; Richardson AK; Lee DJ; He JP; Merikangas KR. Secondhand smoke exposure and mental health among children and adolescents. Archives of Pediatrics & Adolescent Medicine 165(4): 332-338, 2011. (51 refs.)

Objective: To examine a potential association between biologically confirmed secondhand smoke exposure and symptoms of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) major depressive disorder, generalized anxiety disorder, panic disorder, attention-deficit/hyperactivity disorder, and conduct disorder using a nationally representative sample of US children and adolescents. Design: Nationally representative cross-sectional survey of the United States. Setting: Continental United States. Participants: Children and adolescents aged 8 to 15 years who participated in the National Health and Nutrition Examination Survey from 2001 to 2004. Intervention: Measurement of serum cotinine level to assess secondhand smoke exposure among nonsmokers. Main Outcome Measures: The DSM-IV symptoms were derived from selected modules of the National Institute of Mental Health's Diagnostic Interview Schedule for Children Version IV, a structured diagnostic interview administered by trained lay interviewers. Results: Among nonsmokers, serum cotinine level was positively associated with symptoms of DSM-IV major depressive disorder, generalized anxiety disorder, attention-deficit/hyperactivity disorder, and conduct disorder after adjusting for survey design, age, sex, race/ethnicity, poverty, migraine, asthma, hay fever, maternal smoking during pregnancy, and allostatic load. Associations with serum cotinine level were more apparent for boys and for participants of non-Hispanic white race/ethnicity. Conclusions: Our results are consistent with a growing body of research documenting an association between secondhand smoke exposure and mental health outcomes. Future research is warranted to establish the biological or psychological mechanisms of association.

Carpentier PJ; van Gogh MT; Knapen LJM; Buitelaar JK; De Jong CAJ. Influence of attention deficit hyperactivity disorder and conduct disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients. European Addiction Research 17(1): 10-20, 2011. (60 refs.)

Background: Persistent attention deficit hyperactivity disorder (ADHD) and a history of conduct disorder (CD) are highly prevalent among patients with substance use disorders (SUD). We examined the influence of both diagnoses on problem severity, psychiatric comorbidity, and quality of life in methadone-maintained patients. Methods: 193 patients in long-term methadone maintenance treatment (MMT) were assessed for ADHD through a semi-structured interview. Psychiatric disorders and SUD were assessed with the MINI, the CIDI-SAM, and the SIDP-IV. Results: Childhood ADHD was diagnosed in 68 (35.2%) patients; 48 (24.9%) had persisting ADHD; a CD history was present in 116 (60.1%). Patients with adult ADHD had significantly higher problem severity scores, lower quality of life scores, more comorbid SUD and more psychiatric comorbidity. Although both ADHD and CD contributed to problem severity, addictive pathology and psychopathology, ADHD was found to substantially increase the risk of psychiatric comorbidity, independent of CD. Conclusion: ADHD in MMT patients is characterised by greater addiction severity and more comorbid psychopathology, only partly explained by the influence of a coexisting CD. The presence of ADHD in a substantial minority of patients accentuates the need for early detection and treatment of this complicating disorder.

Carpentier PJ; van Gogh MT; Knapen LJM; Buitelaar JK; De Jong CAJ. Influence of Attention Deficit Hyperactivity Disorder and Conduct Disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients. European Addiction Research 17(1): 10-20, 2011. (60 refs.)

Castells X; Ramos-Quiroga JA; Bosch R; Nogueira M; Casas M. Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults. (review). Cochrane Database of Systematic Reviews (6): e-articleCD007813, 2011. (79 refs.)

Background: Attention Deficit Hyperactivity Disorder (ADHD) is a childhood onset disorder that can persist into adulthood. Amphetamines are used to treat adult ADHD, but uncertainties persist about their efficacy and safety. Objectives: To examine the efficacy and safety of amphetamines for adults with ADHD, as well as the influence of dose, drug type and release formulation type. Search strategy: We searched CENTRAL, PubMedicine, EMBASE, CINAHL, PsycINFO, clinicaltrials. gov, UK Clinical Trials Gateway and references obtained from articles and experts in the field. We conducted the electronic searches on 25 February 2010. Selection criteria: Randomized controlled trials comparing the efficacy of amphetamine derivatives against placebo or an active intervention. Data collection and analysis: Two authors extracted data from each included study. We used the standardized mean difference ( SMD) and the risk ratio ( RR) to assess continuous and dichotomous outcomes, respectively. We conducted a stratified analysis to determine the influence of moderating variables. We assessed the trials for risk of bias and drew a funnel plot to investigate the possibility of publication bias. Main results: We included seven studies, which enrolled 1091 participants. All studies were placebo-controlled and three included an active comparator: guanfacine, modafinil and paroxetine. Most studies had short-term follow-up, with a mean study length of 8.1 weeks. Amphetamines improved ADHD symptom severity (SMD = -0.72; 95% CI -0.87 to -0.57) but did not improve retention in treatment overall and were associated with increased dropout due to adverse events (RR 3.03; 95% CI 1.52 to 6.05). The three amphetamine derivatives investigated (dextroamphetamine, lisdexamphetamine and mixed amphetamine salts (MAS)) were all efficacious for reducing ADHD symptoms, but MAS also increased retention in treatment. Different doses did not appear associated with differences in efficacy. We investigated immediate and sustained drug release formulations but found no difference between them on any outcome. When amphetamines were compared to other drug interventions, no differences were found. We did not find any study to be at low risk of bias overall, mainly because amphetamines have powerful subjective effects that may reveal the assigned treatment. Authors' conclusions: Amphetamines improved short-term ADHD symptom severity. MAS also increased retention in treatment. Amphetamines were associated with higher attrition due to adverse events. The short study length and the restrictive inclusion criteria limit the external validity of these findings. Furthermore, the possibility that the results of the included studies were biased was high, which could have led to an overestimation of amphetamine efficacy.

Charach A; Yeung E; Climans T; Lillie E. Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. (review). Journal of The American Academy of Child and Adolescent Psychiatry 50(1): 9-21, 2011. (49 refs.)

Objective: in recent years cohort studies have examined childhood attention-deficit/hyper-activity disorder (ADHD) as a risk factor for substance use disorders (SUDs) in adolescence and young adulthood. The long-term risk is estimated for development of alcohol, cannabis, combined alcohol and psychoactive SUDs, combined SUDs (nonalcohol), and nicotine use disorders in children with AUHD. Method: MEDLINE, CINHAL, PsycINFO, and EMBASE were searched through October 2009; reference lists of included studies were hand-searched. Prospective cohort studies were included if they compared children with ADHD to children without, identified cases using standardized criteria by mean age of 12 years, followed participants until adolescence (nicotine use) or young adulthood (psychoactive substance use disorder, with and without alcohol, alcohol use disorder, cannabis use disorder), and reported SUD outcomes. Two independent reviewers examined articles and extracted and crosschecked data. Effects were summarized as pooled odds ratios (ORs) in a random effects model. Results: Thirteen studies were included. Only two of five meta-analyses, for alcohol use disorder (N = 3,184) and for nicotine use (N = 2,067), estimated ORs showing stability when evaluated by sensitivity analyses. Childhood ADHD was associated with alcohol use disorder by young adulthood (OR = 1.35, 95% confidence interval = 1.11-1.64) and with nicotine use by middle adolescence (OR = 2.36, 95% confidence interval = 1.71-3.27). The association with drug use disorder, nonalcohol (N = 593), was highly influenced by a single study. Conclusions: Childhood ADHD is associated with alcohol and drug use disorders in adulthood and with nicotine use in adolescence.

Covey LS; Hu MC; Winhusen T; Weissman J; Berlin I; Nunes EV. OROS-methylphenidate or placebo for adult smokers with attention deficit hyperactivity disorder: Racial/ethnic differences. Drug and Alcohol Dependence 110(1-2): 156-159, 2010. (14 refs.)

Objective: To explore racial/ethnic difference in OROS-methylphenidate (OMPH) efficacy when added to nicotine patch and counseling for treating nicotine dependence among smokers with attention deficit hyperactivity disorder (ADHD). Method: Participants were adult smokers with ADHD (202 whites and 51 non-whites) randomly assigned to OMPH or placebo in a multi-site, randomized controlled trial. Study outcomes were complete, prolonged, and point-prevalence abstinence at the end of treatment, and weekly ratings of ADHD symptoms, tobacco withdrawal symptoms, and desire to smoke. Results: The rate of four-week complete abstinence (no slips or lapses) was significantly higher with OMPH than placebo among non-white (OMPH = 42.9%, placebo = 13.3%, chi(2)(1)=5.20, p = 0.02) but not white participants (OMPH = 23.1%, placebo =23.5%, chi(2)( 1) = 0.00,p = 0.95). Patterns of prolonged and point-prevalence abstinence among non-whites were similar but fell short of statistical significance. OMPH reduced ADHD symptoms in both race/ethnic groups, and produced greater reductions in desire to smoke and withdrawal symptoms among the non-white than white participants. Change in desire to smoke, but not in withdrawal or ADHD symptoms predicted abstinence. The ability of OMPH to reduce desire to smoke among non-whites appeared to mediate the medication's positive effect on abstinence. Conclusion: Differential efficacy favoring non-whites of a medication for achieving smoking cessation is a potentially important finding that warrants further investigation. OROS-MPH could be an effective treatment for nicotine dependence among a subgroup of smokers.

de los Cobos JP; Sinol N; Puerta C; Cantillano V; Zurita CL; Trujols J. Features and prevalence of patients with probable adult attention deficit hyperactivity disorder who request treatment for cocaine use disorders. Psychiatry Research 185(1-2): 205-210, 2011. (44 refs.)

To characterize those patients with probable adult attention deficit hyperactivity disorder (ADHD) who ask for treatment of cocaine use disorders; to estimate the prevalence of probable adult ADHD among these patients. This is a cross-sectional and multi-center study performed at outpatient resources of 12 addiction treatment centers in Spain. Participants were treatment-seeking primary cocaine abusers recruited consecutively at one center and through convenience sampling at the other centers. Assessments included semi-structured clinical interview focused on Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) ADHD criteria adapted to adulthood, and the Wender-Utah Rating Scale (WURS) for screening childhood history of ADHD according to patients. Probable adult ADHD was diagnosed when patients met DSM-IV criteria of ADHD in adulthood and scored WURS > 32. All participants were diagnosed with current cocaine dependence (n = 190) or abuse (n = 15). Patients with probable adult ADHD, compared with patients having no lifetime ADHD, were more frequently male, reported higher impulsivity, and began to use nicotine, alcohol, cannabis, or cocaine earlier. Before starting the current treatment, patients with probable adult ADHD also showed higher cocaine craving for the previous day, less frequent cocaine abstinence throughout the previous week, and higher use of cocaine and tobacco during the previous month. Impulsivity and male gender were the only independent risk factors of probable adult ADHD in a logistic regression analysis. The prevalence of probable adult ADHD was 20.5% in the sub-sample of patients consecutively recruited (n = 78). A diagnosis of probable adult ADHD strongly distinguishes among treatment-seeking cocaine primary abusers regarding past and current key aspects of their addictive disorder; one-fifth of these patients present with probable adult ADHD.

DeSantis AD; Hane AC. "Adderall is definitely not a drug": Justifications for the illegal use of ADHD stimulants. Substance Use & Misuse 45(1/2): 31-46, 2010. (25 refs.)

In-depth interviews were conducted in 2007 with 175 undergraduate students (94 males, 81 females, 13 non-Caucasian) at a large, public southeastern research university located in an urban area in the United States. Our primary goal was to identify how these students conceive of Attention Deficit Hyperactivity Disorder (ADHD) stimulants and their illegal use. We discovered that these students frame stimulant use as both physically harmless and morally acceptable. Specifically, these students justify their drug use through the use of four recurring pro-stimulant arguments: 1) comparison-and-contrast, 2) all-things-in-moderation, 3) self-medicating, and 4) minimization arguments. We discuss limitations to the study and conclude by suggesting five strategies for prevention researchers that would directly target these four arguments.

Donovan SJ; Levin FR. The "younger-sibling-at-risk design": A pilot study of adolescents with ADHD and an older sibling with substance use disorder. American Journal of Drug and Alcohol Abuse 37(4): 235-239, 2011. (12 refs.)

Introduction: This article introduces a "younger at-risk sibling" design to study progression from other psychopathologies to their substance use disorder (SUD) complications. The design selects not-yet-SUD adolescents with high-risk-for-SUD psychopathology only if an older sibling has SUD. This "proof of concept" pilot study examines the design's feasibility if the younger sibling has attention deficit hyperactivity disorder (ADHD). Method: Subjects were recruited from families at substance abuse treatment centers that had a non-SUD younger child with ADHD, from families at behavior disorder clinics that had a younger child with ADHD and SUD older child, and through general advertisements. Subjects were seen weekly for at least 3 months and monthly thereafter for 3 months. All were treated with open-label lisdexamfetamine dimesylate 30-70 mg per day. Outcomes explored were recruitment, compliance, diversion, ADHD improvement, and substance use interest. Results: 25 families were screened, 13 evaluated, and 8 began medication. ADHD Rating Scale-IV scores obtained by parent-adolescent consensus improved as expected with a stimulant. Rating forms could quantify substance use interest in subjects with some drug culture exposure but encountered a floor effect in those without. The design's complexity and implicit commentary on family dynamics complicated recruitment but may have facilitated retention. Conclusion: Sibling pairs in which the older sibling has substance use and the younger sibling has ADHD exist. Such younger siblings can be recruited into a treatment study. The design may shed light on the pathogenesis and prevention of SUD complications from ADHD and theoretically other SUD comorbidities.

Dosh T; Helmbrecht T; Anestis J; Guenthner G; Kelly TH; Martin CA. A comparison of the associations of caffeine and cigarette use with depressive and ADHD symptoms in a sample of young adult smokers. Journal of Addiction Medicine 4(1): 52-54, 2010. (24 refs.)

Objectives: This study examined the relationship between psychiatric symptoms and nicotine, caffeine, alcohol, and marijuana use in young adult smokers. Methods: Young adult smokers completed self-report measures of nicotine, caffeine, alcohol and marijuana use, Conner's Adult Attention-Deficit/Hyperactivity Disorder Rating Scale-Short Version (CAARS-SS), beck depression inventory (BDI) and Beck Anxiety Inventory (BAI), and provided a breath carbon monoxide sample. Results: Self-reported cigarette use was positively correlated with carbon monoxide, CAARS-SS, and BDI levels. Caffeine intake was correlated with CAARS-SS, BAI, and BDI levels and emerged as the more significant predictor of BDI, BAI, and CAARS-SS scores when regressed with cigarette use. Conclusions: Caffeine use is associated with psychiatric symptoms in young adult cigarette smokers and should be considered in future research.

Eliasen M; Tolstrup JS; Andersen AMN; Gronbaek M; Olsen J; Strandberg-Larsen K. Prenatal alcohol exposure and autistic spectrum disorders: A population-based prospective study of 80,552 children and their mothers. International Journal of Epidemiology 39(4): 1074-1081, 2010. (42 refs.)

Methods: Participants were 80,552 children and their mothers enrolled in the Danish National Birth Cohort from 1996 to 2002. Alcohol consumption was obtained by self-report during pregnancy. Information on ASD was obtained from the Danish Central Psychiatry Register. Follow-up ended on February 2008. Data were analysed by means of Cox regression. Results In total, 401 children were diagnosed with ASD and 157 with infantile autism. No association was found between average alcohol consumption and ASD or infantile autism, respectively. For binge drinking, the adjusted hazard ratio (HR) for ASD was 0.72 [95% confidence interval (CI): 0.53-0.97] among women who binge drank once during pregnancy compared with women who did not binge drink. The corresponding HR for infantile autism was 0.61 (95% CI: 0.36-1.02). However, the HR for ASD was 0.84 (95% CI: 0.51-1.36) when restricting the analysis to first-time pregnancies conceived within 6 months of trying. No estimate was made for infantile autism due to low number of cases. No association was seen for more than one binge episode and for the timing of binge drinking. Conclusion: Our findings do not support that a low prenatal alcohol exposure increases the risk of ASD or infantile autism. The lower risk for women who binge drank once during pregnancy is most likely non-causal.

Faregh N; Derevensky J. Gambling behavior among adolescents with attention deficit/hyperactivity disorder. Journal of Gambling Studies 27(2): 243-256, 2011. (32 refs.)

Impulsivity is inherent to both problem gambling and ADHD. The purpose of this study is to examine ADHD key symptoms, and gambling behaviors and problem severity among adolescents. Additionally, internalizing and externalizing behaviors exhibited among these individuals and the role of these symptoms in gambling are examined. We used a cross-sectional study design and survey 1,130 adolescents aged 12-19. Results indicated that adolescents who screened positive for ADHD were significantly more likely than non-ADHD adolescents to engage in gambling and significantly more likely to develop gambling problems. Those who screened positive as predominantly inattentive and those who screened positive for ADHD Combined (Inattention and Hyperactivity-Impulsivity) were equally likely to gamble, but the latter were twice as likely to have gambling problems. However, we found no significant interaction between the key ADHD symptoms and gambling as the severity of hyperactivity-impulsivity or inattention did not significantly differ with respect to gambling pathology. Emotional problems and depressive affect were the only variables that could significantly differentiate the ADHD types and gambling severity. Our Results highlight the clinical importance of considering the subtype of ADHD among gamblers and the greater association of depressive affect and emotional problems with gambling among adolescents.

Flory K; Malone PS; Lamis DA. Childhood ADHD symptoms and risk for cigarette smoking during adolescence: School adjustment as a potential mediator. Psychology of Addictive Behaviors 25(2): 320-329, 2011. (69 refs.)

Although a large body of research suggests that children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for cigarette smoking during adolescence compared with their non-ADHD peers, much less research has examined why. The current study addressed this gap in the literature by examining middle school adjustment, broadly defined, as a possible mediator of the relation between childhood ADHD symptoms and cigarette smoking during middle adolescence (10th grade). Longitudinal data were collected from a community sample of 754 youth using self-report and parent report along with school records, and a novel statistical technique was used in the process of testing for mediation. Consistent with hypotheses, school adjustment was found to mediate the relation between childhood ADHD symptoms and later cigarette smoking, even after controlling for early externalizing problems. Results have implications for etiological theories of adolescent deviant behavior and suggest that successful smoking prevention programs targeting youth with ADHD should include a school adjustment component.

Frodl T. Comorbidity of ADHD and substance use disorder (SUD): A neuroimaging perspective. Journal of Attention Disorders 14(2): 109-120, 2010. (100 refs.)

Introduction: ADHD has a high comorbidity with substance use disorders (SUD). Both diseases have profound social, psychological, and economic consequences and are therefore highly relevant for health systems. The high comorbidity indicates some shared underlying neurobiological substrates. Knowing these substrates may increase the understanding of the disease and help identify therapeutic processes. Method: Neuroimaging studies of ADHD were reviewed and similarities with SUD identified. For this a PubMed research was conducted with the search terms ADHD, SUD, MRI or positron emission tomography (PET) or spectroscopy or imaging. Results: Similarities were found, in both PET and fMRI studies, between patients with ADHD and those with addiction-related craving. Results from structural MRI and MR spectroscopy do not support a common pathophysiological background, probably because of the lack of studies on craving. Discussion: ADHD and SUD-related craving share some neurobiological similarities. One reason may be that patients with addiction show more craving when they also suffer from ADHD. The present review thus supports the conclusion from an earlier meta-analysis of clinical studies which found that adequate treatment of ADHD reduces craving and relapse into substance use.

Galera C; Bouvard MP; Melchior M; Chastang JF; Lagarde E; Michel G et al. Disruptive symptoms in childhood and adolescence and early initiation of tobacco and cannabis use: The Gazel Youth study. European Psychiatry 25(7): 402-408, 2010. (58 refs.)

Purpose: To examine the link between symptoms of hyperactivity-inattention and conduct disorder in childhood, and the initiation of tobacco and cannabis use, controlling for other behavioral symptoms, temperament and environmental risk factors. Method: The sample (N = 1107 participants, aged 4 to 18 years at baseline) was recruited from the population-based longitudinal Gazel Youth study with a follow-up assessment 8 years later. Psychopathology, temperament, environmental variables, and initiation of tobacco and cannabis use were self-reported. Event time analyses were performed to assess the effects of childhood disruptive symptoms on age at first use of tobacco and cannabis. Results: Proportional hazard models revealed that participants with high levels of childhood symptoms of both hyperactivity-inattention and conduct disorder were at highest risk of early tobacco initiation (in males: hazard ratio [HR]= 2.05; confidence interval [CI]: 1.24-3.38; in females: HR = 2.01; CI: 1.31-3.09), and, in males, of early cannabis initiation (HR = 1.95; CI: 1.04-3.64). Temperament, through activity in both males and females and negative emotionality in females, was also associated to early substance use initiation. Conclusions: Children who simultaneously have high levels of symptoms of hyperactivity-inattention and conduct disorder are at increased risk for early substance initiation. These associations may guide childhood health professionals to consider the liability for early substance initiation in high-risk groups.

Glass K; Flory K. Why does ADHD confer risk for cigarette smoking? A review of psychosocial mechanisms. (review). Clinical Child and Family Psychology Review 13(3): 291-313, 2010. (97 refs.)

Research has documented that adolescents and young adults with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for cigarette smoking, but less attention has examined why this risk exists. The current paper reviews the literature on different psychosocial mechanisms [self-medication hypothesis, social factors (social modeling, social impairments), cognitive factors (attitudes, coping skills), and psychological variables (ADHD symptom dimensions, comorbidity)] that might explain this increased smoking risk. Results of the review suggest that, while the self-medication hypothesis has some theoretical merit, it has not been adequately examined among adolescents and young adults with ADHD. Further, cognitive and social factors may be important mechanisms that help to explain the association between ADHD and cigarette smoking, but research in these areas is sparse. Finally, a larger body of literature suggests that different psychological aspects of ADHD (e.g., comorbidity, symptom dimensions) are related to smoking. Interpretation of findings of many of these studies was hindered due to significant methodological problems and the lack of a guiding theoretical orientation. Potential theories that might facilitate future work in this area are discussed. Future research should continue to explore these important psychosocial mechanisms as well as gene-environment interactions in examining the link between ADHD and cigarette smoking.

Gray KM; Baker NL; Carpenter MJ; Lewis AL; Upadhyaya HP. Attention-Deficit/Hyperactivity Disorder confounds nicotine withdrawal self-report in adolescent smokers. American Journal on Addictions 19(4): 325-331, 2010. (32 refs.)

Individuals with attention-deficit/hyperactivity disorder (ADHD) are more likely than those without ADHD to initiate smoking and develop nicotine dependence. Recent research indicates that adults with ADHD experience more severe nicotine withdrawal symptoms than those without ADHD. However, little is known about nicotine withdrawal in adolescent smokers with history of ADHD. Among a sample of 134 nicotine-dependent adolescents entering a smoking cessation research study, participants completed the Minnesota Nicotine Withdrawal Scale (MNWS) and lifetime diagnostic assessment for ADHD during the baseline visit. Responses on individual items and MNWS total score were compared between participants with and without history of ADHD. In addition, correlations between MNWS responses and current ADHD symptoms were investigated among participants with history of ADHD. Forty-eight participants (36%) met lifetime ADHD criteria. Adolescent smokers with history of ADHD scored significantly higher on MNWS than those without history of ADHD. Among participants with history of ADHD, responses on the MNWS difficulty concentrating, restlessness/impatience, and anxiety/nervousness items each correlated positively with several current ADHD symptoms. Treatment-seeking adolescent smokers with history of ADHD are more likely to endorse nicotine withdrawal symptoms than those without history of ADHD. However, it does not appear that the symptoms reported in this sample represent a valid "withdrawal syndrome," particularly because these smokers had not yet formally attempted to quit. Rather, the data likely reflect common features between ADHD and nicotine withdrawal. Smoking research, particularly among adolescents in whom ADHD is so common, should carefully consider the complex issue of comorbid ADHD and nicotine dependence.

Heffner JL; Johnson CS; Blom TJ; Anthenelli RM. Relationship between cigarette smoking and childhood symptoms of inattention and hyperactivity/impulsivity in alcohol-dependent adults without attention-deficit hyperactivity disorder. Nicotine & Tobacco Research 12(3): 243-250, 2010. (46 refs.)

Symptoms of inattention and hyperactivity/impulsivity that fall below the DSM-IV diagnostic threshold for attention-deficit hyperactivity disorder (ADHD) may be associated with the high prevalence of smoking among individuals with alcohol dependence, yet no studies to date have examined the relationship between subthreshold ADHD symptoms and cigarette smoking in this group. We hypothesized that increasing levels of ADHD symptoms would be associated with increasing risk of lifetime smoking and nicotine dependence, concentration problems secondary to nicotine withdrawal, and maintenance of smoking. Participants were alcohol-dependent adults (n = 242) who did not meet criteria for ADHD or a current Axis I disorder other than alcohol and nicotine dependence. All participants were involved in treatment for alcohol dependence but not smoking cessation. The Semi-Structured Assessment for the Genetics of Alcoholism was administered to collect demographic and smoking history data and to assess symptoms of ADHD and other psychiatric disorders. A higher number of self-reported ADHD symptoms were associated with increased likelihood of ever smoking (p = .026), nicotine dependence (p = .017), and impaired concentration as a symptom of nicotine withdrawal (p = .046). There was no relationship between the number of ADHD symptoms and classification as a former versus current smoker (p = .333). Childhood symptoms of inattention and hyperactivity/impulsivity are related to cigarette smoking and nicotine dependence among alcohol-dependent individuals at levels below the ADHD diagnostic threshold. Conceptualization of ADHD symptoms as occurring on a continuum may aid identification of and early intervention for individuals who are at highest risk for initiating smoking and developing nicotine dependence.

Hennessey KA; Stein MD; Rosengard C; Rose JS; Clarke JG. Childhood attention deficit hyperactivity disorder, substance use, and adult functioning among incarcerated women. Journal of Attention Disorders 14(3): 273-280, 2010. (44 refs.)

Objective: To estimate prevalence of childhood ADHD among incarcerated women and determine its association with substance use and adult functioning. Method: 192 female participants are recruited from the Department of Corrections in Rhode Island. Childhood ADHD is defined as scoring >46 on the Wender Utah Rating Scale. Results: The findings reveal that 46% met criteria for childhood ADHD. Multivariate analysis reveal that women meeting WURS criteria were more likely to be inconsistently employed (OR = 0.23, 95% CI = 0.10-0.54), recently homeless (OR = 2.09, 95% CI = 1.02-4.30), lifetime incarceration of more than 90 days (OR = 3.00, 95% CI = 1.37-6.57), current smokers (OR = 2.99, 95% CI = 1.24-7.20), and ever used marijuana regularly (OR = 3.47, 95% CI = 1.61-7.45). Conclusion: Among incarcerated women, childhood ADHD is associated with negative social and health behaviors.

Hesse M. Course of self-reported symptoms of attention deficit and hyperactivity in substance abusers during early treatment. Addictive Behaviors 35(5): 504-506, 2010. (10 refs.)

Attention deficit and hyperactivity disorder has been associated with poor outcome in studies of substance use disorders. This study aimed to assess the course of self-reported symptoms of both attention deficit and hyperactivity among adults presenting for treatment for substance use disorders. A sample of 75 substance abusers were assessed after they were admitted to a centralized intake unit, and followed at 3 and 6 months after intake by independent interviewers (follow-up rate 81%). Symptoms of attention deficit and hyperactivity were assessed with the Adult Self-report Scale for ADHD (ASRS). Both types of symptoms declined significantly during follow-up, but attention symptoms had a high intraclass correlation (0.79), and hyperactivity had a moderate intraclass correlation (0.64). Both baseline attention deficit and hyperactivity symptoms were associated with worse work and social adjustment after controlling for baseline functioning. Hyperactivity was associated with poorer substance use outcomes at the trend level. In conclusion, both dimensions of ADHD contribute to worse functioning during early treatment for substance abusers, and the ASRS is a reasonably stable measure of ADHD symptoms during early recovery.

Kabir Z; Connolly GN; Alpert HR. Secondhand smoke exposure and neurobehavioral disorders among children in the United States. Pediatrics 128(2): 263-270, 2011. (33 refs.)

OBJECTIVES: The association between parent-reported postnatal secondhand tobacco smoke exposure in the home and neurobehavioral disorders (attention-deficit/hyperactivity disorder, learning disabilities, and conduct disorders) among children younger than 12 years in the United States was examined using the 2007 National Survey on Children's Health. Excess neurobehavioral disorders attributable to secondhand smoke (SHS) exposure in the home in 2007 were further investigated. METHODS: The methods used in this study were multivariable logistic regression models that accounted for potential confounders and complex survey designs to evaluate associations. RESULTS: A total of 6% of 55 358 children (aged < 12 years), corresponding to a weighted total of 4.8 million children across the United States, were exposed to SHS in the home. The weighted prevalence and 95% confidence intervals of each of the children's neurobehavioral outcomes were 8.2% (7.5-8.8) with learning disabilities, 5.9% (5.5-6.4) with attention-deficit/hyperactivity disorder, and 3.6% (3.1-4.0) with behavioral and conduct disorders. Children exposed to SHS at home had a 50% increased odds of having >= 2 childhood neurobehavioral disorders compared with children who were not exposed to SHS. Boys had a significantly higher risk. Older children, especially those aged 9 to 11 years, and those living in households with the highest poverty levels were at greater risk. In absolute terms, 274 100 excess cases in total of these 3 disorders could have been prevented if children had not been exposed to SHS in their homes. CONCLUSIONS: The findings of the study, which are associational and not necessarily causal, underscore the health burden of childhood neurobehavioral disorders that may be attributable to SHS exposure in homes in the United States.

Kalechstein AD; De La Garza R; Newton TF. Modafinil administration improves working memory in methamphetamine-dependent individuals who demonstrate baseline impairment. American Journal on Addictions 19(4): 340-344, 2010. (26 refs.)

Modafinil improves working memory in healthy subjects and individuals diagnosed with schizophrenia and Attention Deficit/Hyperactivity Disorder, though the effects of modafinil have not been evaluated on working memory in methamphetamine-dependent subjects. This double-blind, placebo-controlled study evaluated whether a daily dose of 400 mg of modafinil, administered over three consecutive days, would enhance performance on a measure of working memory relative to test performance at baseline and following 3 days of placebo administration in 11 methamphetamine addicted, nontreatment-seeking volunteers. The results revealed that participants demonstrating relatively poor performance on the third day of a 3-day washout period (ie, at baseline), showed significant improvement on measures of working memory, but not on measures of episodic memory or information processing speed. In contrast, for participants demonstrating relatively high performance at baseline, modafinil administration did not affect test scores. The findings provide an initial indication that modafinil can reverse methamphetamine-associated impairments in working memory.

Kollins SH; McClernon FJ; Van Voorhees EE. Monetary incentives promote smoking abstinence in adults with Attention Deficit Hyperactivity Disorder (ADHD). Experimental and Clinical Psychopharmacology 18(3): 221-228, 2010. (50 refs.)

Individuals with attention deficit hyperactivity disorder (ADHD) smoke at rates significantly higher than the general population and have more difficulty quitting than nondiagnosed individuals. Currently, there are no evidence-based approaches for reducing smoking specifically in individuals with ADHD. Adult regular smokers with or without ADHD participated in a study of extended smoking withdrawal where monetary incentives were used to promote abstinence. Participants were paid according to an escalating schedule for maintaining abstinence measured as self-report of no smoking and an expired air carbon monoxide (CO) level of 4 parts per million. Sixty-four percent (14/22) of smokers with ADHD and 50% (11/22) of smokers without ADHD maintained complete abstinence for the 2-week duration of the study. Twenty-two percent (5/22) and 9% (2/22) of smokers with ADHD and without ADHD, respectively, maintained continued abstinence for up to 10 days following the removal of the contingencies. Though abstinence rates were higher for the smokers with ADHD, the group differences were not statistically significant. Results suggest that monetary incentives may be a useful approach for promoting abstinence in adult smokers with ADHD, perhaps owing to altered reinforcement processes in these individuals.

Konstenius M; Jayaram-Lindstrom N; Beck O; Franck J. Sustained release methylphenidate for the treatment of ADHD in amphetamine abusers: A pilot study. Drug and Alcohol Dependence 108(1-2): 130-133, 2010. (23 refs.)

The efficacy of stimulant treatment in patients with substance use disorders and comorbid attention deficit hyperactivity disorder (ADHD) has been tested for cocaine and alcohol dependence but so far no studies have been conducted in amphetamine dependent individuals. The present trial was a pilot study aiming to test the feasibility of treating amphetamine dependent patients with comorbid ADHD with central stimulant medication. The study was a double-blind, placebo controlled trial with parallel groups design comparing the efficacy of a fixed dose (72 mg) of OROS methylphenidate (MPH) with placebo (PL) in reducing ADHD symptoms in currently abstinent adults with amphetamine dependence and ADHD. Twenty-four treatment seeking patients who met the DSM IV criteria for amphetamine dependence and ADHD were randomized to MPH/PL. The trial was conducted at an outpatient facility with twice weekly visits, measuring ADHD symptoms and drug use. Patients rated their ADHD symptoms on a weekly basis and provided supervised urine specimens for drug toxicology twice weekly. All patients participated in weekly sessions of a skills training programme. Both the groups significantly reduced their self-rated ADHD symptoms during the 12-week treatment but there was no difference between the two treatment arms. Drug use, both measured by urine toxicology and self-report did not differ between the groups. No difference was found between the two groups with regards to craving for amphetamine or in retention in treatment. Larger studies with higher doses combined with individual dosage and longer follow-up periods are warranted.

Lee SS; Humphreys KL; Flory K; Liu R; Glass K. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review. (review). Clinical Psychology Review 31(3): 328-341, 2011. (124 refs.)

Given the clinical and public health significance of substance disorders and the need to identify their early risk factors, we examined the association of childhood attention-deficit/hyperactivity disorder (ADHD) with substance use (nicotine, alcohol, marijuana) and abuse/dependence outcomes (nicotine, alcohol, marijuana, cocaine, other). To strengthen a potential causal inference, we meta-analyzed longitudinal studies that prospectively followed children with and without ADHD into adolescence or adulthood. Children with ADHD were significantly more likely to have ever used nicotine and other substances, but not alcohol. Children with ADHD were also more likely to develop disorders of abuse/dependence for nicotine, alcohol, marijuana, cocaine, and other substances (i.e., unspecified). Sex, age, race, publication year, sample source, and version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) used to diagnose ADHD did not significantly moderate the associations with substance outcomes that yielded heterogeneous effect sizes. These findings suggest that children with ADHD are significantly more likely to develop substance use disorders than children without ADHD and that this increased risk is robust to demographic and methodological differences that varied across the studies. Finally, few studies addressed ADHD and comorbid disruptive behavior disorders (DBD), thus preventing a formal meta-analytic review. However, we qualitatively summarize the results of these studies and conclude that comorbid DBD complicates inferences about the specificity of ADHD effects on substance use outcomes.

Lindblad F; Hjern A. ADHD after fetal exposure to maternal smoking. Nicotine & Tobacco Research 12(4): 408-415, 2010. (29 refs.)

Smoking during pregnancy has been reported to be associated with a twofold to fourfold increased risk of attention-deficit hyperactivity disorder (ADHD) in the offspring. Genetic and socioeconomic confounders may contribute to this association. The aim of this study was to investigate the association between fetal exposure to maternal smoking during pregnancy and ADHD, taking such potential confounders into consideration. A register study in a population of 982,856 children, 6-19 years of age, born at term, and residents in Sweden in 2006 was conducted. Logistic regression was used to calculate odds ratios (ORs) of maternal smoking habits during pregnancy on ADHD medication in the 927,007 study subjects where maternal smoking habits were available from the Medical Birth Register in the presence of socioeconomic and parental psychiatric morbidity confounders. To adjust the analysis also for genetic confounding, we used a within-mother between-pregnancy approach in offspring of 26,292 mothers with inconsistent smoking habits (smoking/non-smoking) between pregnancies. The OR for ADHD medication in offspring of mothers who smoked >= 10 cigarettes/day was 2.86 (2.66-3.07) in the entire study population after adjustment for sex and age, while this same exposure yielded an OR of only 1.26 (0.95-1.58) when two pregnancies of the same mother were analyzed in a within-subjects design. Smoking during pregnancy has a strong association with ADHD in the offspring in the general Swedish population, but this risk is primarily explained by genetic and socioeconomic confounding.

Marco EM; Adriani W; Ruocco LA; Canese R; Sadile AG; Laviola G. Neurobehavioral adaptations to methylphenidate: The issue of early adolescent exposure. (review). Neuroscience and Biobehavioral Reviews 35(8): 1722-1739, 2011. (213 refs.)

Exposure to psychostimulants, including both abused and therapeutic drugs, can occur first during human adolescence. Animal modeling is useful not only to reproduce adolescent peculiarities but also to study neurobehavioral adaptations to psychostimulant consumption. Human adolescence (generally considered as the period between 9/12 and 18 years old) has been compared with the age window between postnatal days (pnd) 28/35 and 50 in rats and mice. These adolescent rodents display basal hyperlocomotion and higher rates of exploration together with a marked propensity for sensation-seeking and risk-taking behaviors. Moreover, peculiar responses to psychostimulants, including enhanced locomotor sensitization, no drug-induced stereotypy and reduced place conditioning have been described in adolescent rodents. During this age window, forebrain dopamine systems undergo profuse remodeling, thus providing a neuro-biological substrate to explain behavioral peculiarities observed during adolescence, as well as the reported vulnerabilities to several drugs. Further, methylphenidate (MPH, better known as Ritalin (R)), a psychostimulant extensively prescribed to children and adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD), raises concerns for its long-term safety. Using magnetic resonance techniques, MPH-induced acute effects appear to be different in adolescent rats compared to adult animals. Moreover, adolescent exposure to MPH seems to provoke persistent neurobehavioral consequences: long-term modulation of self-control abilities, decreased sensitivity to natural and drug reward, enhanced stress-induced emotionality, together with an enhanced cortical control over subcortical dopamine systems and an enduring up-regulation of Htr7 gene expression within the nucleus accumbens (NAcc). In summary, additional studies in animal models are necessary to better understand the long-term consequences of adolescent MPH, and to further investigate the safety of the prescription and administration of such pharmacological treatment at early life stages.

McRae-Clark AL; Carter RE; Killeen TK; Carpenter MJ; White KG; Brady KT. A placebo-controlled trial of atomoxetine in marijuana-dependent individuals with Attention Deficit Hyperactivity Disorder. American Journal on Addictions 19(6): 481-489, 2010. (48 refs.)

This study evaluated the effects of atomoxetine on the symptoms of attention deficit hyperactivity disorder (ADHD) and marijuana use in marijuana-dependent adults. In conjunction with motivational interviewing, participants received either atomoxetine (n = 19) or matching placebo (n = 19) for 12 weeks. Participants randomized to atomoxetine had greater improvement in ADHD on the Clinical Global Impression-Improvement scale than participants treated with placebo. No treatment group differences in self-rated ADHD symptoms, overall Wender-Reimherr Adult Attention Deficit Disorder Scale scores, or marijuana use outcomes were noted. These results suggest that atomoxetine may improve some ADHD symptoms but does not reduce marijuana use in this population.

Motlagh MG; Katsovich L; Thompson N; Lin HQ; Kim YS; Scahill L et al. Severe psychosocial stress and heavy cigarette smoking during pregnancy: An examination of the pre- and perinatal risk factors associated with ADHD and Tourette syndrome. European Journal of Epidemiology 19(10): 755-764, 2010. (62 refs.)

Attention-deficit/hyperactivity disorder (ADHD) is frequently diagnosed in children with Tourette syndrome (TS). The basis for this co-occurrence is uncertain. This study aimed to determine if specific pre- and perinatal risk factors, including heavy maternal smoking and severe psychosocial stress during pregnancy, were associated with one or both disorders, or neither. We compared maternal report data on pre- and perinatal risk factors on 222 children between the ages of 7 and 18 years including 45 individuals with TS alone, 52 individuals with ADHD alone, 60 individuals with condition of comorbid TS + ADHD, and 65 unaffected control children. Pre- and perinatal histories as well as psychiatric assessments were performed using standardized questionnaires and semi-structured interviews with the mothers and children. Logistic regression was used to determine the odds ratio for each variable of interest. Compared to the mothers of unaffected control children, the mothers of children with ADHD alone reported higher rates of heavy smoking (> 10 cigarettes per day) during pregnancy and higher levels of severe psychosocial stress during pregnancy (OR = 13.5, p < 0.01 and OR = 6.8, p < 0.002, respectively). The TS + ADHD and the TS alone patients also had higher rates heavy maternal smoking and high levels of psychosocial stress compared to the control children, but these differences failed to reach statistical significance (heavy smoking: OR = 8.5, p < 0.052, OR = 4.6, p < 0.19, respectively; severe psychosocial stress: OR = 3.1, p < 0.07, OR = 2.6, p < 0.11, respectively). Heavy maternal smoking and severe levels psychosocial stress during pregnancy were independently associated with a diagnosis of ADHD. TS patients also had higher rates of these risk factors, but the ORs failed to reach statistical significance. Efforts are needed to reduce the frequency of these risk factors in high-risk populations. Future studies, using genetically sensitive designs, are also needed to sort out the causal pathways.

Nomura Y; Marks DJ; Halperin JM. Prenatal exposure to maternal and paternal smoking on attention deficit hyperactivity disorders symptoms and diagnosis in offspring. Journal of Nervous and Mental Disease (9): 672-678, 2010. (52 refs.)

The study examined the effect of maternal and paternal smoking during pregnancy on the child's inattention and hyperactivity/impulsivity symptoms, and the risk for attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Generalized estimating equations, incorporating data from multiple informants (parents and teachers), was used to evaluate levels of ADHD as a function of parental smoking. The risk for ADHD, ODD, and comorbid ADHD and ODD was evaluated using polytomous logistic regression. We found that maternal, but not paternal, smoking was significantly associated with elevated inattention, hyperactivity/impulsivity, and total ADHD symptoms in children. Children of smoking, relative to nonsmoking, mothers had a significant increased risk for comorbid ADHD and ODD and ADHD, but not ODD. Although father's smoking was not associated with an increased risk, as it strongly influenced mothers' smoking, intervention for both parents may be most effective in preventing the pathway to ADHD-related problems in the children.

Reid RC; Carpenter BN; Gilliland R; Karim R. Problems of self-concept in a patient sample of hypersexual men with attention-deficit disorder. Journal of Addiction Medicine 5(2): 134- 140, 2011. (60 refs.)

Objectives: Earlier evidence suggests comorbid attention-deficit disorder (ADHD) among those seeking treatment for hypersexual behavior. This article examines which facets of ADHD symptoms are most strongly associated with hypersexual behavior among a patient sample of men (N = 81). Methods: ADHD diagnosis was made by 2 clinicians, and symptom characteristics were measured using the Conners' Adult ADHD Rating Scale and the Sexual Compulsivity Scale. Results: Among ADHD symptoms, inattentive features were most prevalent. A stepwise regression analysis revealed that the Problems with Self-Concept subscale of the Conners' Adult ADHD Rating Scale was the strongest predictor of scores on the Sexual Compulsivity Scale. Surprisingly, subscales that measured traits of impulsivity, inattention, memory problems, and hyperactive restlessness did not contribute additional predictive variance in the statistical model. Conclusions: The results of these findings suggest that clinicians should exercise caution in assuming that common characteristics of ADHD, such as impulsivity and hyperactivity, exert the strongest influence on hypersexual behavior. Rather, our results provide evidence that the associated features of ADHD, such as problems with low self-esteem, might be more salient factors in influencing hypersexuality severity among patients with comorbid hypersexual behavior and ADHD.

Sevak RJ; Stoops WW; Rush CR. Behavioral effects of d-amphetamine in humans: Influence of subclinical levels of inattention and hyperactivity. American Journal of Drug and Alcohol Abuse 36(4): 220-227, 2010. (33 refs.)

Objective: Several studies suggest a link between stimulant abuse and attention-deficit hyperactivity disorder (ADHD) symptoms (e. g., inattention and hyperactivity). To further assess the nature of this relationship, the present study examined the association between subclinical symptoms of inattention and hyperactivity and the behavioral effects of d-amphetamine. Methods: Participants were classified into a High-(n = 8) or Low-Score (n = 9) group based on their responses on a rating scale that assessed inattention and hyperactivity symptoms. Results: The participants did not differ across the High-Score and Low-Score groups in their ability to discriminate d-amphetamine. The participants in the High-Score group were significantly more sensitive to the positive participant-rated effects of d-amphetamine (e. g., Good Effects, Like Drug), but less sensitive to drug-induced increases in blood pressure and heart rate. Conclusion: The selective increase in positive subjective effects of d-amphetamine suggests that individuals with subclinical inattention and hyperactivity symptoms may have increased vulnerability to stimulant abuse.

Silva RR; Skimming JW; Muniz R. Cardiovascular safety of stimulant medications for pediatric attention-deficit hyperactivity disorder. Clinical Pediatrics 49(9): 840-851, 2010. (62 refs.)

Attention-deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder that is often treated with stimulants such as methylphenidate and mixed amphetamine salts. Despite their efficacy and long history of use, there is concern about their potential for adverse cardiovascular effects in children and adolescents. Data from placebo-controlled and open-label extension trials published after 2000 were reviewed, and cardiovascular adverse event data were compared. Both placebo-controlled and open-label extension trials have repeatedly shown stimulant-induced increases in mean blood pressure, heart rate, and QT interval in children, adolescents, and adults. Although these increases seem relatively minor, their existence raises questions regarding whether stimulants could influence the likelihood of sudden death or other serious cardiovascular consequences, especially in patients with underlying heart problems. Moreover, questions have been raised regarding the necessity of screening patients for occult or unrecognized heart problems that are felt to be adversely affected by stimulant use. Obtaining a baseline electrocardiogram for any patient starting stimulant treatment is reasonable if access to such screening is readily available and not too costly.

Singh I; Kendall T; Taylor C; Mears A; Hollis C; Batty M et al. Young people's experience of ADHD and stimulant medication: A qualitative study for the NICE Guideline. Child and Adolescent Mental Health 15(4): 186-192, 2010. (18 refs.)

Background: The NICE ADHD Guideline Group found a lack of research evidence on young people's experiences with stimulant medications. The present study was commissioned to help fill this gap in the evidence base and to inform the Guideline. Method: Focus groups and 1: 1 interviews with 16 UK young people with ADHD. Results: Young people were positive about taking medication, feeling that it reduced their disruptive behaviour and improved their peer relationships. Young people experienced stigma but this was related more to their symptomatic behaviours than to stimulant drug medication. Conclusions: The study's findings helped to inform the NICE guideline on ADHD by providing evidence that young people's experiences of medication were in general more positive than negative. All NICE Guidelines involving recommendations for the treatment of young people should draw on research evidence of young people's experiences of treatments.

Sollman MJ; Ranseen JD; Berry DTR. Detection of feigned ADHD in college students. Psychological Assessment 22(2): 325-335, 2010. (56 refs.)

Significant motivations and incentives exist for young-adult students to seek a diagnosis of attention-deficit/hyperactivity disorder (ADHD). With ADHD information readily accessible on the Internet, today's students are likely to be symptom educated prior to evaluation. This may result in false-positive diagnoses. particularly when students are motivated to convey symptoms. We evaluated the utility of ADHD symptom checklists, neurocognitive tests, and measures initially developed to detect feigned neurocognitive or psychiatric dysfunction (symptom validity tests [SVTs]). The performance of 31 undergraduates financially motivated and coached about ADHD via Internet-derived information was compared to that of 29 ADHD undergraduates following medication washout and 14 students not endorsing symptomatology. Results indicated malingerers readily produced ADHD-consistent profiles. Symptom checklists, including the ADHD Rating Scale and Conners's Adult ADHD Rating Scale-Self-Rating Form: Long, were particularly susceptible to faking. Conners's Continuous Performance Test-II findings appeared more related to motivation than condition. Promising results were seen with all cognitive SVTs (Test of Memory Malingering [TOMM]. Digit Memory Test, Letter Memory Test. and Nonverbal Medical Symptom Validity Test). particularly TOMM Trial 1 when scored using Trial 2 criteria. All SVTs demonstrated very high specificity for the ADHD condition and moderate sensitivity to faking, which translated into high positive predictive values at rising base rates of feigning. Combining 2 or more failures resulted in only modest declines in sensitivity but robust specificity. Results point to the need for a thorough evaluation of history, cognitive and emotional functioning, and the consideration of exaggerated symptomatology in the diagnosis of ADHD.

Thompson J; Thompson JR. Acute myocardial infarction related to methylphenidate for adult attention deficit disorder. Journal of Emergency Medicine 38(1): 18-21, 2010. (17 refs.)

Adult Attention Deficit Disorder is increasingly diagnosed and treated. Psychostimulant medications, such as methylphenidate, are commonly prescribed for this condition, but the long-term safety of such medications in an adult population is unknown at present. Because these medications are closely related to amphetamines, it is expected that toxic side effects would be similar. We present the case of a 27-year-old man who suffered an acute myocardial infarction due to coronary vasospasm related to use of methylphenidate complicated by concomitant use of pseudoephedrine.

Walker LR; Abraham AA; Tercyak KP. Adolescent caffeine use, ADHD, and cigarette smoking. Children's Health Care 39(1): 73-90, 2010. (59 refs.)

The purpose of this study was to describe the prevalence of adolescent caffeine use and its association with attention deficit hyperactivity disorder (ADHD) and cigarette smoking. A total of 448 adolescents between the ages of 13 and 21 years consecutively presenting for routine, well-child care were studied. Twenty-four percent had a pre-existing diagnosis of ADHD, and 47% reported a positive lifetime history of cigarette smoking. Eighty-five percent of participants reportedly consumed a caffeinated beverage within the past 30 days; 38% had consumed 1+ cups of caffeinated coffee, and 78% had consumed 1+ glasses of another caffeinated beverage other than coffee (e.g., tea or soft drinks). After controlling for sociodemographic and other potential confounding factors, an ADHD diagnosis and a positive lifetime smoking history were significantly associated with caffeine use: Adolescents with ADHD were nearly twice as likely to use more caffeine than were adolescents without ADHD (odds ratio [OR] = 2.08; 95% confidence interval [CI] = 1.23, 3.50, p = .006); lifetime smokers were 80% more likely to use more caffeine than were adolescents who had never smoked (OR = 1.80; 95% CI = 1.16, 2.79, p = .009). Caffeine use is elevated among adolescents diagnosed with ADHD and those who have ever tried cigarette smoking. Although caffeine is a non-illicit psychostimulant, these findings add to the emerging data on substance use behaviors among adolescents with ADHD. Health care professionals who work with adolescents with ADHD should regularly screen for both cigarette and caffeine use among their patients.

Weafer J; Milich R; Fillmore MT. Behavioral components of impulsivity predict alcohol consumption in adults with ADHD and healthy controls. Drug and Alcohol Dependence 113(2-3): 139-146, 2011. (72 refs.)

Background: The degree to which distinct behavioral components of impulsivity predict alcohol consumption is as yet not well-understood. Further, the possibility that this relation might be more pronounced in groups characterized by heightened impulsivity (i.e., individuals with ADHD) has not been tested. Methods: The current study examined the degree to which three specific behavioral components of impulsivity (i.e., poor response inhibition, poor attentional inhibition, and increased risk-taking) were associated with quantity and frequency of alcohol consumption in a group of young adult social drinkers with ADHD (n = 33) and in a comparison control group (n = 21). Participants performed the delayed ocular return task (attentional inhibition), the cued go/no-go task (behavioral inhibition), and the balloon analogue risk task (risk-taking). Results: Both poor behavioral inhibition and greater risk-taking were related to greater quantity of consumption in the entire sample, whereas poor attentional inhibition was related to greater quantity specifically among those with ADHD. By contrast, only risk-taking was associated with frequency of consumption, and this was found specifically in the control group. Conclusions: These findings provide important information regarding the potential role of distinct behavioral components of impulsivity in drinking behavior, and highlight unique relevance of attentional impairments to drinking behavior in those with ADHD.

Weiss N. Assessment and treatment of ADHD in adults. Psychiatric Annals 41(1): 24-32, 2011. (61 refs.)

Multiple studies have demonstrated that up to 50% of adult patients with ADHD have comorbid substance use problems. Other comorbidities include learning disorders; intellectual disability (mental retardation); impulse control disorders (Tourette's syndrome, obsessive-compulsive disorder); eating disorders; personality disorders; and autism spectrum disorders, although current DSM nomenclature excludes a diagnosis of ADHD in the setting of autism. This article covers clinical presentation, assessment and diagnosis, comorbidity and differential diagnosis, treatment. It also discusses stimulant medications, their safety and tolerability, and also their misuse, abuse and diversion. A non-stimulant medication, atomoxetine, is also reviewed. Cognitive behavioral therapy is also discussed, although medications are considered the first choice in treatment.

Wilens TE; Martelon M; Joshi G; Bateman C; Fried R; Petty C et al. Does ADHD predict substance-use disorders? A 10-year follow-up study of young adults with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry 50(6): 543-553, 2011. (56 refs.)

Objective: High rates of substance-use disorders (SUD) have been found in samples of adolescents and adults with attention-deficit/hyperactivity disorder (ADHD). Predictors of SUD in children with ADHD who are at risk for the development of SUDs remain understudied. The main aims of this study were to identify clinically meaningful characteristics of children that predicted the future development of SUDs and to see whether the role of these characteristics varied by sex. Method: Subjects were children and adolescents with (n = 268; mean age +/- standard deviation = 10.9 +/- 3.2 years) and without (n = 229; mean age 11.9 +/- 3.3 years) DSM-III-R ADHD followed prospectively and blindly over a 10-year follow-up period onto young adult years. Subjects were assessed with structured diagnostic interviews for psychopathology and SUDs. Results: Over the 10-year follow-up period, ADHD was found to be a significant predictor of any SUD (hazards ratio 1.47; 95% confidence interval 1.07-2.02; p = .01) and cigarette smoking (2.38; 1.61-3.53; p < .01). Within ADHD, comorbid conduct disorder (2.74; 1.66-4.52; p < .01) and oppositional defiant disorder (2.21; 1.40-3.51; p < .01) at baseline were also found to be significant predictors of SUDs. Similar results were found for cigarette-, alcohol-, and drug-use disorders. There were few meaningful sex interaction effects. No clinically significant associations were found for any social or family environment factors or for cognitive functioning factors (p > .05 for all comparisons). Conclusions: These results indicate that ADHD is a significant risk factor for the development of SUDs and cigarette smoking in both sexes.

Wilens TE; Morrison NR. The intersection of attention-deficit/hyperactivity disorder and substance abuse. (review). Current Opinion in Psychiatry 24(4): 280- 285, 2011. (35 refs.)

Purpose of review: The link between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) continues to be an area of great interest. In this report more recent work exploring the developmental relationship between ADHD and SUDs and associated concurrent disorders is discussed. Recent findings: Recent work highlights the role of treatment of ADHD in children on subsequent cigarette smoking and SUDs in adolescence and adulthood. Contemporary data suggest that ADHD may be underdiagnosed in SUD populations. Studies in patients with ADHD and SUDs suggest that SUDs treatment needs to be sequenced initially with ADHD treatment quickly thereafter. Recent studies also highlight concerns associated with the misuse and diversion of prescription stimulants in ADHD adolescents and young adults and indicate that extended-release stimulants may reduce the likelihood for abuse. Summary: Practitioners are increasingly recognizing the overlap between ADHD and SUDs, and treatment modalities including cognitive behavioral therapy and pharmacotherapy demonstrate mixed results in the treatment of these comorbid disorders. Areas in need of further investigation include the mechanism(s) by which ADHD leads to SUDs, diagnostic criteria associated with ADHD in SUD individuals, and prevention and treatment strategies for these populations.

Winhusen TM; Somoza EC; Brigham GS; Liu DS; Green CA; Covey LS et al. Impact of attention-deficit/hyperactivity disorder (ADHD) treatment on smoking cessation intervention in ADHD smokers: A randomized, double-blind, placebo-controlled trial. Journal of Clinical Psychiatry 71(12): 1680-1688, 2010. (44 refs.)

Objective: High smoking rates in adults with attention-deficit/hyperactivity disorder (ADHD) and nicotine's amelioration of ADHD suggest that effective ADHD treatment might facilitate abstinence in smokers with ADHD. The present study evaluated if using osmotic-release oral system methylphenidate (OROS-MPH) to treat ADHD enhances response to smoking cessation treatment in smokers with ADHD. Method: A randomized, double-blind, placebo-controlled, 11-week trial with a 1-month follow-up was conducted at 6 clinical sites between December 2005 and January 2008. Adults (aged 18-55 years) meeting DSM-IV criteria for ADHD and interested in quitting smoking were randomly assigned to OROS-MPH titrated to 72 mg/d (n = 127) or placebo (n = 128). All participants received brief weekly individual smoking cessation counseling for 11 weeks and 21 mg/d nicotine patches starting on the smoking quit day (day 27) through study week 11. Outcome measures included prolonged smoking abstinence and DSM-IV ADHD Rating Scale (ADHD-RS) score. Results: Of 255 randomly assigned participants, 204 (80%) completed the trial. Prolonged abstinence rates, 43.3% and 42.2%, for the OROS-MPH and placebo groups, respectively, did not differ significantly (OR = 1.1; 95% Cl, 0.63-1.79; P = .81). Relative to placebo, OROS-MPH evidenced a greater reduction in DSM-IV ADHD-RS score (P < .0001) and in cigarettes per day during the post-quit phase (P = .016). Relative to placebo, OROS-MPH increased blood pressure and heart rate to a statistically, but not clinically, significant degree (P < .05); medication discontinuation did not differ significantly between treatments. Conclusions: Treatment for ADHD did not improve smoking cessation success; OROS-MPH, relative to placebo, effectively treated ADHD and was safe and generally well tolerated in this healthy sample of adult ADHD smokers.

Xu XH; Cook RL; Ilacqua VA; Kan HD; Talbott EO. Racial differences in the effects of postnatal environmental tobacco smoke on neurodevelopment. Pediatrics 126(4): 705-711, 2010. (38 refs.)

OBJECTIVES: We used the 2001-2004 National Health and Nutrition Examination Survey to examine the association between postnatal environmental tobacco smoke exposure, measured as serum cotinine levels, and attention-deficit/hyperactivity disorder (ADHD) among children 4 to 15 years of age. We further investigated the interactions of race and serum cotinine levels with ADHD. METHODS: Logistic regression models were used to evaluate associations. RESULTS: This study found that the prevalence of ADHD increased as blood cotinine levels increased. The effects of blood cotinine levels on ADHD differed according to race. Compared with children of the same racial group with the lowest blood cotinine levels, the odds ratios were 2.72 (95% confidence interval: 1.25-5.93) for Mexican American children and 5.32 (95% confidence interval: 1.55-18.3) for children in other racial groups with the highest blood cotinine levels, with controlling for the effect of maternal smoking during pregnancy. However, no significant associations between blood cotinine levels and ADHD were observed among non-Hispanic white or non-Hispanic black children. CONCLUSIONS: The findings of this study underscore the possibility of racial disparities in the effects of environmental tobacco smoke on behavioral problems in children. These findings warrant further investigation.

Yang LK; Shang CY; Gau SSF. Psychiatric comorbidities in adolescents with attention-deficit hyperactivity disorder and their siblings. Canadian Journal of Psychiatry 56(5): 281-292, 2011. (48 refs.)

Objective: Despite high psychiatric comorbidities in adolescents with clinical diagnosis of attention-deficit hyperactivity disorder (ADHD), little is known about psychiatric comorbidities in their siblings. We investigated the psychiatric comorbid conditions in adolescents with ADHD, their siblings, and healthy control subjects from their school. Method: The sample included 136 adolescent probands with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), diagnostic criteria; 136 siblings (47 affected and 89 unaffected) and 136 age- and sex-matched healthy school control subjects. All participants and their parents received the structured psychiatric interviews for current and lifetime DSM-IV psychiatric disorders of the participants. Results: The rate of ADHD (34.6%) in the siblings of probands with ADHD was about 7 times higher than in the general population. Probands with ADHD were significantly more likely than unaffected siblings (OR 6.38; 95% CI 3.43 to 11.88) and healthy school control subjects (OR 9.60; 95% CI 5.31 to 17.34) to have a DSM-IV psychiatric disorder, including oppositional defiant disorder (ODD), conduct disorder (CD), tic disorders, major depressive disorder, specific phobia (more than control subjects only), nicotine use disorder, and sleep disorders. The affected siblings were significantly more likely than healthy school control subjects to have ODD, CD, specific phobia, and to have consumed alcohol (ORs ranging from 2.30 to 20.16). Conclusions: Our findings suggest that siblings of probands with ADHD have increased risks for ADHD and that the affected siblings have more psychiatric comorbidities than healthy school control subjects. It warrants early identification of ADHD symptoms and other psychiatric comorbid conditions as well in siblings of adolescents with ADHD.