Running head: A REVIEW OF ADHD AND RISK FACTORS FOR SUBSTANCE ABUSE

A Review of ADHD and Risk Factors Associated with Substance Abuse Jaylene Bettcher APSY 651 Disorders of Learning and Behaviour Dr. Brent Macdonald November 30, 2010

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE A Review of ADHD and Risk Factors Associated with Substance Abuse Attention-deficit hyperactivity disorder (ADHD) is a common childhood neurobehavioural disorder that is characterized by problems with attention, impulsivity, and hyperactivity (Glass and Flory, 2010). According to Marshal and Molina (2006), core symptoms of ADHD may place children at greater risk for academic failure, social isolation, and affiliation with deviant peer groups, which may consequently lead to substance use and abuse. ADHD is often found to co-occur with two behavioural disorders, oppositional defiant disorder (ODD) and conduct disorder (CD), that also place children at greater risk for substance abuse (Marshal & Molina, 2006). Are the core symptoms of ADHD responsible for placing children at greater risk for substance abuse? Or are comorbid symptoms responsible for moderating the relationship between ADHD and substance abuse? ADHD types and Risk Factors ADHD is one of the most common neurobehavioural disorders in North America, affecting 3-7% of school-aged children, most of which are boys (Salmeron, 2009). Although the precise etiology of ADHD is uncertain, Salmeron (2009) explains that ADHD is the result of many environmental and genetic factors, both known and unknown. According to the American Psychiatric Association (DSM-IV-TR) the diagnostic criteria for ADHD are separated into two clusters: inattention, and hyperactivity/impulsivity. Inattention and hyperactivity/impulsivity are further separated into three subtypes, which are predominantly inattentive type (ADHD-PI), predominantly hyperactive and impulsive type (ADHD-PHI), and combined type (ADHD-C) (2000). The following paragraphs will further examine each subtype and the differential risk factors within each subtype that are associated with substance abuse. Many children that are diagnosed with ADHD-PI have a profound inability to maintain attention; they are forgetful, easily distracted, and often avoid tasks that involve sustained

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE concentration (Barkley, 2003). Children with ADHD-PI may be at risk for substance abuse disorders not only because they are deemed less popular by their peers, but also because they tend to perform poorly in school (Glass & Flory, 2010). According to a study by Marshal and Molina (2006), both children and their parents rated children with ADHD-PI less affable than typically developing children. This finding may implicate that children with ADHD-PI are at risk for social failure and low self-esteem, which are two risk factors associated with substance abuse (Realmuto et al., 2009). A study by Molina, Smith, and Pelham (2001) found that many children with ADHD-PI scored lower on standardized achievement tests compared to children with ADHD-PHI. Salmeron (2009) explains that academic difficulties are correlated with increased frustration, decreased self-esteem, and rejection by peers, all of which may lead to affiliation with deviant peer groups, and consequently substance abuse. Many children diagnosed with ADHD-PHI are restless, careless, and boisterous, and they may frequently defy social regulations (Barkley, 2003). Children with ADHD-PHI often take part in impulsive, sensation-seeking behaviours, and in turn they may find it problematic to regulate their emotions and behaviours while interacting with other children (Marshal & Molina, 2006). Salmeron (2009) explains that typically developing children may believe that children with ADHD-PHI display inappropriate behaviours that are both offensive and intolerable, and consequently typically developing children may reject and alienate their peers with ADHD-PHI. As previously noted, children who encounter rejection and social isolation are more likely to associate with deviant peers and develop substance abuse disorders in adolescence (Marshal & Molina, 2006). Furthermore, Ivanov, Schulz, London, and Newcorn (2008) confirm that impulsive behaviours are ubiquitously correlated with substance abuse. ADHD and Substance Abuse

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE ADHD is a heterogeneous disorder, not only do symptoms vary among ADHD types, but also, individualized factors may either alleviate or aggravate the severity and persistence of symptoms. The following studies portray this heterogeneity, as there are differential results depicting the relationship between ADHD and substance use and abuse. This section will explore and synthesize the results from studies on different ADHD types, substances, and mediating risk factors in order to determine if core symptoms of ADHD are primarily responsible for placing children at greater risk for substance abuse. According to Molina and Pelham (2003), studies that separate ADHD-PI symptoms from ADHD-PHI symptoms often find differential relationships with substance abuse. In 2001, Burke et al. examined the prevalence of cigarette smoking in youth with ADHD-PI compared to youth with ADHD-PHI. Burke et al. (2001) used diagnostic interviews and parent teacher reports to assess ADHD type (either ADHD-PI or ADHD-PHI), smoking prevalence, and to control for ODD and CD symptoms (individuals that presented with these symptoms were excluded from the study). The 177 participants were assessed at age 9-12, and again at age 13-15. Burke et al. (2001) found that there was a significant increase in smoking prevalence among the participants with ADHD-PI compared to the participants with ADHD-PHI. These results may implicate that ADHD type may be a significant predictor in the development of substance abuse, more specifically; ADHD-PI symptoms may be risk factors for cigarette smoking. Glass and Flory (2010) suggest that children and adolescents with ADHD-PI may smoke cigarettes to alleviate their inattentive symptoms, and that cigarettes may be a form of self medication. Glass and Flory (2010) further explain that nicotine has a stimulatory effect on the central nervous system that may improve attention span and cognitive processes. Although ADHD-PI may be a significant predictor of smoking, it is important to note that Burke et al.

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE (2001) did not control for variables like parental smoking, academic failure, and affiliation with deviant peer groups in their study. These variables have been found to mediate smoking in children with ADHD-PI, and consequently inattentive symptoms may not solely predict smoking patterns in youth with ADHD (Molina & Pelham, 2003). Molina and Pelham (2003) explored the relationship between early substance use and abuse in children with ADHD compared to children without ADHD. Parent and teacher rating scales and clinical interviews were utilized to assess ADHD, substance use (cigarette and alcohol), and externalizing problems (ODD or CD symptoms) in 242 participants when they were age 5-12, and again when they were age 13-18. In order to accurately analyze the results, the participants were separated into three groups: youth without ADHD (control group), youth with ADHD, and youth with ADHD and CD. Molina and Pelham (2003) found that the youth with ADHD, particularly youth with inattentive symptoms, reported that they used alcohol and cigarettes more often than youth without ADHD. They also found that youth with ADHD and comorbid CD reported that they often used illicit drugs, whereas few individuals in the control group or the ADHD group reported that they had tried illicit substances. Molina and Pelham (2003) concluded that childhood ADHD is correlated with an increased risk for cigarette and alcohol use, as well as earlier age of first use. Consistent with Burk et al. (2001), Molina and Pelham (2003) found that inattentive symptoms predict cigarette and alcohol use and abuse more than hyperactive and impulsive symptoms. However, the results must be interpreted with caution because hyperactive and impulsive symptoms in late adolescence may either decrease or present as inattentive symptoms (Barkley, 2005). Thus the youth with ADHD-PHI may have presented as the youth with ADHDPI, which may create an inaccurate finding that youth with ADHD-PI are at greater risk for

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE cigarette and alcohol use compare to youth with ADHD-PHI. However, further studies need to be completed in order to determine if ADHD is a significant predictor of cigarette and alcohol abuse, or if comorbid externalizing symptoms and or early age of first use are significant predictors of cigarette and alcohol abuse. Jestor et al. (2008) also examined the differential relationship between ADHD types and substance use. Jestor et al. (2008) assessed 335 child participants and separated them into four groups: typically developing children (131 participants), children with ADHD-PI (110 participants), children with ADHD-PHI (12 participants), and children with ADHD and CD (82 participants). The participants were further assessed for substance use and abuse through clinical interviews and self-report questionnaires. Jestor et al. (2008) found that the children with ADHD reported that they used substances more often than the typically developing children. Also, the children with ADHD-PHI and ADHD and CD reported earlier substance use for both alcohol and illicit substances compared to children with ADHD-PI and typically developing children. The finding that children with ADHD-PHI and ADHD and CD reported earlier and more frequent substance use, contradicts Burke et al. (2001) and Molina and Pelhams (2003) finding that ADHD-PI is a primary predictor of cigarette and alcohol use. Jestor et al. (2008) reason that ADHD-PHI may be a milder form of CD, and therefore, many participants with ADHD-PHI may have been included in the ADHD/CD group, which may contribute to the large difference in sample size between ADHD-PHI and ADHD-PI. Thus it is uncertain whether childhood ADHDPHI symptoms or CD symptoms are indicative of alcohol and illicit substance use and abuse. Therefore, additional studies on ADHD and ADHD and CD need to be reviewed in order to distinguish which symptomolgy has greater predictive value for substance abuse.

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE The previous studies examined the relationship between ADHD types, substance types, and mediating risk factors for substance abuse. The findings indicate that ADHD-PI may be a significant risk factor for cigarette and alcohol use, while ADHD-PHI may be a significant risk factor for alcohol use and illicit drug use. The studies reviewed revealed that core symptoms of ADHD place many children at risk for substance abuse. However, it is unknown if symptoms either directly contribute to substance abuse, or if symptoms indirectly contribute to substance abuse by placing children at risk for aberrant behaviours, which may lead to substance abuse. The relationship between ADHD and comorbid ODD or CD also needs further exploration in order to determine if comorbidity is a significant risk factor for substance abuse. ADHD/ODD/CD and Substance Abuse ODD and CD are the two most common comorbid disorders among youth with ADHD. According to Glass and Flory (2010) approximately 45-85% of youth with ADHD exhibit diagnostic criteria for either ODD or CD. The diagnostic criteria for ODD include defiant, hostile, and negative behaviours, whilst the diagnostic criteria for CD include violating social regulations, norms, and others rights (DSM-IV-TR, 2000). It has been suggested that ODD and or CD may moderate the relationship between ADHD and substance abuse. The following studies will review the relationship between ADHD, ODD, CD and substance abuse, in order to determine if ODD and CD are essential factors in predicting adolescent substance abuse. A longitudinal study by Realmuto et al. (2009) compared the relationship between ADHD and substance use to the relationship between ADHD/ODD and substance use. Realmuto et al. (2009) assessed 112 participants for ADHD, externalizing problems (ODD symptoms), and substance use/abuse at age 11- 15 and again at age 12-16. The results indicated that youth with ADHD and externalizing symptoms were more likely to engage in substance use compared to

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE youth with ADHD without externalizing symptoms and typically developing youth. Although Realmuto et al. (2009) found that childhood ADHD, when absent of externalizing symptoms, is not a reliable predictor of substance abuse in adolescence, they also found that compared to the typically developing participants, the participants with childhood ADHD had more physical health problems and psychosocial problems. According to Marshal and Pelham (2003) psychosocial problems may mediate affiliation with deviant peer groups, which may contribute to aberrant behaviours like substance abuse. August et al. (2006) investigated if externalizing disorders (ODD and CD) were significant risk factors for substance abuse in youth with ADHD-C. The participants were separated into three groups; youth with ADHD-C, youth with ADHD and externalizing problems (most met criteria for ODD), and typically developing youth. The participants were assessed through parent reports and self reports from childhood to late adolescence to determine if they met the criteria for ADHD-C, externalizing disorders, and substance abuse (tobacco, alcohol, and marijuana). The results from the study indicated that there was no significant increase of substance use or abuse among the youth with ADHD-C or the typically developing youth, which is contrary to findings by Burke et al. (2001) and Marshal and Pelham (2003). However, August et al. (2006) assessed youth with ADHD-C, so individuals with ADHD-PI may have been excluded from the study. August et al. (2006) also found that the youth with ADHD and externalizing problems had significantly higher reports of alcohol abuse, marijuana abuse, and tobacco use compared to the youth with ADHD-C and the typically developing youth. This finding was consistent with Molina and Pelhams (2003) finding that comorbid externalizing disorders are associated with increased drug use. Therefore, it may be plausible to infer that externalizing behaviours moderate the relationship between ADHD and substance use and abuse.

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE Marshal and Molina (2006) examined the implications of externalizing disorders and deviant peer affiliations on substance abuse in adolescents with ADHD. The participants were 142 individuals with either ADHD or ADHD and comorbid ODD or CD, who were assessed for behavioural disorders, affiliation with deviant peers, and substance use at age 5-12 and again at age 13-17. The results indicated that affiliation with deviant peer groups was highly correlated with individuals with ADHD-PI and individuals with ADHD and comorbid ODD or CD (Marshal & Molina, 2006). The possibility exists that ODD is a keystone factor in this pathway. Children with ODD are argumentative, noncompliant, spiteful, and defiant toward authority. Either by choice or default (peer rejection), these children are attracted to other children with similar behavioral characteristics (August et al., 2006, pp. 830). Therefore, according to August et al. (2006) substance abuse in youth with ADHD and comorbid ODD or CD may be a result of social reinforcement and modeling through peers. The previous studies examined the relationship between ADHD and comorbid externalizing disorders (ODD and CD), and substance abuse. The findings from these studies indicate that ODD and CD moderate the relationship between ADHD and substance use and abuse. In addition, the findings also indicate that aberrant behaviours like affiliating with deviant peer groups mediate the relationship between ADHD and comorbid ODD or CD and substance abuse. As a result, the prognosis of children with ADHD and comorbid ODD or CD may be less favourable than children with ADHD. However, it is important to take into account that the youth with ADHD and comorbid ODD or CD may have exaggerated their substance use and their peers substance use in attempt to defy and violate social regulations, which is characteristic of ODD and CD (Marshal & Molina, 2006).

A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE Future Recommendations The studies in this review focused on the relationship between ADHD and substance use and abuse, and whether or not childhood ADHD is a risk factor for adolescent substance abuse. There were numerous discrepancies between the studies as to whether the types of ADHD symptoms, severity of ADHD symptoms, persistence of ADHD symptoms, or comorbid symptoms were the primary risk factor for substance use in adolescents (August et al., 2006). This indicates that subsequent research needs to occur to understand whether substance abuse is causal, consequent, or co-occurring with ADHD or ADHD and comorbid externalizing disorders. Although future research is needed, early detection of risk factors (ADHD symptoms, comorbid ODD or CD, and aberrant behaviours) associated with substance abuse may allow school psychologists to identify children and adolescents at risk for substance abuse. Moreover, this may promote the development of successful early intervention programs, which may increase an at risk individuals resiliency and prognosis. Many children and adolescents with ADHD are at greater risk for academic failure, social isolation, affiliation with deviant peer groups, and substance abuse (Marshal & Molina, 2006). This paper specifically focused on the relationship between ADHD and substance abuse, and whether or not this relationship was moderated by comorbid ODD or CD. The differential findings from this review indicate the complexity and interrelatedness of the variables involved, therefore, it was difficult to determine if one factor was more indicative of substance abuse than the other. This implication may suggest that there are multiple predictors and risk factors associated with ADHD and substance abuse, and instead of merely taking into account one factor, we must observe how ADHD symptoms, severity of symptoms, persistence of symptoms, and comorbidity influence and interact with one another (August et al., 2006). By developing a

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A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE holistic perspective, we may be able to better understand risk factors associated with childhood ADHD, which may lead to better prevention and intervention programs.

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A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. August, G. J., Winters, K. C., Realmuto, G. M., Fanhorst, T., Botzet, A., & Lee, S. (2006). Prospective study of adolescent drug use among community samples of ADHD and NonADHD participants. American Academy of Child and Adolescent Psychiatry, 45, 824832. doi:10.1097/01.chi.0000219831.16226.f8 Barkley, R. A. (2003). Autistic disorder. In R. A. Barkley, & E. J. Mash (Eds.). Child psychopathology, 2nd edition (p. 409-454). New York: Guilford Press Burke, J. D., Loeber, R., & Lahey, B. B. (2001). Which aspects of ADHD are associated with tobacco use in early adolescence? Journal of Child Psychology and Psychiatry and Allied Disciplines, 42, 493-502. Retrieved from the Academic Search Complete database on November 25, 2010. Glass, G., & Flory, K. (2010). Why does ADHD confer risk for cigarette smoking? A review of psychosocial mechanisms. Clinical Child and Family Psychology Review, 13, 291-313. doi:10.1007/s10567-010-0070-3 Ivanov, I., Schulz, K. P., London, E. D., & Newcorn, J. H. (2008). Inhibitory control deficits in childhood and risk for substance use disorders: A review. The American Journal of Drug and Alcohol Abuse, 34, 239-258. doi: 10.1080/00952000802013334 Jester, J. M., Nigg, J. T., Buu, A., Puttler, L. I., Glass, J. M., Heitzeg, M. M.,...Zucker, R. A. (2008). Trajectories of childhood aggression and inattention/hyperactivity: Differential effects on substance abuse in adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 1158-1164. doi:10.1097/CHI.0b013e3181825a4e

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A REVIEW OF ADHD AND RISK FACTORS ASSOCIATED WITH SUBSTANCE ABUSE Marshal, M. P., & Molina, B. S., (2006). Antisocial behaviors moderate the deviant peer pathway to substance use in children with ADHD. Journal of Clinical Child and Adolescent Psychology, 35, 216-226. doi:10.1207/s15374424jccp3502_5 Molina, B. S., Smith, B., & Pelham, W. E. (2001). Factor structure and criterion validity of secondary school teacher ratings of ADHD and ODD. Journal of Abnormal Child Psychology, 29, 71-81. Retreived from the Academic Search Complete Database on November 24, 2010. Molina, B. S., & Pelham, W. E. (2003). Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. Journal of Abnormal Psychology, 112, 497507. doi: 10.1037/0021-643X.112.3.497 Realmuto, G. M., Winters, G. C., August, G. J., Lee, S., Fahnhorst, T., & Botzet, A. (2009). Drug use and psychosocial functioning of a community-derived sample of adolescents with childhood ADHD. Journal of Child & Adolescent Substance Abuse, 18, 172-192. doi: 10.1080/10678280902724176 Salmeron, P. A. (2009). Childhood and adolescent attention-deficit hyperactivity disorder: Diagnosis, clinical practice guidelines, and social implications. Journal of the American Academy of Nurse Practitioners, 21, 488-497. doi:10.1111/j.1745-7599.2009.00438.x

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