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J Gambl Stud (2011) 27:243–256

DOI 10.1007/s10899-010-9211-3

ORIGINAL PAPER

Gambling Behavior Among Adolescents with Attention


Deficit/Hyperactivity Disorder

Neda Faregh • Jeff Derevensky

Published online: 25 July 2010


Ó Springer Science+Business Media, LLC 2010

Abstract 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 signifi-
cantly 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.

Keywords ADHD  ADHD types  Gambling  Depressive affect

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a heterogeneous childhood disorder


involving two components: inattention and hyperactivity–impulsivity (American Psychi-
atric Association 2000). These two symptom dimensions account for three subtypes of
individuals with ADHD (Lahey et al. 2005). Predominantly Inattentive type, Predominantly

N. Faregh (&)  J. Derevensky


International Centre for Youth Gambling Problems and High Risk Behaviors, McGill University,
3724 McTavish Ave., Montreal, QC H3A 1Y2, Canada
e-mail: Neda.faregh@mcgill.ca

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Hyperactive–Impulsive type, and Combined type. The characteristics and correlates of each
subtype are different. Those fitting criteria of the Inattentive type generally have poor peer
relations and poor concentration which often results in inadequate school performance and
they are reported to have a sluggish cognitive tempo (Biederman and Faraone 2005b; Milich
et al. 2001). In contrast, Hyperactive–Impulsive individuals tend to experience conduct and
externalizing behavioral problems (Cumyn et al. 2009). This type is often incorrectly
assumed to be closely linked to the Combined type but the predominantly Hyperactive–
Impulsive type is distinct even though in many cases it is a precursor to ADHD Combined,
especially if the diagnosis occurs in preschool years (Nigg 2006). Those with ADHD
Combined typically exhibit problematic aspects of the other two subtypes (Biederman and
Faraone 2005a).
In general, children and adolescents with ADHD tend to have poorly regulated moti-
vational behavior and are inept at anticipating future outcomes of their behavior. The
relevant literature is divided as to whether the symptomatic ADHD behaviors (i.e., choices
that result in immediate gains despite future repercussions) are due to biopsychosocial
mechanisms that lead to insensitivity to negative consequences or due to mechanisms that
lead to hypersensitivity to immediate rewards. Either way, both behavioral and motiva-
tional inhibitions seem to be involved in the decision making of individuals with ADHD,
likely due to different causal pathways that may be implicated (Brown et al. 2001).
Although ADHD often attenuates with age, many adolescents and adults continue to
display typical symptoms of inattention and/or impulsivity and there are some indications
that a new diagnosis for late-onset adult ADHD may be warranted (Thome and Reddy
2009).
The rate of comorbid disorders among children and adolescents with ADHD is high
(Angold et al. 1999). The psychiatric literature suggests the presence of comorbidities is
not the exception but rather the rule where externalizing disorders commonly occur in
ADHD boys and internalizing disorders commonly occur in ADHD girls (Levy et al.
2005).
There is also evidence that the impulse control problems often associated with ADHD
place individuals, especially adolescents, at increased risk for developing other problems
and/or disorders that would normally involve impulse regulations (Cumyn et al. 2009; Lee
et al. 2008; Owens et al. 2009). Disregard for future costs of immediate gratification is also
a symptom of other impulse control disorders (e.g., substance abuse and problem gam-
bling). It is therefore not surprising that problem gambling is common among those with
ADHD. The rate of both ADHD and other impulse control disorders among problem
gamblers is higher than chance levels (Specker et al. 1995). A recent study of adolescent
problem gamblers found a significantly higher proportion of problem gamblers than non-
problem gamblers reported clinical ADHD symptoms (Derevensky et al. 2007). Among
adults, impulsivity and impaired sustained attention among pathological gamblers have
been shown to have significant associations with a history of childhood ADHD (Rodri-
guez-Jimenez et al. 2006). Clinical evidence for the co-occurrence of ADHD and problem
gambling suggests the necessity of screening for one when the other is present (Gupta and
Derevensky 2004). Readers interested in the topic of gambling problems among adults
with ADHD are referred to the works of Carlton et al. (1987), Rugle and Melamed (1993),
and Specker et al. (1995) among others.
The outcomes associated with problem gambling remain a population health concern
and are particularly problematic among adolescents. Adolescents are especially susceptible
to developing gambling problems and the prevalence of problem gambling among ado-
lescents is considerably higher (4–6%) than among adults (Derevensky et al. 2007;

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Dickson et al. 2002). Due to current trends toward the proliferation and expansion of
gambling venues (land-based and online) there is concern that gambling problems will also
escalate. Whereas ADHD is well established, problem gambling among those with ADHD
is less well understood.
To date, studies have suggested that the symptoms of ADHD precede those of problem
gambling. A longitudinal study of kindergarteners found that early impulsivity was a
significant predictor of later engagement in gambling behavior and problem development
(Pagani et al. 2009). Adolescent problem gamblers have been shown to have significantly
higher numbers of ADHD symptoms (Derevensky et al. 2007). Because impulsivity is
common to both problem gamblers and those with ADHD, it has been suggested that the
effect of impulsivity on problem gambling is mediated by ADHD (Breyer et al. 2009).
Other correlates common to both problem gambling and ADHD include higher rates
of depression, suicidality, and substance abuse (Derevensky et al. 2007; McCann and
Roy-Byrne 1998b).
It is well established that children and adolescents with gambling problems have higher
rates of internalizing and externalizing behavior disorders including conduct and emotional
problems, anxiety, family discord, substance abuse, and cognitive problems (Blaszczynski
and Nower 2002; Clarke et al. 2006; Dannon et al. 2006). These difficulties are also well
documented correlates of ADHD (Angold et al. 1999; Copeland et al. 2009). However, it is
unclear how these symptoms play out among different ADHD types and levels of gambling
involvement. To date, relatively few studies have examined both disorders simultaneously
within the same population, nor have studies differentiated between the subtypes based on
key ADHD symptoms. The purpose of this study is to examine key self-reported ADHD
symptoms and gambling problem severity. Additionally, internalizing and externalizing
behaviors exhibited among individuals with ADHD and the role of these symptoms in
gambling are examined.

Method

Participants

Adolescents (N = 1130) from four English speaking high schools in Quebec (87.7%) and
two English speaking high schools in Ontario in grades 7–12 (grades 7–11 in Quebec)
provided data for this study (female = 569). Participants’ ages ranged from 11 to 19.

Procedure

High schools in Southern Quebec and Eastern Ontario were contacted about the study and
their collaboration was sought. Project description and ethics documents approved by
McGill University Research Ethic boards were submitted to each school. After obtaining
permission from the school boards, individual high schools were contacted for their per-
mission to conduct the testing which lasted approximately 50 min. Parental consents and
students’ assents were obtained. Trained research assistants administered questionnaires
during regular class times. Gambling was defined for participants as ‘‘any activity that
involved an element of risk where money is wagered and could be won or lost.’’ Completed
questionnaires were collected and scores were recorded using computerized scanning
equipment.

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Measures

Gambling Activities Questionnaire (GAQ) (Gupta and Derevensky 1998) provides infor-
mation about frequency of participation in different forms of gambling (e.g., poker, lottery,
etc.). Respondents answered on a three-point scale (never, less than once a week, and once
a week or more). An individual who indicated never having participated in any form of
gambling was considered a non-gambler. The GAQ is reported to have good face validity.
Questions are analyzed individually, and no cumulative scores are calculated. This mea-
sure was primarily used to identify non-gamblers as those who did not engage in any form
of gambling in the past year.
The DSM-IV-MR-J (Fisher 2000) is a measure used to screen youth for pathologi-
cal gambling. This is a 12-item (nine category) screen adapted for adolescents from the
DSM-IV criteria for adult pathological gambling and the original DSM-IV-J for adoles-
cents to focus on adolescents’ past year gambling. The response categories were ‘‘never,’’
‘‘once or twice,’’ ‘‘sometimes,’’ or ‘‘often.’’ This measure is considered a conservative
screen of problem and pathological gambling compared to other screening instruments.
Internal consistency and reliability are considered adequate (Cronbach’s alpha = 0.75)
(Fisher 2000). Gupta and Derevensky’s (1998) scheme of categorizing gamblers was
included: scores of 4 or more on the nine categories were categorized as probable path-
ological gamblers (PPG); scores of 2 or 3 were categorized as at-risk gamblers, scores of
0 or 1 were considered social gamblers.
The Conners-Wells’ Adolescent Self-Report Scale (Conners 2004) consists of 87 items
and ten subscales, with possible answers ranging from ‘‘not true at all’’ to ‘‘very much
true,’’ measuring a wide variety of psychological and academic problems. Raw scores were
converted to standardized T-scores. This scale provides derived subscales that directly
relate to DSM-IV criteria of ADHD (American Psychiatric Association 2000). The scale’s
reliability and internal consistency range between 0.75 and 0.90 and the test–retest reli-
ability is reported to range from 0.60 to 0.90 for its subscales.
The Conners’ subscales include: (a) Family problems, (b) Emotional problems, (c)
Conduct problems, (d) Cognitive problems/Inattention, (e) Anger control problems, (and f)
Hyperactivity. Two additional subscales are calculated: (1) DSM-IV Symptoms: Inatten-
tive; and (2) DSM-IV Symptoms: Hyperactive–Impulsive. High scores on these subscales
are indicative of an above average correspondence with the DSM-IV diagnostic criteria for
Inattentive type and for Hyperactive–Impulsive type ADHD, respectively.
The Millon Adolescent Clinical Inventory (MACI) (Millon et al. 2006) was used to
screen for internalizing and externalizing symptoms. The MACI is a standardized instru-
ment for assessing adolescent traits and clinical syndromes covering a wide range of
psychological problems. There are 160 items with 29 age- and gender-adjusted subscales.
The three dimensions covered by subscales are adolescent personality, concerns, and
syndromes. Thirteen of the subscales were used in this analysis based on their theoretical
relevance to symptoms of ADHD and problem gambling (see Table 1). For clinical
applications, scores of 60 and above are considered significant. Test–retest reliability
ranges between 0.57 and 0.91 for each of the subscales. Overall the test–retest reliability
for the Personality Pattern subscales was 0.81; for the Expressed Concerns subscales 0.79;
and for the Clinical Syndrome subscales 0.80.
Individuals who answered less than 85% of questions were discarded from the sample.
The DSM-IV items with missing values were coded as 0. Mean item scores were imputed
for all other measures for missing values.

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Table 1 The MACI dimensions and subscales


MACI dimensions

Personality pattern Expressed concerns Clinical syndromes

Unruly: Antisocial and rebellious. Peer insecurity: Feeling of being Substance-abuse proneness:
High scorers tend to reject social rejected and ignored by one’s Maladaptive patterns of drug
norms and often clash with peers. High scorers report and alcohol use
parents and authority figures unsuccessful attempts to obtain
approval, and being isolated
Oppositional: Disconnected, Social insensitivity: Indifference to Delinquency predisposition:
sullen, and passive-aggressive. the welfare of others. High Participation in behavior that
High scorers are unpredictable; scorers are willing to breach the has led to the violation of the
they can be friendly one time, rights of others to obtain rights of others. Behaviors
and irritable the next. Individuals personal gains, they lack include rule-breaking
feel confused and contrite about empathy, and they do not care
their moodiness, but seem for close interpersonal
unable to do anything about it relationships
Self-demeaning: High scorers tend Family discord: Feeling that the Impulsive propensity: Tendency to
to sabotage their own efforts to family is a source of tension and act out feelings with minimal
achieve success, and undermine conflict. Individuals report little provocation. High scorers
the assistance of others. They do mutual support among family demonstrate little control over
not allow themselves the members and feeling estranged sexual and aggressive urges
possibility of feeling pleasure, from their parents. This may be
and find security in their misery due to individual rebelliousness
or parental rejection
Childhood abuse: Perception of Anxious feelings: Persistent
being the victim of emotional, feelings of stress
verbal, physical, or sexual abuse Depressive affect: Feelings of
by parents, siblings, relatives or despair
family friends. High scorers also
report feelings of shame or Suicidal tendency: Having suicidal
disgust as a result of their thoughts and plans. High scorers
experiences are preoccupied with death

Analysis

Due to the small number of predominantly hyperactive–impulsive subtype (0.3%), these


individuals could not be meaningfully analyzed on their own. It has been suggested that the
predominantly hyperactive–impulsive subtype is unstable and those with this diagnosis are
frequently rediagnosed as Combined type (Nigg 2006). Therefore, participants with this
ADHD subtype were merged with the Combined group.
Tests and comparisons were carried out on three nested groups separately. The first
group consisted of the full sample (N = 1133). The second consisted of individuals with
ADHD (N = 322). The third consisted of individuals with ADHD and gambling problems
(N = 56). Comparisons consisted of examining gambler categories and ADHD types and
their profiles. Internalizing and externalizing variables were examined for the three groups
with respect to their ADHD type and gambling severity.
Chi-square tests, One way and Multivariate Analyses of Variance, and multinomial
logistic regressions were carried out to compare the non-, social, and at-risk gamblers with
problem gamblers on the basis of Conners’ ADHD and MACI subscales.

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Result

Adolescents between 11 and 15 years of age made up 45.5% of the sample and the
remaining were between 16 and 19 years old. Mean differences between the younger
(11–15) and older (16–19) groups on measures of inattention and hyperactivity–impul-
sivity were not significant.
Slightly more males (54.0%) than females engaged in gambling during the past year. As
expected, more males (76.8%) than females were identified as either at-risk or PPG. Of all
respondents 70.4% were social gamblers and the remaining were non-gamblers (19.3%),
at-risk gamblers (7.2%), and PPG (3.0%). There were no significant age by gambling or
age by ADHD status associations.
Participants were categorized as screening positive for ADHD if their scores on the
DSM-IV Symptoms: Inattentive, and the DSM-IV Symptoms: Hyperactive–Impulsive,
exceeded 1.5 SD above the mean (T-score C65). Those with T-scores C65 on both vari-
ables were classified as screening positive for ADHD Combined. Scores above 65 indicate
an above average correspondence with the DSM-IV diagnostic criteria for Inattentive type
and for Hyperactive–Impulsive type, respectively (Conners 2004). After removing cases
with missing values, the sample consisted of 29.4% ADHD, any type (inatten-
tive = 25.4%, hyperactive–impulsive = 0.3%, and combined = 3.7%). Problematic lev-
els of inattention were observed among 32.2% of all males and 26.1% of all females
(v2 = 5.11, P \ 0.05). Problematic levels of hyperactive–impulsive characteristics were
observed among 3.3% of males and 4.6% of females (v2 = 1.29, n.s.). In the remainder of
this manuscript we will refer to individuals who have screened positive for ADHD as
individuals with ADHD to simplify the writing process, without implying that our meth-
odology has generated a diagnosis of ADHD.
Individuals with any ADHD type and with any level of gambling problem were com-
pared. Among at-risk and PPGs, the proportion of ADHD and non-ADHD’s did not differ
significantly (50.9 vs. 49.1%). Among individuals with ADHD, 17.4% also had gambling
problems whereas only 7.0% of non-ADHD’s had gambling problems (v2 = 30.1,
P \ 0.001). Among the remaining ADHD types, 15.8% with Inattentive type and 27.3% of
individuals with hyperactive–impulsive/combined type (v2 = 49.34, P \ 0.05) exhibited
gambling problems at the at-risk or PPG levels.
Results showed that in general the scores on the Conners’ subscales had a positive linear
trend as gambling severity moved from non-gamblers to social gambler, to at-risk, and to
PPG (Fig. 1). To further examine these profiles the full sample was used to carry out
multinomial logistic regression. From this sample 48 cases had missing values and were
eliminated from the analysis. All but one of the Conners’ ADHD subscales were regressed
as covariates on gambling categories with PPGs as the reference. The anger control
problem subscale was not used because it lacked clinical significance (mean T-score \65)
in our sample. Given the small number of female PPGs, gender was not included as a factor
and gender-analyses were not carried out. The final model log likelihood test was sig-
nificant (v2 = 85.86, P \ 0.001). Main effects were significant (a \ 0.05) for two of the
covariates: emotional problems and conduct problems. The parameter estimates revealed
that when all variables were included in the model together, non-gamblers, social gam-
blers, and at-risk gamblers significantly differed from PPG’s on the emotional problems
subscales. Specifically, compared to PPGs, the odds of being a non-gambler decreased for
each unit increase in emotional problems by approximately 10% (OR = 0.89, P \ 0.001).
Similarly, compared to PPGs, the odds of being a social-gambler decreased for each unit
increase in emotional problems by approximately 8% (OR = 0.92, P \ 0.003). Lastly,

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Fig. 1 Mean t-scores on ADHD subscales and gambling categories, the Y-axis reference line denotes
T-score cut-off at 65

compared to PPGs, the odds of being an at-risk gambler decreased for each unit increase in
emotional problems by approximately 7% (OR = 0.93, P \ 0.03). Parameter estimates
and their confidence intervals are shown in Table 2. The analyses were repeated for
participants with ADHD only. Emotional problems were the only significant covariates in
the model with significant ORs 0.89, 0.91, and 0.91 for non-gamblers, social gamblers, and
at-risk gamblers, respectively. The test was repeated for all non-ADHDs and none of the
subscales were significant.
Key ADHD symptoms of inattention and hyperactivity–impulsivity were examined.
The results revealed that for ADHD cases only (N = 322) the key ADHD symptoms did
not differ significantly among gambling types. When non-ADHD’s were examined
(N = 790), the average T-scores were below the threshold levels for all gambler types, as
expected, for both inattention and hyperactivity–impulsivity.
In order to investigate these observations further, MANOVAs were carried out to
determine whether there were significant differences between ADHD types and gambling
categories with respect to ADHD symptoms. The key ADHD symptoms (DSM-IV
symptoms: Inattentive and DSM-IV symptoms: Hyperactive–Impulsive) were entered as
dependent variables. ADHD types and gambling categories were entered as factors. The
tests of between-subjects effects showed the main effect for ADHD type was significant
(F = 254.27, P \ 0.001) but the main effect for gambling categories was not significant
(see Table 3 for means and SDs). Bonferonni adjusted post hoc multiple comparison tests
were significant for both inattention scores and hyperactivity–impulsivity scores for
ADHD types (P \ 0.001), as expected, but not for gambling categories. The interaction

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Table 2 Results of multinomial


Gambling Wald Sig. Exp(B) 95% confidence
logistic regression for ADHD
categorya interval for Exp(B)
problem profiles
Lower Upper
bound bound

Non-gamblers
Family problems 0.032 0.859 1.005 0.948 1.066
Emotional problems 12.208 0.000 0.902 0.851 0.956
Conduct problems 2.707 0.100 0.949 0.893 1.010
Cognitive problems 0.878 0.349 1.034 0.964 1.108
Hyperactivity 0.149 0.700 0.989 0.936 1.045
Social gamblers
Family problems 0.001 0.980 0.999 0.947 1.055
Emotional problems 9.790 0.002 0.920 0.873 0.969
Conduct problems 0.454 0.501 0.981 0.926 1.038
Cognitive problems 0.033 0.855 1.006 0.944 1.073
Hyperactivity 0.142 0.707 1.010 0.960 1.062
At-risk gamblers
Family problems 0.001 0.980 0.999 0.947 1.055
Emotional problems 9.790 0.002 0.920 0.873 0.969
Conduct problems 0.454 0.501 0.981 0.926 1.038
Cognitive problems 0.033 0.855 1.006 0.944 1.073
a
Hyperactivity 0.142 0.707 1.010 0.960 1.062
The reference category is PPG

effect was not significant. These results confirmed the lack of significant findings for key
ADHD symptoms within the ADHD types with respect to gambling categories. See Figs. 2
and 3.
In order to examine the role of internalizing and externalizing problems in gamblers
with ADHD, 13 selected MACI subscales were examined in relation to ADHD types and
gambling categories. For participants with ADHD only and at-risk/PPGs with ADHD,
depressive affect was the only MACI subscale that reached problem threshold (T C 65).
A Univariate Analysis of Variance (ANOVA) revealed that for participants with ADHD,
depressive affect was marginally significant (F = 2.831, P \ 0.06). The simple contrast
hypothesis test results revealed that participants without ADHD scored lower and were
significantly different from those with Inattentive and Combined types (P \ 0.05) on
depressive affect (Fig. 4).

Discussion

The purpose of this study was to examine ADHD and gambling among a sample of
adolescents. We sought to examine key ADHD symptoms with respect to gambling
engagement and gambling severity as well as common correlates of both disorders.
The prevalence of ADHD in our sample was higher than expected. Canadian prevalence
studies based on National Longitudinal Survey of Children and Youth suggest that upwards
of 17% of girls and 23% of boys exhibit hyperactive-compulsive symptoms while 18% of
girls and 14% of boys exhibit inattention symptoms (Romano et al. 2002). We expect this

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Table 3 Mean values of


DSM-IV ADHD Gambling Mean SD N
inattention and huperactivity–
symptoms type category
impulsivity for different
ADHD subtypes and
gambling categories Inattention 0 Non-gamblers 47.04 8.24 181
Social gamblers 49.41 8.16 535
At-risk gamblers 51.74 7.25 43
PPG 51.09 7.75 11
Inattentive Non-gamblers 75.14 7.43 27
Social gamblers 74.47 7.17 207
At-risk gamblers 77.11 7.95 34
PPG 77.10 7.65 10
Combined Non-gamblers 85.50 4.12 4
Social gamblers 78.28 11.05 28
At-risk gamblers 85.00 4.58 3
PPG 83.11 8.13 9
Hyperactivity– 0 Non-gamblers 42.34 5.89 181
impulsivity Social gamblers 44.27 6.30 535
At-risk gamblers 44.44 6.45 43
PPG 45.81 7.84 11
Inattentive Non-gamblers 51.66 5.86 27
Social gamblers 53.29 5.77 207
At-risk gamblers 55.29 6.10 34
PPG 53.20 5.18 10
Combined Non-gamblers 68.25 2.62 4
Social gamblers 69.03 4.17 28
At-risk gamblers 70.00 5.00 3
PPG 69.77 5.01 9

difference may be due to the self-report nature of the instruments used in this study.
Additionally, some differences are expected when different measures are used to catego-
rize individuals as screening positive for ADHD. Problematic levels of inattention and
hyperactivity–impulsivity had a reverse trend from what has been noted in previous lit-
erature in that more females than males exhibited high levels of hyperactivity–impulsivity,
with more males than females exhibiting high levels of inattention. The current results
suggesting that Inattention was the most common subtype of ADHD are consistent with
findings of other ADHD prevalence studies (Carlson and Mann 2000; McCann and Roy-
Byrne 1998a).
Half of participants with ADHD in our sample engaged in gambling compared to only
17% of those without. They also were more likely to have gambling problems. This finding
confirms the results of earlier studies that suggest individuals with ADHD are more likely
to gamble and to experience gambling problems. In fact, half of all adolescents with
gambling problems in our sample screened positive for some type of ADHD. An exami-
nation of ADHD subtypes revealed that although equal proportions of Inattentive and
Combined types engaged in gambling activities, adolescents with the ADHD Combined
were significantly more likely to have gambling problems.
The long version of the Conners-Wells’ Adolescent Self-Report Scales provides seven
subscales that group similar symptoms into problem profiles. Among these, the Anger

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Fig. 2 Estimated marginal means for hyperactivity–impulsivity for gambler categories and ADHD
subtypes. The Y-axis reference line denotes T-score cut-off at 65

Control Problem subscale did not surpass threshold levels for any of the gambling types
suggesting that although it is a contributing factor to ADHD, it is not a problematic factor
for gambling engagement or pathology. The remaining subscales were examined with
respect to gambling categories. These results revealed that when problem profiles were
examined simultaneously, only the Emotional Problems subscale differentiated between
gambling severities. Symptoms in the Emotional Problems profile suggest that individuals
with high scores tend to have low self-esteem and low self-confidence and tend to express
feelings of loneliness and isolation. They also have more worries and concerns than their
peers. In our sample, each unit increase (equivalent to one T-score) in emotional prob-
lems significantly increased the odds of being a PPG by 10%. The results were similar for
the full population and for those with ADHD only. However, when the test was repeated
for participants without ADHD emotional problems were no longer a significant con-
tributing factor to any of the gambling categories, suggesting that none of the problem
profiles were severe enough or important enough to be a significant factor in gambling
engagement or gambling problems. Overall, family problems, emotional problems, con-
duct problems, cognitive problems, and anger control problems are worse among those with
any level of gambling problems independent of ADHD status, especially among PPGs.
When key ADHD symptoms (i.e., inattention and hyperactivity–impulsivity) were
examined among the full sample the results revealed that levels of hyperactivity–impul-
sivity and inattention were higher among PPGs when compared to other gambler types but
these differences were only pronounced among those without ADHD. When those with

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Fig. 3 Estimated marginal means for inattention for gambler categories and ADHD subtypes. The Y-axis
reference line denotes T-score cut-off at 65

ADHD were examined alone, the differences were not pronounced. When ADHD subtypes
were tested separately the differences were no longer significant. This suggests that among
adolescents, as levels of inattention and hyperactivity–impulsivity increase so does gam-
bling severity. However, the ADHD Inattentive and the ADHD combined types did not
differ on measures of gambling severity. Although within a given level of gambling
severity, ADHD types differed significantly from each other on measures of inattention and
of hyperactivity–impulsivity. Within each ADHD type, the levels of inattention and
hyperactivity–impulsivity were the same regardless of gambling severity. That is, levels of
inattention (Fig. 3) and hyperactivity–impulsivity (Fig. 4) were significantly different for
different ADHD types, as expected, but within a given ADHD type these levels were not
significantly different from each other whether the individual was a non-gambler or a PPG.
This was an unexpected finding in our sample results.
In terms of internalizing and externalizing disorders, we only found one variable to be
of significance among those with ADHD. Depressive affect was significantly different
among ADHD types, and among gamblers. However, the most notable differences were
among PPGs with ADHD Combined. Similar to emotional problems, we found that among
our subsample of participants with ADHD and gambling problems, depressive affects
differentiated among gambler types, but did so depending on the subtype of ADHD. What
is unexpected in our findings is the lack of significant results on the other 12 MACI
subscales studied suggesting a lack of significant contribution from a range of previously
studied contributors to gambling problems and ADHD.

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Estimated Marginal Means

Gambling Category

Fig. 4 Estimated marginal means for depressive affect and ADHD subtypes. The Y-axis reference line
denotes T-score cut-off at 65

Conclusion

Our results suggest that the mediating effect of ADHD in problem gambling may be
specific to ADHD types. Individuals with different ADHD subtypes have different like-
lihoods of gambling engagement problems. The internalizing factors, namely emotional
problems and depressive affect, are associated with gambling problems and the association
is especially pronounced for those with ADHD combined.
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 the development of gambling problems among adolescents. There is a particular
pattern of co-occurrence of these two internalizing problems and the Combined subtype
of ADHD among adolescents with gambling problems. The presence of these two
psychosocial risk factors indicate greater severity of gambling problems among ado-
lescents and these individuals with the ADHD Combined type may be at higher risk of
developing gambling problems. Although these results are interesting and shed light on
internalizing factors as important contributors to problem development among ADHD
and problem gamblers, they also have a number of limitations. While efforts were made
to ensure random representation of adolescents as participants, the sample included a
higher than normal percentage of youth who screened positive for ADHD. No infor-
mation regarding ADHD treatment and medication use were available and therefore
were not controlled for. All data were provided as self-reports from adolescents and no

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J Gambl Stud (2011) 27:243–256 255

corroborative reports from responsible adults were used. The cross-sectional design of
this study cannot afford any directionality of results. Further studies are needed to
replicate these findings.

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