Childhood ADHD, Comorbidity, and Risk for Late-Adolescent Drug Abuse
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Childhood ADHD, Comorbidity, and Risk for Late-Adolescent Drug Abuse Ken Winters, Ph.D. Center for Adolescent Substance Abuse Research, Department of Psychiatry, University of Minnesota 2004 APA Annual Meeting New York Our Ex-Governor was a professional wrestler. Lake Wobegon Staff:

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Childhood ADHD, Comorbidity, and Risk for Late-Adolescent Drug Abuse

Ken Winters, Ph.D.

Center for Adolescent Substance Abuse Research,

Department of Psychiatry, University of Minnesota

2004 APA Annual Meeting

New York


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Our Ex-Governor was a Drug Abuse

professional wrestler.

Lake Wobegon Staff:

All above average.

Women are strong.

Men are good looking.

U of Minnesota,

Center for Adolescent

Substance Abuse Research


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Acknowledgements Drug Abuse

  • Funding provided by NIMH and NIDA(DA 12995)

  • Special thanks to the staff who made this study and presentation possible:

    • Gerry August, Ph.D. (co-Investigator)

    • George Realmuto, M.D. (co-Investigator)

    • Tamara Fahnhorst, M.P.H.

    • Andria Botzet, M.A.

    • Jessie Breyer, B.A.

    • Jodi Helseth, M.A.


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Timeline: Drug AbuseNIMH – NIDA

Baseline Follow-up Follow-upFollow-up

1 23

Year 1991 1994 19952001

Age 7-9 10-12 11-1318-19


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Samples Drug Abuse

  • ADHD sample initially identified at baseline with a multigate screening procedure; over 7,000 students (21 urban elementary schools) received scores on Conner’s HI scales

  • Revised Conner’s Teacher & Parent Rating Scales-Hyperactivity Index

  • Gate 1 - Teacher (HI-T) cut off score > 1.75 SD

  • Gate 2 - Parent (HI-P) cut off score > 1.75 SD

  • Comparison sample screened from same schools

  • HI-T < 1.0 SD

  • Screened youth assessed with parent DICA-R at Baseline, F-UP 1, F-UP 2


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Eligibility for current study Drug Abuse

  • ADHD group

    • DSM-III-R diagnosis of ADHD

    • “High Water Mark” diagnosis (Baseline, F-UP 1, F-UP 2)

      • included: ADHD only and ADHD w/externalizing

      • excluded: ADHD w/internalizing and subclinical ADHD

    • Data collected at F-UP 3

  • Comparison group

    • Absence of any DSM-III-R diagnosis(Baseline, F-UP 1, F-UP 2)

    • Data collected at F-UP 3


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    Groups for the Analysis Drug Abuse

    n attrition

    ADHD Group

    ADHD only 29 6

    ADHD w/externalizing 96 13

    Comparison 99 5

    Overall attrition: 9.7%


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    Attrition Effects at Drug AbuseF-UP 3 for the ADHD Sample – Baseline HI-T/HI-P

    AssessedAttrition (n = 125) (n = 19)

    Baseline Mean (SD) Mean (SD) t

    HI-T 2.18 (.39) 2.22 (.43) ns

    HI-P 1.97 (.42) 2.15 (.41) 1.99 (.05)


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    Attrition Effects at Drug AbuseF-UP 3 for the ADHD Sample – Other Variables

    • Cases that do not have data at Follow-up 3 show

      • …. a trend toward

        • lower IQ,

        • lower baseline SES,

        • more frequently in a single-parent household,

        • having younger parents

      • …. at a significant level

        • biological mother with a lower level of

        • education


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    Outcome Assessment Measures Drug Abuse

    Follow-up 3:

    1. Drug Use FrequencyMonitoring the Future Survey (Johnston et al., 2000)

    all major drug categories (including tobacco)

    1=never; 7=40+

    2. DSM-IV SUD

    Adolescent Diagnostic Interview (Winters et al., 1993)

    Alcohol Abuse/Dependence

    Marijuana Abuse/Dependence

    Other Drug Abuse/Dependence

    Use consequences


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    Outcome Assessment Measures Drug Abuse

    • Follow-up 3:

    • Focus of the outcome variables:

      • lifetime drug use

      • prior year drug use

      • SUD diagnostic data


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    Demographics Drug Abuse

    ADHD-only ADHD w/ext. Comp

    n 29 96 99

    Gender (% male)86.3% 77.9% 69.2%

    Mean age 18.1 18.5 18.2

    % grad high school or current95.2% 89.3% 98.6%

    Mean IQ (KBIT) 105.1 100.6 106.7

    Mean SES (baseline)* 48.1 45.2 50.4 (.01)

    % single parent family 24.1% 26.3% 7.1% (.01)

    Ethnicity: 88% Caucasian

    * Hollingshead, 1975, (occupation code x 5) x (education code x 3); Range 17 - 66


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    Research questions Drug Abuse

    1. What are the late adolescent drug use behavior outcomes of children with ADHD?

    2. Do ADHD children with comorbid CD/ODD report greater drug use than ADHD children without comorbid CD/ODD?

    3. What other childhood and adolescent characteristics distinguish drug-abusing from non-drug-abusing ADHD participants?


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    LIFETIME DRUG USE (Y/N) Drug Abuse

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext Comp 2 Variables % % %

    Used alcohol 95.7 88.7 84.1 ns

    Used marijuana 73.971.0 51.2 7.52 (.02)

    Used cocaine 8.732.8 15.0 9.02 (.01)

    Used amph. 8.7 24.6 15.0 ns

    Used ecstasy 4.3 31.1 17.5 8.29 (.02)

    Used any other drug 17.4 47.5 28.8 8.77 (.01)

    Used tobacco 73.9 83.3 68.8 ns


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    PRIOR YEAR DRUG USE (Y/N) Drug Abuse

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext Comp 2 Variables % % %

    Used alcohol 87.0 80.6 75.6 ns

    Used marijuana 52.2 61.3 43.9 4.3 (.02)

    Used cocaine 8.7 26.2 13.8 5.2 (.02)

    Used amphet. 4.3 13.1 10.0 ns

    Used ecstasy 0 14.8 10.0 ns

    Used any other drug 8.7 29.5 13.8 7.4 (.02)

    Used tobacco 81.3 94.0 81.5 ns


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    OTHER DRUG USE VARIABLES (Y/N) Drug Abuse

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext Comp 2 Variables % % %

    Tobacco - daily users 24.1 31.3 27.3 ns

    Heavy alcohol (40+/ past yr)13.0 24.2 29.3 ns

    Binge Drinking 17.9 32.6 20.9 ns

    (girls=4+ drinks per sitting, boys=5+ drinks per sitting)

    Heavy marij. (40+/ past yr)8.7 29.0 15.9 5.9 (.05)

    Heavy other drug (40+/ past yr)0 3.3 0 ns

    Early onset (<13 years) 9.1 27.9 15.4 5.1(.05)


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    OTHER DRUG USE VARIABLES - continuous measures of use history where significance found

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext. CompF

    Variables M M M

    Lifetime use

    Total frequency 18.8 23.6 19.0 3.4 (.03)

    Marijuana3.2 4.6 3.3 3.1 (.05)

    Ecstasy 1.01.81.3 4.5 (.01)

    Prior year use

    Total frequency 16.8 21.5 18.4 3.2 (.04)

    Amphetamine1.3 1.8 1.3 3.4 (.04)

    Ecstasy 1.01.61.2 3.9 (.02)


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    SUD DIAGNOSES history where

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext. Comp2 Variables % % %

    Alcohol abuse/dep 17.2 28.7 22.4 ns

    Marijuana abuse/dep 13.8 31.3 20.6 5.0(.05)

    Other drug abuse/dep 3.4 6.4 4.0 ns

    Dep.on 1+ substances 13.8 21.9 18.2 ns


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    Other SUD and RELATED VARIABLES history where

    F-UP 3: Youth self-report

    ADHD-only ADHD w/ext. CompF

    Variables M M M

    # Alcohol sym (0-11)0.9 1.4 1.2 ns

    # Marij. sym (0-11)0.9 1.9 1.1 3.3 (.05)

    # Other Drug sym (0-11)0.1 0.4 0.2 ns

    # Total Drug sym (0-11)1.9 3.4 2.4 3.8 (.05)

    Dependence Vulnerability 0.9 1.4 1.0 ns

    (# dep sym/ # drugs used)

    Use Consequences (0-14) 1.0 1.9 1.3 ns


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    Research questions history where

    1. What are the late adolescent drug use behavior outcomes of children with ADHD?

    2. Do ADHD children with comorbid CD/ODD report greater drug use than ADHD children without comorbid CD/ODD?

    3. What other childhood and adolescent characteristics distinguish drug-abusing from non-drug-abusing ADHD participants?


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    VARIABLES DISTINGUISHING ADHD SUBJECTS: history where SUD+ (n = 40) vs SUD- (n = 85)

    Significant Variables (p < .01)

    Childhood:

    BASC -Aggression (> score SUD+)

    BASC - Anxiety (> score SUD+)

    BASC - Depression (> score SUD+)

    Early onset (< 13-years) drug use (> SUD+)


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    VARIABLES DISTINGUISHING ADHD SUBJECTS: history where SUD+ (n = 40) vs SUD- (n = 85)

    Significant Variables (p < .01)

    Adolescence:

    BASC - Aggression (> score SUD+)

    BASC - Conduct (> score SUD+)

    BASC - Hyperactivity (> score SUD+)

    BASC - Attention (> score SUD+)

    Woodcock Johnson (< performance SUD+)

    High school drop-out (> SUD+)

    Life stress events (> events SUD+)

    Psychostimulant medication (> SUD+)


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    VARIABLES NOT DISTINGUISHING ADHD SUBJECTS: history where SUD+ vs SUD-

    Non-Significant Variables

    Childhood BASC - Hyperactivity, Conduct & Attention

    Adolescent BASC – Anxiety, Depression

    SES

    Maternal depression

    Maternal control/coping

    Maternal locus of control

    Single parent family

    IQ

    Childhood WJ

    Childhood WRAT

    Childhood psychostimulant medication


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    Summary history where

    • Late adolescent drug use outcomes were assessed from a community-based sample diagnosed as ADHD in their youth.

    • Drug use behaviors, including drug use history and SUD diagnoses, were generally elevated in the ADHD w/externalizing compared to the ADHD only and Comparison groups (small to medium effect sizes)

      • In terms of drug specificity, marijuana and ecstasy, to a lesser degree, emerged as two drugs with relatively consistent elevations among the ADHD w/externalizing group.


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    Summary history where

    • ADHD youth with a late adolescent SUD diagnosis showed some distinguishing characteristics

      • childhood: internalizing cluster, aggression, early drug use onset

      • adolescence: externalizing cluster,stressful life events, school/learning problems


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    Thank You history where


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    Extras history where


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    Summary of Baseline Demographic Data for the Groups history where

    • The groups did not differ significantly on race, age, or gender.

    • Significant differences painted a more severe picture for the

    • ADHD w/externalizing group; they more frequently…

      • came from single-parent households

      • had a lower SES

      • lower IQ

      • a greater number of ADHD symptoms

      • scored less favorably on all parent-rated BASC scales,

  • The comparison group almost always scored more favorably on the

  • baseline demographic and psychosocial variables.


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    Diagnostic Assessment Measures history where

    Baseline, Follow-up 1, & Follow-up 2:

    Diagnostic Interview for Children & Adolescents

    (Reich, 1992; DICA-R) DSM-III-R - Based

    ADHD

    Oppositional Defiant Disorder

    Conduct Disorder

    Overanxious Disorder

    Avoidant Disorder

    Separation Anxiety Disorder

    Major Depressive Disorder (Past & Present)

    Dysthmia

    Adjustment Disorder


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    Stimulant Medication Grouping history where

    Never Used Stimulants vs. Childhood Use vs. Adolescent Use vs. Extended Use

    • Inclusion criteria (must have positive ADHD diagnosis):

    • Never Used Stimulants: No stimulant use reported at all time points (Follow-ups 1994, 1995, 1997, & 2000)

    • Childhood Use: Stimulant medication use reported only at 1994 and/or 1995 time points

    • Adolescent Use: Stimulant medication use reported only at 1997 and/or 2000 time points

    • Extended Use: Stimulant medication use reported during at least one time point in each of the childhood and adolescent years


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    Demographics history where (by Stimulant Medication Groupings)

    ChildAdol.ExtendNever

    n 26 24 22 53

    Gender (%male) 85.7 79.2 81.8 78.7

    Mean age 18.9 18.4 18.1 18.4

    % grad high school or current 100 87.5 87.5 90.6

    Mean IQ (KBIT) 102.7 103.5 104.6 105.7

    Mean SES (baseline)* 41.2 48.9 50.3 45.2

    % from div/sep family 23.1 29.2 22.7 26.9

    Ethnicity: groups > 88% Caucasian

    * Hollingshead, 1975, (occupation code x 5) x (education code x 3); Range 17 - 66


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    Association Between Stimulant Medication Groups and Various Mediating or Moderating Variables

    • Significant differences did not emerge for most variables

    • across the 4 stimulant medication groups

    • Significant differences emerged between the groups on:

      • SES (childhood < adolescent & extended stimulant use)

      • early onset of marijuana use (childhood < extended)

      • Barkley parent scales of inattention and hyperactivity

      • ( inattention and hyperactivity = never used stimulants

      • or childhood-only use)


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    Stimulant Medication Grouping Categorical Outcome Variables Mediating or Moderating VariablesPRIOR YEARDRUG USE(Y/N)

    Variables Child Adol. Extend Never 2 % % % %

    Used alcohol prior year 92.9 94.7 88.9 88.2 .8

    Used marijuana prior year 57.1 73.7 78.9 73.5 1.9

    Used cocaine prior year 28.6 36.8 17.6 23.5 1.9

    Used amphetamines prior year 14.3 21.1 17.6 23.5 .6

    Used ecstasy prior year 21.4 26.3 17.6 26.5 .6

    Used any other drug prior yr. 35.7 47.4 29.4 35.3 1.35

    Used tobacco prior year 80.0 100 100 85.2 5.4


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    Stimulant Medication Grouping Continuous Outcome Variables SYMPTOM COUNT(0-11; 4 abuse, 7 dependence )

    Variables Child Adol. Extend NeverF M(sd)M(sd)M(sd) M(sd)

    # Alcohol ab/dep symp 1.0 (2.1)1.8 (3.1) 1.5 (2.0) 1.1 (2.1) .9

    # Marijuana ab/dep sym 1.4 (3.0) 2.1 (3.1) 1.3 (2.4) 1.2 (2.4) .7

    # Other Drug ab/dep sym 0.1 (.6) 1.2 (2.9) 0.3 (1.3) 0.1 (.5) 3.3 (p<.02)

    # Total Drug ab/dep sym 2.5 (5.0) 5.1 (7.4) 3.1 (4.6) 2.3 (4.4) 1.7


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    Stimulant Medication Groupings Categorical Outcome Variables

    Variables Child Adol. Extend Never2 % %% %

    Alcohol abuse/dep 19.2 30.4 36.4 23.1 2.3

    Marijuana ab/dep 19.2 37.5 .22.7 28.3 2.4

    Other drug ab/dep 3.8 16.7 4.5 2.0 6.9

    Dep.on 1+ substances 15.4 37.5 22.7 13.2 6.6

    Tobacco - daily users7.7 50.0 45.5 24.5 14.1 (p<..00)


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    Initial Screening Categorical Outcome Variables

    • 7,231 1st - 4th grade children screened from 22 suburban elementary schools

    • Participated in a brief intervention program for children with disruptive behavior

    • Multigate screen

    • Revised Conner’s Teacher & Parent Rating Scales- Hyperactivity Index

    • Gate 1 - Teacher (HI-T) cut off score 1.6*

    • Gate 2 - Parent (HI-P) cut off score 1.3*

    • * 1.75 standard deviation units above the mean

    • * scores range from 0 - 3


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    Screening and Initial Sample cont. Categorical Outcome Variables

    • 148 refused consent after Gate 1

    • 494 screened at Gate 2

    • 400 screened positive with HI-P (5.5% of orig. sample)

    • 91 lost mostly due to school boundary change

    • Thus, 309 disruptive children were eligible for the intervention


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    10-Year Tracking Method Categorical Outcome Variables

    • Letter was sent to parents outlining follow-up study

    • Phone call to parents/youth detailing protocol

    • Youth and parents interviewed individually at nearby library or research office

    • Participants were compensated for their participation ($75 youth, $25 parent)

    • Web-based tracking techniques utilized for hard-to-find participants


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    ADHD Status Grouping Criteria Categorical Outcome Variables

    ADHD-only vs. ADHD with externalizing vs. Comparisons

    • Inclusion criteria for the ADHD-only and ADHD w/ext. groups

    • DICA-R Parent used to diagnose disorders

    • DSM-III-R-Based

    • Conducted at Baseline (1991), FU-1 (1994), & FU-2 (1995)

    • Diagnosis endorsed at least once during the 3 time points

    • ADHD-only group had no co-morbid diagnoses

    • ADHD w/ext. includes ODD/CD diagnosis at 1 of 3 time points

    • Inclusion criteria for the Comparison Group

    • HI-P & HI-T negative (<1 SD from the mean, score = <1.1)

    • No Diagnosis of ADHD, ext. or int. disorders at FU-1 & FU-2


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    Diagnostic Assessment Measures Categorical Outcome Variables

    Baseline, Follow-up 1, & Follow-up 2:

    Diagnostic Interview for Children & Adolescents

    (Reich, 1992; DICA-R) DSM-III-R - Based

    ADHD

    Oppositional Defiant Disorder

    Conduct Disorder

    Overanxious Disorder

    Avoidant Disorder

    Separation Anxiety Disorder

    Major Depressive Disorder (Past & Present)

    Dysthmia

    Adjustment Disorder


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    Outcome Assessment Measures Categorical Outcome Variables

    Follow-Up 3 (2001)

    1. Drug Use Frequency (DUF) (including tobacco )Based on Monitoring the Future Survey items:1 = never 5 = 10-19 times

    2 = 1-2 times6 = 20-39 times

    3 = 3-5 times 7 = 40+

    4 = 6-9 times

    2. DSM-IV Diagnostic Interview

    Adolescent Diagnostic Interview (Winters et al., 1993)

    Alcohol Abuse/Dependence

    Marijuana Abuse/Dependence

    Other Drug Abuse/Dependence (not including tobacco)


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    Outcome Assessment Measures Categorical Outcome Variables

    • Follow-Up 3 (2001)

    • Focus of the outcome variables for this presentation...

      • prior year drug use (yes/no)

      • diagnostic data


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    Categories of Analyses Categorical Outcome Variables

    #1. Grouping (Standard)

    ADHD vs.Comparisons (no diagnosis)

    #2.Grouping (Externalizing)

    ADHD only vs. ADHD/ODD/CD vs. Comp.

    #3 Grouping (Internalizing)

    ADHD/Anxiety/Depression vs. Comparisons


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    #1 Grouping (Standard) Categorical Outcome Variables

    ADHD vs. Comparisons (no diagnosis)

    • Inclusion criteria for the ADHD Group

    • DICA-R Parent used to diagnose ADHD

    • DSM-III-R-Based

    • Conducted at Baseline (1991), FU-1 (1994) & FU-2 (1995)

    • Diagnosis endorsed at 1 of the 3 timepoints

    • Inclusion criteria for the Comparison Group

    • HI-P & HI-T negative (<1 SD from the mean, score = <1.1)

    • No Diagnosis at FU-1 & FU-2 (no ADHD, depression, anxiety, oppositional defiant, or conduct disorder)


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    Thank You Categorical Outcome Variables


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