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Attention Deficit Hyperactivity Disorder (ADHD) Subtypes, Co-Occurring Psychiatric Symptoms and Sexual Risk Behaviors among Adolescents Receiving Substance Abuse Treatment

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Background: Adolescents entering substance abuse treatment report clustered psychiatric symptoms and sexual risk behaviors representing differential levels of impairment and risk for maladaptive health outcomes. Objectives: To examine the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) subtypes among adolescents receiving outpatient substance abuse treatment; To document group differences in (a) past-year psychiatric symptom scores and (b) sexual risk behaviors by ADHD subtype and gender. Methods: Self-report data were collected via structured interviews from 394 adolescents (280 males, M ¼ 16.33 years, SD ¼ 1.15 years), enrolled in an HIV/STI risk reduction intervention for adolescents receiving outpatient substance abuse treatment. ADHD diagnostic subtypes and other past-year psychiatric symptoms were assessed using the Brief Michigan Version of the Composite Internal Diagnostic Interview (UM-CIDI). Adolescents provided self-report data on sexual risk behaviors. Results: Multivariate analyses of variance (MANOVAs) documented that Inattentive and Hyperactive-Impulsive ADHD subtypes were significantly associated with higher scores for all past-year psychiatric symptoms. The combined ADHD subtype was significantly associated with higher scores for all psychiatric symptoms except affective disorder. Girls reported significantly higher mean symptoms than boys for alcohol abuse and dependence, anxiety, and affective disorder symptoms. Sexual risk behavior scores were not associated with ADHD status, but girls reported consistently higher scores for multiple risk behavior outcomes. Several psychiatric disorder symptoms were significant covariates of multiple sexual risk behaviors. Conclusion/Importance: Brief screenings for ADHD, other psychiatric disorders and sexual risk behaviors can provide data for tailoring substance abuse services to improve adolescent health outcomes for high-risk subgroups.
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Substance Use & Misuse
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Attention Deficit Hyperactivity Disorder (ADHD)
Subtypes, Co-Occurring Psychiatric Symptoms
and Sexual Risk Behaviors among Adolescents
Receiving Substance Abuse Treatment
Timothy Regan & Jonathan Tubman
To cite this article: Timothy Regan & Jonathan Tubman (2019): Attention Deficit Hyperactivity
Disorder (ADHD) Subtypes, Co-Occurring Psychiatric Symptoms and Sexual Risk Behaviors
among Adolescents Receiving Substance Abuse Treatment, Substance Use & Misuse, DOI:
10.1080/10826084.2019.1657895
To link to this article: https://doi.org/10.1080/10826084.2019.1657895
Published online: 10 Sep 2019.
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ORIGINAL ARTICLE
Attention Deficit Hyperactivity Disorder (ADHD) Subtypes, Co-Occurring
Psychiatric Symptoms and Sexual Risk Behaviors among Adolescents
Receiving Substance Abuse Treatment
Timothy Regan
a
and Jonathan Tubman
b
a
Department of Psychological & Brain Sciences, Texas A&M University College Station, College Station, Texas, USA;
b
Department of
Psychology, American University, Washington D.C., USA
ABSTRACT
Background: Adolescents entering substance abuse treatment report clustered psychiatric
symptoms and sexual risk behaviors representing differential levels of impairment and risk
for maladaptive health outcomes. Objectives: To examine the prevalence of Attention Deficit
Hyperactivity Disorder (ADHD) subtypes among adolescents receiving outpatient substance
abuse treatment; To document group differences in (a) past-year psychiatric symptom
scores and (b) sexual risk behaviors by ADHD subtype and gender. Methods: Self-report data
were collected via structured interviews from 394 adolescents (280 males, M¼16.33 years,
SD ¼1.15 years), enrolled in an HIV/STI risk reduction intervention for adolescents receiving
outpatient substance abuse treatment. ADHD diagnostic subtypes and other past-year psy-
chiatric symptoms were assessed using the Brief Michigan Version of the Composite Internal
Diagnostic Interview (UM-CIDI). Adolescents provided self-report data on sexual risk behav-
iors. Results: Multivariate analyses of variance (MANOVAs) documented that Inattentive and
Hyperactive-Impulsive ADHD subtypes were significantly associated with higher scores for
all past-year psychiatric symptoms. The combined ADHD subtype was significantly associ-
ated with higher scores for all psychiatric symptoms except affective disorder. Girls reported
significantly higher mean symptoms than boys for alcohol abuse and dependence, anxiety,
and affective disorder symptoms. Sexual risk behavior scores were not associated with
ADHD status, but girls reported consistently higher scores for multiple risk behavior out-
comes. Several psychiatric disorder symptoms were significant covariates of multiple sexual
risk behaviors. Conclusion/Importance: Brief screenings for ADHD, other psychiatric disorders
and sexual risk behaviors can provide data for tailoring substance abuse services to improve
adolescent health outcomes for high-risk subgroups.
KEYWORDS
ADHD; substance abuse
treatment; psychiatric
symptoms; sexual risk
behaviors; adolescents;
gender
Attention-Deficit/Hyperactivity Disorder is one of the
most commonly diagnosed neurodevelopmental disor-
ders among children, with 5% of the nations children
assigned a current diagnosis and more than 1 in 10
receiving a lifetime diagnosis (Sibley, Kuriyan, Evans,
Waxmonsky, & Smith, 2014; Visser et al., 2014).
ADHD is characterized by a persistent pattern of
inattention and/or hyperactivity-impulsivity that inter-
feres with functioning or development (American
Psychiatric Association [APA], 2013). This symptom
pattern is associated with negative developmental out-
comes including comorbid psychological disorders
(Larson, Russ, Kahn, & Halfon, 2011; Yoshimasu
et al., 2012), and substance abuse and dependence
during adolescence and adulthood (Breyer, Lee,
Winters, August, & Realmuto, 2014; Gudjonsson,
Sigurdsson, Sigfusdottir, & Young, 2012; Lee,
Humphreys, Flory, Liu, & Glass, 2011). The wide-
spread prevalence of ADHD diagnoses, the associated
negative developmental outcomes, and long-term
social and financial burdens to families and society
define this disorder as a significant public health con-
cern (Doshi et al., 2012; Polanczyk, Willcutt, Salum,
Kieling, & Rohde, 2014).
ADHD and co-occurring psychiatric disorders
Children with ADHD diagnoses are significantly more
likely to develop substance use disorders (SUDs) than
children without ADHD diagnoses (Lee et al., 2011).
Childhood ADHD has been found to predict greater
initial exposure to substances at earlier ages and more
CONTACT Timothy Regan tregan2149@tamu.edu Department of Psychological & Brain Sciences, Texas A&M University College Station, College
Station, TX 77843, USA.
ß2019 Taylor & Francis Group, LLC
SUBSTANCE USE & MISUSE
https://doi.org/10.1080/10826084.2019.1657895
rapid progression of substance use during adolescence
(Molina et al., 2018). Chan, Dennis and Funk (2008)
found that over 60% of adolescents receiving sub-
stance abuse treatment services met criteria for a cur-
rent diagnosis of ADHD. Therefore, a lifetime
diagnosis of ADHD is a significant risk factor for the
development of substance abuse problems or sub-
stance dependence disorders.
In addition to SUDs, ADHD and associated symp-
toms are often comorbid with other psychiatric disor-
ders. Most children with ADHD have at least one
comorbid psychiatric disorder. In one large-scale
study, parental reports about children diagnosed with
ADHD indicated co-occurring diagnoses of learning
disabilities (46%), conduct disorder (27%), anxiety
(18%), and depression (14%), with economically dis-
advantaged children having a 3.8 times greater likeli-
hood of having three or more comorbid diagnoses
(Larson et al., 2011). In a community birth cohort
study comparing incident cases of ADHD to popula-
tion-based controls, diagnosis of ADHD was associ-
ated with significantly higher odds of manifesting
diagnoses of adjustment disorders, oppositional defi-
ant disorder, conduct disorder, mood disorders, anx-
iety disorders, and SUDs (Yoshimasu et al., 2012).
Diagnostic subtypes of ADHD
Assignment of a diagnosis of ADHD is defined in
part by three separate subtypes which manifest unique
symptom presentations: the predominantly inattentive,
predominantly hyperactive/impulsive and combined
subtypes (APA, 2013). Subtypes of ADHD appear to
be associated with differential risk for specific co-
occurring psychiatric disorders. First, evidence sup-
ports associations between ADHD subtype and spe-
cific substance use problems and SUDs. For example,
the Inattentive subtype appears to share a robust rela-
tionship with nicotine dependence among adolescents
and emerging adults (e.g., Pingault et al., 2013; Wilens
et al., 2009), while the Hyperactive-Impulsive subtype
predicts initiation of tobacco, alcohol, marijuana and
illicit drug use and subsequent SUDs in population-
based samples (Elkins, McGue, & Iacono, 2007;
Liebrenz, Gamma, Ivanov, Buadze, & Eich, 2015). In
contrast, other studies have noted that the Combined
subtype of ADHD predicts more severe substance
abuse outcomes, is associated with seeking substance
abuse treatment (Kaye et al., 2016) and more exten-
sive psychiatric comorbidity among treatment-seekers
(Wilens et al., 2009), compared to the Inattentive and
Hyperactive/Impulsive subtypes. However, other studies
have reported no clear relation between ADHD sub-
types and differential substance abuse outcomes. For
example, a large population-based study indicated
increased endorsement of ADHD symptoms alone was
associated with higher odds of endorsing alcohol,
tobacco and illicit SUDs, with no differences by sub-
type (Capusan, Bendtsen, Marteinsdottir, & Larsson,
2016). Thus, there is mixed evidence to support associ-
ations between ADHD subtypes and differential out-
comes for substance use problems and SUDs.
Gender and ADHD subtype
Although evidence documents that ADHD diagnoses
co-occur with a range of psychiatric disorders, gender
may influence the development of specific comorbid
diagnoses. For example, boys are more likely than
girls to be diagnosed with ADHD, with the gender
ratio estimated at approximately 2.3:1 for community
samples (Ramtekkar, Reiersen, Todorov, & Todd,
2010). Similarly, boys are more likely than girls to
receive a lifetime SUD diagnosis, with an estimated
gender ratio of approximately 2:1 (APA, 2013).
However, researchers have argued that girls diagnosed
with ADHD and SUD may have more severe presen-
tations than boys. Girls with ADHD are more likely
to experience severe internalizing problems, including
anxiety disorders and nonsuicidal self-injury (Eme,
2017). In addition, girls with SUDs are more likely to
experience elevated depression symptoms (e.g., Poulin,
Hand, Boudreau, & Santor, 2005).
Gender may interact with ADHD subtype and
influence co-occurring psychopathology and degree of
impairment in treatment samples. Hurmic et al.
(2015) examined adult outpatient clients receiving
substance abuse treatment services and reported that
the Hyperactive-Impulsive subtype was more preva-
lent among women, while the Combined subtype was
associated with higher likelihood of polysubstance use
and legal problems. However, a study of adults seek-
ing treatment for ADHD found no differences in
types of comorbid disorders across ADHD subtypes,
although gender differences were documented. Men
with ADHD were more likely to endorse SUDs, in
particular marijuana and polysubstance dependence,
while women with ADHD were more likely to
endorse personality pathology, in particular border-
line types (Soendergaard et al., 2016). Therefore, it
may be important to include gender and ADHD sub-
type in study design and treatment planning efforts,
as these factors may be related to systematic differen-
ces in both degree of psychiatric impairment at
2 T. REGAN AND J. TUBMAN
treatment entry, as well as treatment engagement and
treatment outcomes.
ADHD and sexual risk behaviors
In addition to co-occurring psychiatric disorders, ado-
lescents receiving substance abuse treatment may
report extensive co-occurring sexual risk behaviors.
A recent meta-analysis documented a significant
positive relation between substance use and sexual
risk behavior among adolescents in clinical settings
(r¼0.418; Ritchwood, Ford, DeCoster, Sutton, &
Lockman, 2015). Youth presenting for substance abuse
treatment report earlier onset of sexual activity, more
lifetime sexual partners, less condom use, and more
exposure to sexually-transmitted infections (STIs) than
community-based samples of youth (Tapert, Aarons,
Sedlar, & Brown, 2001). In addition to substance abuse,
lifetime diagnosis of comorbid psychiatric disorders is
associated with significant increases in adolescentssex-
ual risk-taking (Brown et al., 2010). With regard to
ADHD, among young women, Inattentive subtype
symptoms were uniquely associated with using alcohol
before sex, while Hyperactive/Impulsive subtype symp-
toms were uniquely associated with greater odds of
having three or more sexual partners in the prior year,
and greater odds of a lifetime risky male sexual partner
(Hosain, Berenson, Tennen, Bauer, & Wu, 2012).
Therefore, some evidence suggests that specific sexual
risk behaviors are associated with ADHD subtype, gen-
der, and co-occurring psychiatric disorders.
Adolescents receiving substance use treatment serv-
ices typically report clustered psychiatric symptoms
and sexual risk behaviors, reflecting differential
impairment and risk for maladaptive health outcomes
(Oshri, Tubman, Wagner, Leon-Morris, & Snyders,
2008). The presence of ADHD and co-occurring diag-
noses can pose a substantial challenge to treatment
engagement and positive treatment outcomes
(Schoenfelder & Kollins, 2014; Tamm et al., 2013).
Similarly, ADHD and co-occurring psychiatric disor-
ders are associated with specific forms of sexual risk
behavior in clinic samples of adolescents, indicating
great likelihood of short- and long-term negative
health outcomes (e.g., Brown et al., 2010). Therefore,
screening adolescents for ADHD and co-occurring
psychiatric symptoms at treatment entry may provide
treatment service providers important information
about specific psychiatric impairments and broader
patterns of health risk behaviors that can be addressed
during substance abuse treatment planning and imple-
mentation. Adolescents with SUDs, ADHD and co-
occurring disorders may benefit from integrated inter-
ventions that incorporate modalities that can address
addictive disease processes, co-occurring psychiatric
disorders and associated health-risk behaviors (Wilens
& Morrison, 2012).
The present study
The present study was based on baseline data from
part of a larger study (R01 AA 014322), evaluating a
brief motivational intervention (BMI) for HIV/STI
risk reduction among adolescents receiving outpatient
treatment services. We examined heterogeneity among
ADHD subtypes to determine if overall patterns of
comorbid psychiatric symptoms and co-occurring sex-
ual risk behaviors varied systematically by ADHD
subtype, as has been documented in previous examina-
tions of substance abuse treatment response and out-
comes (Tamm, Adinoff, Nakonezny, Winhusen, &
Riggs, 2012). Additionally, we examined heterogeneity
of comorbid psychiatric symptoms and co-occurring
sexual risk behaviors to identify systematic variation by
gender, given the lack of consistent findings in broader
substance abuse literatures (e.g., Lee et al., 2011).
The study evaluated two hypotheses. First, we
expected that the more complex, severe form of
ADHD (i.e., Combinedtype) would be associated with
more extensive patterns of comorbid psychiatric symp-
toms and sexual risk behaviors. Second, we did not
expect that overall patterns of comorbid psychiatric
symptoms and co-occurring sexual risk behaviors to
vary systematically by gender due to the high levels of
both reported in this treatment sample of adolescents
in previous analyses (e.g., Tubman, Oshri, Taylor, &
Morris, 2011). Evaluation of these hypotheses in a
diverse, multi-ethnic sample of adolescents receiving
outpatient substance abuse treatment services provides
important information to treatment providers regarding
multivariate relations between a common risk factor
for SUDs (i.e., ADHD) and (a) co-occurring patterns
of psychopathology and (b) preventable sources of
morbidity among vulnerable youth.
Materials and methods
Participants
The sample consisted of 394 adolescents, including 280
males (71.1%) and 114 females (28.9%), receiving sub-
stance use treatment services at two outpatient facilities
in South Florida. Inclusion criteria for the study were:
(1) parental consent, (2) adolescent assent, and (3) sex-
ual activity during the prior six months, based on the
SUBSTANCE USE & MISUSE 3
parent studys HIV/STI risk reduction aims. Adolescents
who, by case manager report, were actively suicidal or
exhibited significant cognitive deficits or developmental
delays were not eligible to participate due to ethical con-
cerns about client safety and the cognitive capacities
required for the psychotherapeutic intervention delivered
in the treatment arm of the larger study.
Participantsages ranged from 12 to 18 years old
(M¼16.33 years; SD ¼1.15 years). The sample was
ethnically diverse and included adolescent who identi-
fied as non-Hispanic White (25.4%), Hispanic
(44.9%), non-Hispanic Black (20.6%), or from other
(9.1%) racial/ethnic groups. The majority of the
participants (83.2%) were born in the United States,
and 44.9% and 55.1% of their fathers and mothers,
respectively, were also born in the United States. Most
of the sample (n¼295, 74.8%) reported their father,
mother, or both as their primary caregiver(s). Over
half of the participants (n¼208, 52.7%) reported
repeating one or more school grades.
Participantsprevalence rates for past-year diagnoses
of ADHD varied by subtype: Inattentive subtype (37.3%),
Hyperactive-Impulsive subtype (28.9%) and Combined
subtype (21.5%). Participants reported a mean of 10.74
lifetime sex partners and 4.89 past-year sex partners. At
the time of last intercourse, 37.1% reported not using a
condom. Boys (M¼11.79) reported higher average num-
bers of lifetime sex partners than girls (M¼8.13), F(1,
376) ¼5.59, p<.05), but there was no significant differ-
ence in their numbers of past-year sex partners between
boys (M¼5.17) and girls (M¼4.19). Girls (58.2%) were
more likely than boys (28.6%) to report not using a con-
domatlastintercourse,v
2
(1, n¼383) ¼28.879, p<.001.
Girls also reported lower mean ratings than boys for how
often they used condoms during sex [3.99 vs. 3.25, F(1,
381) ¼28.675, p<.001], as well as how likely they were
to use a condom every time they have sex in the future
[2.20 vs. 2.70, F(1, 381) ¼6.618, p<.01]. The majority of
participants reported lifetime substance use,
including: marijuana (93.6%), opioids (32.0%), hallucino-
gens (29.0%), amphetamines (19.0%), and heroin (3.1%).
In addition, 75% of the sample reported alcohol use dur-
ing the prior 180 days. During the prior 12 months 89.1%
of the sample met diagnostic criteria for one or more
DSM-IV diagnoses, including: Drug Abuse (76.1%), Drug
Dependence (45.4%), Alcohol Abuse (41.3%), Alcohol
Dependence (15.0%), and Conduct Disorder (48.9%).
DSM-IV psychiatric diagnoses
Past year DSM-IV psychiatric symptoms were assessed
via adolescentsself-report using the Brief Michigan
Version of the Composite International Diagnostic
Interview (UM-CIDI; Kessler et al., 1998), a compre-
hensive, structured diagnostic interview developed by
the World Health Organization (WHO). The UM-
CIDI is administered by trained lay interviewers as a
means to assess disorders defined by the Diagnostic
and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2013). The administration of
the UM-CIDI included skip patterns and probe ques-
tions. This instrument was developed to standardize
the assessment of psychiatric disorders in community
settings and samples (Kessler, Wittchen, Abelson, &
Zhao, 2000). The UM-CIDI has excellent interrater
reliability and good test-retest reliability, as well as
sufficient validity based on concordance with clinical
judgments and structured clinical interviews (Haro et al.,
2006; Kessler et al., 2004). Among adolescents in the
National Comorbidity Survey-Adolescent Supplement
(NCS-A), UM-CIDI-generated diagnoses demonstrated
good aggregate concordance with blinded clinical diag-
nostic ratings generated using the K-SADS (Kessler
et al., 2009). The UM-CIDI yields categorical diagnoses
for three subtypes of ADHD including: the Inattentive
Subtype, the Hyperactive-Impulsive Subtype, and the
Combined Subtype. Analyses for the present study also
included six aggregated symptom score categories
derived from the UM-CIDI. These included: (a)
ADHD, (b) Conduct Disorder (CD)/Oppositional
Defiant Disorder (ODD), (c) Affective Disorders
(Major Depressive Disorder, Dysthymia), (d) Anxiety
Disorders [Generalized Anxiety Disorder (GAD),
Specific Phobia, Social Phobia, Panic Disorder], (e)
Alcohol Abuse and Dependence Disorders, and (f)
Drug Abuse and Dependence Disorders.
Sexual risk behaviors
Adolescents provided self-report data for several sex-
ual risk behavior variables that index behavioral risk
for HIV/STI exposure (Coates, Richter, & Caceres,
2008), including unprotected intercourse, numbers of
sex partners, co-occurring substance use and sexual
behavior, in addition to expectancies about sexual risk
behaviors co-occurring with alcohol or drug use.
Adolescents reported for the previous six months how
often they or a partner (a) drank alcohol or (b) used
drugs to get high before or during sex. These two
items were scored on a Likert scale, from 1 (never)to
5(always). Adolescents also provided a global rating
of unprotected intercourse by responding to the state-
ment, When you have sex, how often do you use a
condom? using a Likert scale from 1 (never)to5
(every time). Adolescents reported their numbers of
(a) past year and (b) lifetime sex partners.
4 T. REGAN AND J. TUBMAN
Adolescents also responded to the four items from
the Risky Sex Scale (OHare, 2001) assessing alcohol-
sexual behavior outcome expectancies. The items
assessed greater likelihood after using alcohol or drugs
of: having sex with a new date; having sex with a
familiar friend; having unprotected sex; or having
unplanned sex. Each item used the five-point response
format, from 1 (strongly disagree)to5(strongly agree).
In this sample, the estimated Cronbach alpha was 0.78
for this subscale. Subscale scores were predictive of
independent measures of sex under the influence of
drugs, count measures of unprotected sex, and con-
dom use at last intercourse (Tubman, Des Rosiers,
Schwartz, & OHare, 2012).
Procedure
Adolescents were approached in groups during their
first week of enrollment in outpatient substance abuse
treatment and invited to participate in a brief motiv-
ational HIV/STI risk reduction intervention. They
were read the eligibility criteria and were invited to
meet with a project staff member to confirm their eli-
gibility and begin the informed consent process.
Adolescents who met inclusion criteria were assessed
for DSM-IV psychiatric symptoms and were adminis-
tered a battery of questionnaires before being enrolled
in the HIV/STI risk reduction intervention. In the
broader NIAAA-funded study, participants completed
a 60- to 90-min assessment of substance use, sexual
risk behaviors, and demographics, as well as putative
mediators and moderators of intervention impact.
Trained graduate students collected data using a struc-
tured interview protocol on laptop computers at each
clients substance abuse treatment facility. The clinical
interview was completed with the participant only.
Active consent was obtained from both adolescents
and a primary caregiver via procedures approved by
the Institutional Review Board (IRB) at the sponsoring
university. Participants were compensated $25 for
completing the baseline assessment.
Analytic plan
Multiple analysis of variance (MANOVA) was used to
document significant differences in the aggregate lev-
els of self-reported psychiatric symptoms (anxiety dis-
orders, affective disorders, CD/ODD, alcohol abuse
and dependence, and drug abuse and dependence) by
ADHD diagnostic status and gender. Patterns of sig-
nificant differences in psychiatric symptoms by
ADHD diagnostic status and gender were examined
across ADHD subtypes to identify inconsistencies in
patterning of group differences. Group differences in
sexual risk behaviors were also investigated in a series
of three MANCOVAs that used ADHD subtype and
gender as fixed factors, five UM-CIDI-generated
symptom counts as covariates and six measures of
sexual risk behaviors as dependent variables outcomes.
Results
Table 1 summarizes the means, standard deviations,
ranges and intercorrelations among total scores for six
self-reported psychiatric symptom scores from the
CIDI. Self-reported scores are highest for total ADHD
symptoms, total anxiety symptoms and total conduct
disorder symptoms and lowest for alcohol abuse and
dependence symptoms. Each of the six symptoms has
a wide range of reported scores. Correlations among
psychiatric symptom scores ranged from 0.22 to 0.49,
with the highest correlations between forms of
Table 1. Means, standard deviations, ranges, and intercorrelations among psychiatric symptom scores and sexual risk behaviors
in a sample of adolescents receiving outpatient treatment services.
Psychiatric symptom scores 12345678 9 101112
1. ADHD 0.340.300.430.300.360.170.110.06 0.210.02 0.03
2. Anxiety 0.490.280.220.250.110.150.07 0.06 0.04 0.06
3. Affective 0.240.390.360.160.240.160.05 0.05 0.11
4. Conduct disorder 0.320.430.200.210.150.290.140.06
5. Alcohol abuse/dependence 0.450.350.230.150.200.04 0.05
6. Drug abuse/dependence 0.290.410.170.400.110.12
Sexual risk behaviors
7. Alcohol use before sex 0.41 0.150.310.170.16
8. Drug use before sex ––0.170.300.160.14
9. Condom use during sex 0.170.05 0.04
10. Alcohol-sexual outcome expectancies ––0.06 0.09
11. Lifetime sex partners 0.61
12. Past-year sex partners
Mean 8.70 8.00 3.02 8.20 1.57 4.51 2.13 2.62 3.77 3.13 10.74 4.90
SD 5.45 5.41 4.06 3.18 2.23 3.50 1.11 1.35 1.27 1.02 13.68 7.73
Range 18 32 18 17 10 11 4 4 4 4 149 90
Note: p<.05. N¼394.
SUBSTANCE USE & MISUSE 5
internalizing disorders (i.e., anxiety and affective dis-
order symptoms) and forms of externalizing disorders
(i.e., ADHD, CD, and SUD symptoms). The lowest
correlations were between anxiety disorder symptoms
and AUD symptoms. Correlations between psychiatric
disorder symptoms and sexual risk behavior scores
were less consistently statistically significant. For
example, psychiatric symptom scores were signifi-
cantly related to measures of substance use before or
condom use during sex, but generally not significantly
correlated with measures of cumulative sex partners.
Group differences in past year psychiatric
symptoms by clinical status for ADHD and gender
Table 2 summarizes mean psychiatric symptom scores
for anxiety, affective, conduct, and substance use
disorders by clinical status for ADHD Inattentive
Subtype and gender. There was a significant multivari-
ate pattern of differences in mean psychiatric symp-
toms scores by ADHD Inattentive Subtype clinical
status [Pillais Trace ¼0.11, F(5, 373) ¼9.24, p<
.001] and gender [PillaisTrace¼0.16, F(5, 373) ¼
14.44, p<.001]. Compared to adolescents without the
diagnosis, adolescents assigned diagnoses of ADHD
Inattentive Subtype reported significantly higher average
symptom scores for: anxiety disorders, F(1,377) ¼10.05,
p<.01; affective disorders, F(1,377) ¼13.46, p<.001;
conduct disorder, F(1,377) ¼22.09, p<.001; alcohol
abuse and dependence, F(1,377) ¼21.09, p<.001 and
drug abuse and dependence, F(1,377) ¼26.32,
p<.001. In addition, compared to boys in this sample,
girls reported significantly higher average symptom
scores for: anxiety disorders, F(1,377) ¼18.10,
p<.001; affective disorders, F(1,377) ¼57.31, p<.001,
as well as alcohol abuse and dependence, F(1,377) ¼
15.81, p<.001. All statistical interactions between clin-
ical status for ADHD Inattentive Subtype and gender
on mean psychiatric symptom scores were
nonsignificant.
Table 3 summarizes mean psychiatric symptom
scores for anxiety, affective, conduct, and substance use
disorders by clinical status for ADHD Hyperactive-
Impulsive Subtype and gender. There was a significant
multivariate pattern of differences in mean psychiatric
symptoms scores by ADHD Hyperactive-Impulsive
Subtype clinical status [PillaisTrace¼0.13, F(5, 373)
¼11.16, p<.001] and gender [Pillais Trace ¼0.14,
F(5, 373) ¼12.30, p<.001]. Compared to adolescents
without the diagnosis, adolescents assigned diagnoses
of ADHD Hyperactive-Impulsive Subtype reported sig-
nificantly higher average symptom scores for: anxiety
disorders, F(1,377) ¼14.31, p<.001; affective disor-
ders, F(1,377) ¼7.01, p<.01; conduct disorder,
F(1,377) ¼34.17, p<.001; alcohol abuse and depend-
ence, F(1,377) ¼23.02, p<.001 and drug abuse and
dependence, F(1,377) ¼20.62, p<.001. In addition,
compared to boys in this sample, girls reported signifi-
cantly higher average symptom scores for: anxiety dis-
orders, F(1,377) ¼17.14, p<.001; affective disorders,
Table 2. Mean psychiatric symptoms score by ADHD inattentive type status and gender.
Clinical diagnosis No diagnosis
Boys (n¼101) Girls (n¼41) Boys (n¼170) Girls (n¼69)
MSDMSDMSDMSD
Psychiatric symptom score
Anxiety disorders
a,c
8.87 5.65 11.17 7.05 6.75 3.26 9.50 6.43
Affective disorders
b,c
2.90 3.43 6.76 4.49 1.79 3.16 4.62 5.01
Conduct disorder
b
9.43 2.90 9.37 2.93 8.11 2.63 7.71 2.41
Alcohol abuse/dependence
b,c
1.85 2.16 3.24 2.95 1.08 1.84 1.70 2.37
Drug abuse/dependence
b
5.90 3.06 6.10 3.58 3.81 3.22 4.20 3.76
Note. Pillais Trace
ADHD
¼0.11, F(5, 373) ¼9.24, p<.001. Pillais Trace
gender
¼0.16, F(5, 373) ¼14.44, p<.001.
a
p
ADHD
<.01;
b
p
ADHD
<.001;
c
p
gender
<.001.
Table 3. Mean psychiatric symptoms score by ADHD hyperactive-impulsive type status and gender.
Clinical diagnosis No diagnosis
Boys (n¼76) Girls (n¼34) Boys (n¼195) Girls (n¼76)
M SD M SD M SD M SD
Psychiatric symptom score
Anxiety disorders
a,c
9.12 5.91 11.88 7.67 6.92 3.51 9.34 6.09
Affective disorders
b,c
2.96 3.50 6.41 4.34 1.91 3.18 4.97 5.11
Conduct disorder
b
9.66 2.67 9.97 2.96 8.19 2.75 7.59 2.27
Alcohol abuse/dependence
b,c
1.99 2.39 3.44 2.95 1.12 1.77 1.75 2.42
Drug abuse/dependence
b
5.83 3.34 6.32 3.68 4.11 3.18 4.28 3.68
Note. Pillais Trace
ADHD
¼0.13, F(5, 373) ¼11.16, p<.001. Pillais Trace
gender
¼0.14, F(5, 373) ¼12.30, p<.001.
a
p
ADHD
<.01;
b
p
ADHD
<.001;
c
p
gender
<.001.
6 T. REGAN AND J. TUBMAN
F(1,377) ¼48.09, p<.001, as well as alcohol abuse and
dependence, F(1,377) ¼15.28, p<.001. All statistical
interactions between clinical status for ADHD
Hyperactive-Impulsive Subtype and gender on mean
psychiatric symptom scores were nonsignificant.
Table 4 summarizes mean psychiatric symptom
scores for anxiety, affective, conduct, and substance
use disorders by clinical status for ADHD Combined
Subtype and gender. There was a significant multivari-
ate pattern of differences in mean psychiatric symp-
toms scores by ADHD Combined Subtype clinical
status [Pillais Trace ¼0.10, F(5, 373) ¼8.16,
p<.001] and gender [Pillais Trace ¼0.12, F(5, 373)
¼10.18, p<.001]. Compared to adolescents without
the diagnosis, adolescents assigned diagnoses of
ADHD Combined Subtype reported significantly
higher average symptom scores for: anxiety disorders,
F(1,377) ¼7.93, p<.01; conduct disorder, F(1,377) ¼
25.81, p<.001; alcohol abuse and dependence,
F(1,377) ¼16.10, p<.001 and drug abuse and
dependence, F(1,377) ¼18.20, p<.001. In addition,
compared to boys in this sample, girls reported sig-
nificantly higher average symptom scores for: anxiety
disorders, F(1,377) ¼10.75, p<.001; affective disor-
ders, F(1,377) ¼38.83, p<.001, as well as alcohol
abuse and dependence, F(1,377) ¼12.07, p<.001. All
statistical interactions between clinical status for
ADHD Combined Subtype and gender on mean psy-
chiatric symptom scores were nonsignificant.
Three sets of supplementary cross-tabulation analy-
ses were conducted to help interpret group differences
in substance abuse and dependence symptoms, i.e.,
one for each ADHD subtype by lifetime use of specific
substances or prior experience with substance abuse
treatment. Across the three sets of analyses, robust
patterns of findings emerged suggesting that, com-
pared to adolescents without any subtype diagnosis of
ADHD, adolescents assigned a diagnosis of any sub-
type of ADHD were more likely to report lifetime pat-
terns of polysubstance use, including higher rates of:
regular cigarette use, as well as use of sedatives/
barbiturates, pain killers/analgesics, tranquilizers, inha-
lants, powder cocaine, and hallucinogens. In addition,
adolescents assigned a diagnosis of any subtype of
ADHD were more likely to report lifetime experience
of inpatient, residential or day treatment for substance
use problems. Across the entire sample, 80.2% of the
participants endorsed marijuana as their drug
of choice.
Group differences in sexual risk behaviors
by clinical status for ADHD and gender
Group differences in sexual risk behaviors were inves-
tigated in a series of three MANCOVAs that used
ADHD subtype and gender as fixed factors, five UM-
CIDI-generated symptom counts as covariates and six
measures of sexual risk behaviors as dependent varia-
bles. Covariates included total psychiatric symptoms
scores for anxiety disorders, affective disorders, con-
duct disorder, alcohol abuse and dependence and
drug abuse and dependence. Across these three
MANCOVAs, there were no significant multivariate
patterns of differences in mean sexual risk behavior
variables by ADHD Inattentive Subtype clinical status
[Pillais Trace ¼0.015, F(6, 354) ¼0.874, NS],
ADHD Hyperactive-Impulsive Subtype clinical status
[Pillais Trace ¼0.014, F(6, 354) ¼0.817, NS], or
ADHD Combined Subtype clinical status [Pillais
Trace ¼0.016, F(6, 354) ¼0.969, NS]. Across these
three MANCOVAs, there were no significant statis-
tical interactions between gender and ADHD Subtype.
In the MANCOVA including ADHD Inattentive
Subtype, gender was associated with significant group
differences in sexual risk behavior [Pillais Trace ¼
0.173, F(6, 354) ¼12.333, p<.001]. Compared to
boys in this sample, girls reported significantly lower
condom use scores, F(1,359) ¼23.357, p<.001,
(M
boys
¼3.98, M
girls
¼3.27); lower numbers of life-
time sex partners, F(1,359) ¼6.323, p<.05 (M
boys
¼
11.80, M
girls
¼8.09); lower numbers of past-year sex
partners, F(1,359) ¼4.39, p<.05 (M
boys
¼5.20, M
girls
Table 4. Mean psychiatric symptoms score by ADHD combined type status and gender.
Clinical diagnosis No diagnosis
Boys (n¼55) Girls (n¼27) Boys (n¼216) Girls (n¼83)
M SD M SD M SD M SD
Psychiatric symptom score
Anxiety disorders
a,c
9.45 6.17 11.22 7.44 7.05 3.71 9.77 6.43
Affective disorders
c
2.91 3.64 6.15 3.60 2.03 3.19 5.18 5.26
Conduct disorder
b
9.80 2.76 9.96 3.08 8.30 2.74 7.80 2.38
Alcohol abuse/dependence
b,c
2.07 2.28 3.37 2.83 1.19 1.88 1.92 2.57
Drug abuse/dependence
b
6.31 3.27 6.19 3.61 4.15 3.19 4.49 3.77
Note. Pillais Trace
ADHD
¼0.10, F(5, 373) ¼8.16, p<0.001. Pillais Trace
gender
¼0.12, F(5, 373) ¼10.18, p<.001.
a
p
ADHD
<.01;
b
p
ADHD
<.001;
c
p
gender
<.001.
SUBSTANCE USE & MISUSE 7
¼4.15); less frequent use of alcohol before sex,
F(1,359) ¼4.714, p<.05 (M
boys
¼2.19, M
girls
¼2.06)
and greater likelihood of engaging in sexual risk
behaviors when using alcohol or other drugs, F(1,359)
¼24.854, p<.001 (M
boys
¼2.97, M
girls
¼3.50).
Significant covariates included conduct disorder symp-
toms [Pillais Trace ¼0.050, F(6, 354) ¼3.120,
p<.01], alcohol abuse and dependence symptoms
[Pillais Trace ¼0.070, F(6, 354) ¼4.439, p<.001]
and drug abuse and dependence symptoms [Pillais
Trace ¼0.166, F(6, 354) ¼11.760, p<.001]. Conduct
disorder symptoms covaried significantly with lifetime
sex partners (p<.05) and alcohol-sexual risk behavior
expectancies (p<.01); alcohol abuse and dependence
symptoms covaried significantly with frequency of
alcohol use before sex (p<.001); drug abuse and
dependence symptoms covaried significantly with fre-
quency of alcohol use before sex (p<.05), frequency
of drug use before sex (p<.001) and alcohol-sexual
risk behavior expectancies (p<.001).
In the MANCOVA including ADHD Hyperactive-
Impulsive Subtype, gender was associated with signifi-
cant group differences in sexual risk behavior [Pillais
Trace ¼0.151, F(6, 354) ¼10.478, p<.001].
Compared to boys in this sample, girls reported sig-
nificantly lower condom use scores, F(1,359) ¼
21.443, p<.001 (M
boys
¼3.98, M
girls
¼3.27); less fre-
quent use of alcohol before sex, F(1,359) ¼4.945,
p<.05 (M
boys
¼2.19, M
girls
¼2.06) and greater likeli-
hood of engaging in sexual risk behaviors when using
alcohol or other drugs, F(1,359) ¼21.701, p<.001
(M
boys
¼2.97, M
girls
¼3.50). Significant covariates
included conduct disorder symptoms [Pillais Trace ¼
.053, F(6, 354) ¼3.270, p<.01], alcohol abuse and
dependence symptoms [Pillais Trace ¼0.073, F(6,
354) ¼4.651, p<.001] and drug abuse and depend-
ence symptoms [Pillais Trace ¼0.157, F(6, 354) ¼
10.977, p<.001]. Conduct disorder symptoms
covaried significantly with lifetime sex partners
(p<.05), alcohol-sexual risk behavior expectancies
(p<.01) and condom use frequency (p<.05); alcohol
abuse and dependence symptoms covaried signifi-
cantly with frequency of alcohol use before sex
(p<.001); drug abuse and dependence symptoms
covaried significantly with frequency of alcohol use
before sex (p<.05), frequency of drug use before sex
(p<.001), condom use frequency (p<.05) and alco-
hol-sexual risk behavior expectancies (p<.001).
In the MANCOVA including ADHD Combined
Subtype, gender was associated with significant group
differences in sexual risk behavior [Pillais Trace ¼
0.131, F(6, 354) ¼8.917, p<.001]. Compared to boys
in this sample, girls reported significantly lower con-
dom use scores, F(1,359) ¼19.201, p<.001 (M
boys
¼
3.98, M
girls
¼3.27) and greater likelihood of engaging
in sexual risk behaviors when using alcohol or other
drugs, F(1,359) ¼15.981, p<.001 (M
boys
¼2.97,
M
girls
¼3.50). Significant covariates included conduct
disorder symptoms [Pillais Trace ¼0.054, F(6, 354)
¼3.372, p<.01], alcohol abuse and dependence
symptoms [Pillais Trace ¼.071, F(6, 354) ¼4.533,
p<.001] and drug abuse and dependence symptoms
[Pillais Trace ¼0.166, F(6, 354) ¼11.703, p<.001].
Conduct disorder symptoms covaried significantly
with lifetime sex partners (p<.05) and alcohol-sexual
risk behavior expectancies (p<.01); alcohol abuse and
dependence symptoms covaried significantly with fre-
quency of alcohol use before sex (p<.001); drug
abuse and dependence symptoms covaried signifi-
cantly with frequency of alcohol use before sex
(p<.01), frequency of drug use before sex (p<.001),
condom use frequency (p<.05) and alcohol-sexual
risk behavior expectancies (p<.001).
Discussion
The findings of the present study did not support the
hypotheses evaluated by the analyses. However, the
findings revealed important information that can
assist in treatment planning and tailoring intervention
content to reduce risk for maladaptive health out-
comes among adolescents receiving outpatient sub-
stance abuse treatment services. With regard to our
first hypothesis, positive status for the Combined
Subtype of ADHD was not associated with more
severe patterning of psychiatric symptoms and sexual
risk behaviors. Adolescents reported comparable levels
for most co-occurring psychiatric symptoms across
the Inattentive, Hyperactive-Impulsive, and Combined
subtypes and each ADHD subtype demonstrated a
similar pattern of significant differences in reported
psychiatric symptoms compared to adolescents not
assigned an ADHD diagnosis. In contrast, ADHD
subtype status was not significantly associated with
higher multivariate patterns of sexual risk behavior.
Our findings contradict some research suggesting
that endorsement of both the inattentive and hyper-
active/impulsive symptoms of ADHD is associated
with overall greater clinical severity, compared to one
set of symptoms alone (e.g., Kaye et al., 2016; Wilens
et al., 2009). Methodological issues may in part
explain the different findings of our study, including
the use of the briefer UM-CIDI by research inter-
viewers rather than longer structured interviews by
8 T. REGAN AND J. TUBMAN
experienced clinicians, and the inclusion of a diverse,
multicultural sample of adolescents recruited from
outpatient treatment facilities serving the general pub-
lic. The lack of significant gender by ADHD subtype
interactions is congruent with earlier studies that
document lack of gender differences in subtype
comorbidities, as well as a lack of differences in pat-
terns of comorbidities across ADHD subtypes.
However, this finding does not match other research
findings that suggest comorbidity profiles may differ
by ADHD subtype status and gender (e.g., Levy, Hay,
Bennett, & McStephen, 2005; Soendergaard et al.,
2016). More research is needed to determine if and
how gender may influence subtype presentations of
ADHD and the patterning of co-occurring psychiatric
symptoms. Our data, drawn from a diverse sample of
adolescents receiving outpatient treatment services,
suggest that specific ADHD subtypes alone do not
confer differential vulnerability for co-occurring psy-
chopathology or sexual risk behaviors.
Contrary to our second hypothesis, significant gen-
der differences were documented in multivariate pat-
terns of co-occurring psychiatric symptoms and sexual
risk behaviors. Girls in our sample reported higher
average scores than boys for anxiety, affective, alcohol
abuse and dependence disorder symptoms, as well as
for sexual risk behaviors under the influence of alco-
hol or other drugs and frequency of condom use.
These results are congruent with earlier research stud-
ies that documented adolescent girls may be at unique
risk for internalizing disorders (Jensen & Steinhausen,
2015) and alcohol, marijuana, and illicit drug abuse
and dependence when compared to boys (Elkins,
Saunders, Malone, Keyes et al., 2018; Elkins, Saunders,
Malone, Wilson, et al., 2018; Sihvola et al., 2011). Our
studys data also provide some initial support to the
idea that girls may be at greater risk for alcohol abuse
and/or sexual risk behaviors as a means to cope with
internalizing distress. While our study was cross-sec-
tional and used self-report data, these results warrant
further investigation in order to confirm possible gen-
der differences.
The results of our study extend findings in the
existing research literature documenting substantial
co-occurrence between ADHD and substance abuse
problems. In our sample, overall prevalence rates of
past-year ADHD diagnoses were 29.2% across the
subtypes, similar to previous studies of adolescents in
substance abuse treatment (Chan et al., 2008; van
Emmerik-van Oortmerssen et al., 2012). Our data
indicate that adolescents with any ADHD diagnosis in
our sample were more likely to endorse both cigarette
and illicit drug use, and report more extensive histor-
ies of treatment for substance abuse. These findings
lend support to the notion that subtypes of ADHD do
not confer differential risk for substance abuse out-
comes (Capusan, Bendtsen, Marteinsdottir, & Larsson,
2016). Rather, adolescents with any ADHD diagnosis
may be at risk for early onset of problematic sub-
stance use (Biederman et al., 2006; Dunne, Hearn,
Rose, & Latimer, 2014).
Substance abuse risk from ADHD may be con-
ferred, in part, by psychiatric symptoms co-occurring
with ADHD. Our findings indicate that ADHD symp-
toms are significantly correlated with anxiety, affect-
ive, conduct, and SUD disorder symptoms, consistent
with previous research documenting significant associ-
ations between ADHD, SUDs, and other co-occurring
diagnoses among adolescents (Larson et al., 2011; Lee
et al., 2011; Storr, Pacek, & Martins, 2012; Yoshimasu
et al., 2012). Psychiatric diagnoses, including ADHD,
often predate SUDs and become exacerbated as sub-
stance use accelerates, promoting negative develop-
mental outcomes as reciprocal influences persist (Deas
& Brown, 2006; Wilens & Biederman, 2006). The
overrepresentation of ADHD and other co-occurring
internalizing and externalizing psychiatric symptoms
in substance abuse treatment samples is explained in
part by underlying deficits in emotion regulation (e.g.,
Shadur & Lejuez, 2015) and impulsivity (e.g., Wilens
& Zulauf, 2015), in addition to other individual-level
characteristics. Future research may determine specific
mechanisms of risk for development of SUDs, includ-
ing externalizing pathways, internalizing pathways or
combinations of both (e.g., Cicchetti & Handley, 2019;
Farmer et al., 2016).
The lack of significant relations between ADHD
diagnostic status and indicators of sexual risk behavior
may be explained in several ways. First, earlier analy-
ses of this sample documented significant between-
group differences in some forms of sexual risk behav-
ior, between a cluster of adolescents with very low lev-
els of current psychopathology and four other clusters
of adolescents with higher levels of psychopathology
(Oshri et al., 2008). In the present analysis, both ado-
lescents with and without a current ADHD diagnosis
reported high levels of co-occurring psychiatric symp-
toms and comparable high levels of sexual risk behav-
iors. Second, a study by Sarver, McCart, Sheidow, and
Letourneau (2014) found that the relation between
impulsivity and sexual risk behavior was almost
entirely mediated by conduct and substance use prob-
lems. In our sample, clients both with and without a
current ADHD diagnosis reported high levels of co-
SUBSTANCE USE & MISUSE 9
occurring conduct disorder and SUD symptoms.
Therefore, patterning of sexual risk behavior may be
better explained by a general propensity towards
externalizing behaviors, rather than influences specific
to ADHD. Third, an earlier study documenting that
childhood ADHD prospectively predicted risky sexual
behaviors in early adulthood was restricted to an
entirely male and largely Caucasian sample of com-
munity individuals (Flory, Molina, Pelmham, Gnagy,
& Smith, 20 (Flory et al., 2006). Therefore, the
ADHD-sexual risk behavior relation may not general-
ize to other groups. The sample used in the present
study was younger, more diverse in terms of gender
and race/ethnicity, and recruited from outpatient sub-
stance abuse treatment centers.
Implications for substance abuse treatment
Most adolescents receiving treatment for substance
abuse problems experience co-occurring psychiatric
symptoms. Adolescents assigned ADHD diagnoses, in
addition to ongoing substance use problems, are likely
to benefit from integrated approaches to the treatment
of these co-occurring conditions. Personalized feed-
back can be provided on how substance abuse may
worsen comorbid psychiatric conditions (Esposito-
Smythers, Rallis, Machell, Williams, & Fischer, 2018).
The combination of stimulant medication and cogni-
tive behavioral therapy (CBT) has shown effectiveness
for decreasing substance use among adolescents with
comorbid ADHD and SUD (Tamm et al., 2013), in
particular, extended release stimulants that display low
potential for abuse (Zaso, Park, & Antshel, 2015).
Other interventions that may aid in addressing
comorbid conditions involve envisioning the pros and
cons of a future without substance use, setting prac-
tical goals for both SUDs and comorbid conditions,
and developing strategies to overcome SUD treatment
barriers (Esposito-Smythers et al., 2018). Discussion of
both SUDs and co-occurring mental health issues may
emphasize how decreasing substance use can have
positive effects on mental health more broadly.
Additional assessments for adolescents manifesting
severe psychiatric symptoms can determine if an ado-
lescent needs adjunctive interventions for co-occurring
psychiatric conditions.
Adolescents accessing substance abuse treatment
services should be screened routinely for ADHD
symptoms, in addition to substance use severity, and
impairment related to co-occurring psychiatric disor-
ders (e.g., Matthys et al., 2014). Attending to core
developmental needs of adolescents, such as the need
to demonstrate autonomy and competence, is critical
to engage youth in substance abuse treatment,
enhance motivation to change maladaptive behaviors
and facilitate positive treatment outcomes for co-
occurring mental and behavioral health issues
(Brauers, Kroneman, Otten, Lindauer, & Popma,
2016). While adolescentsmental health needs can act
as significant barriers to their engagement with sub-
stance abuse treatment, frameworks that address both
psychopathology and substance abuse have the cap-
acity, not only to enhance adolescentswillingness to
engage in substance abuse treatment, but also to
transform the systems that deliver treatment services
for SUDs (Ford & Blaustein, 2013).
Our findings also have significant implications for
HIV/STI risk reduction efforts in the context of ado-
lescent substance abuse treatment programs. Boys and
girls in treatment for substance abuse may endorse
substantially different patterns of sexual risk behav-
iors. Thus, HIV/STI prevention materials imple-
mented in treatment settings should be tailored to
provide gender-appropriate behavioral risk reduction
strategies. Several randomized controlled trials aimed
at empowering women who use alcohol and other
drugs to negotiate condom use with potential sexual
partners, as well as biomedical prevention strategies to
reduce HIV risk when women are unable to negotiate
condom use, have shown initial efficacy (e.g.,
Wechsberg et al., 2015). As substance use is more
strongly related to sexual risk behavior among women
(Ritchwood et al., 2015), addressing the role of alcohol
and drug use in enacting sexual risk behavior is par-
ticularly important for risk reduction among adoles-
cent girls. Adolescents receiving substance abuse
treatment services can benefit from routine screening
for sexual risk behaviors, in addition to ADHD symp-
toms and co-occurring psychiatric impairment, as
adolescents in our study reported substantial hetero-
geneity in these behavioral health concerns.
Limitations
The results of the present study should be interpreted
in the context of several important limitations. First,
the data analyzed were collected from a single source,
which can result in inflated associations among varia-
bles. More stable estimates of psychiatric symptoms
may have been obtained using multiple informants
and assessment techniques. These self-report data
were also subject to biases, including distorted recall
and social desirability. Second, the cross-sectional
analyses presented do not allow causal statements to
10 T. REGAN AND J. TUBMAN
be drawn from the findings. Third, the analyses pre-
sented are based on a sample of adolescents receiving
outpatient substance abuse treatment services. These
findings may not generalize to samples of adolescents
undergoing inpatient treatment or to adolescents with
substance use problems in community settings. Last, it
is possible that the ADHD symptoms assessed in our
study are the result of prolonged substance abuse.
Despite these limitations, this study documented
multivariate patterns of psychiatric symptoms associ-
ated with ADHD diagnostic status, regardless of
ADHD subtype, that did not generalize to co-occur-
ring sexual risk behaviors. The screening of adolescent
clients entering treatment for substance use problems
is warranted to facilitate treatment planning and to
better understand barriers to treatment engagement,
as well as the unique needs of boys and girls receiving
these services. Future research is needed to under-
stand more fully the influence of combinations of
ADHD subtypes, co-occurring psychiatric symptom
profiles, and sexual risk behaviors on the health and
well-being of adolescents receiving substance abuse
treatment services.
Disclosure of interest
The authors report no conflict of interest.
Funding
The study from which the data were derived for this article
was supported by Grant R01 AA14322. The authors have
no relevant financial conflicts to report.
ORCID
Timothy Regan http://orcid.org/0000-0001-9886-8809
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Biederman, J., Monuteaux, M. C., Mick, E., Wilens, T. E.,
Fontanella, J. A., Poetzl, K. M., Faraone, S. V. (2006).
Is cigarette smoking a gateway to alcohol and illicit drug
use disorders? A study of youths with and without atten-
tion deficit hyperactivity disorder. Biological Psychiatry,
59(3), 258264. doi:10.1016/j.biopsych.2005.07.009
Brauers, M., Kroneman, L., Otten, R., Lindauer, R., &
Popma, A. (2016). Enhancing adolescentsmotivation for
treatment in compulsory residential care: A clinical
review. Children and Youth Services Review,61, 117125.
doi:10.1097/01.chi.0000166173.72815.83
Breyer, J. L., Lee, S., Winters, K. C., August, G. J., &
Realmuto, G. M. (2014). A longitudinal study of child-
hood ADHD and substance dependence disorders in
early adulthood. Psychology of Addictive Behaviors,28(1),
238246. doi:10.1037/a0035664
Brown, L. K., Hadley, W., Stewart, A., Lescano, C.,
Whiteley, L., Donenberg, G., & DiClemente, R. (2010).
Psychiatric disorders and sexual risk among adolescents
in mental health treatment. Journal of Consulting and
Clinical Psychology,78(4), 590597. doi:10.1037/a0019632
Capusan, A. J., Bendtsen, P., Marteinsdottir, I., & Larsson,
H. (2016). Comorbidity of adult ADHD and its subtypes
with substance use disorder in a large population-based
epidemiological study. Journal of Attention Disorders. doi:
10.1177/1087054715626511
Chan, Y. F., Dennis, M. L., & Funk, R. R. (2008).
Prevalence and comorbidity of major internalizing and
externalizing problems among adolescents and adults pre-
senting to substance abuse treatment. Journal of
Substance Abuse Treatment,34(1), 1424. doi:10.1016/j.
jsat.2006.12.031
Cicchetti, D., & Handley, E. D. (2019). Child maltreatment
and the development of substance use and disorder.
Neurobiology of Stress,10, 100144. doi:10.1016/j.ynstr.
2018.100144
Coates, T. J., Richter, L., & Caceres, C. (2008). Behavioural
strategies to reduce HIV transmission: How to make
them work better. The Lancet,9639, 669684. doi:10.
1016/S0140-6736(08)60886-7
Deas, D., & Brown, E. S. (2006). Adolescent substance abuse
and psychiatric comorbidities. Journal of Clinical
Psychiatry,67(Suppl. 7), 1823.
Doshi, J. A., Hodgkins, P., Kahle, J., Sikirica, V., Cangelosi,
M. J., Setyawan, J., Neumann, P. J. (2012). Economic
impact of childhood and adult attention-deficit/hyper-
activity disorder in the United States. Journal of the
American Academy of Child & Adolescent Psychiatry,51,
9901002. doi:10.1016/j.jaac.2012.07.008
Dunne, E. M., Hearn, L. E., Rose, J. J., & Latimer, W. W.
(2014). ADHD as a risk factor for early onset and height-
ened adult problem severity of illicit substance use: An
accelerated gateway model. Addictive Behaviors,39(12),
17551758. doi:10.1016/j.addbeh.2014.07.009
Elkins, I. J., McGue, M., & Iacono, W. G. (2007).
Prospective effects of attention-deficit/hyperactivity dis-
order, conduct disorder, and sex on adolescent substance
use and abuse. Archives of General Psychiatry,64(10),
11451152. doi:10.1001/archpsyc.64.10.1145
Elkins, I. J., Saunders, G. R., Malone, S. M., Keyes, M. A.,
McGue, M., & Iacono, W. G. (2018). Associations
between childhood ADHD, gender, and adolescent alco-
hol and marijuana involvement: A causally informative
design. Drug and Alcohol Dependence,184,3341. doi:10.
1016/j.drugalcdep.2017.11.011
Elkins, I. J., Saunders, G. R., Malone, S. M., Wilson, S.,
McGue, M., & Iacono, W. G. (2018). Mediating pathways
from childhood ADHD to adolescent tobacco and mari-
juana problems: Roles of peer impairment, internalizing,
adolescent ADHD symptoms, and gender. Journal of
Child Psychology and Psychiatry,59(10), 10831093. doi:
10.1111/jcpp.12977
SUBSTANCE USE & MISUSE 11
Eme, R. (2017). Gender differences in juvenile attention-def-
icit/hyperactivity disorder. Annals of Psychiatry and
Mental Health,5(3), 1103.
Esposito-Smythers, C., Rallis, B., Machell, K., Williams, C.,
& Fischer, S. (2018). Brief interventions for adolescents
with substance abuse and comorbid psychiatric problems.
In P. M. Monti, S. M. Colby, & T. O. Tevyaw (Eds.),
Brief interventions for adolescent alcohol and substance
abuse (pp. 188212). New York, NY: The Guilford Press.
Farmer, R. F., Gau, J. M., Seeley, J. R., Kosty, D. B., Sher,
K. J., & Lewinsohn, P. M. (2016). Internalizing and exter-
nalizing disorders as predictors of alcohol use disorder
onset during three developmental periods. Drug and
Alcohol Dependence,164,3846. doi:10.1016/j.drugalcdep.
2016.04.021
Flory, K., Molina, B. S., Pelham, @Jr W. E., Gnagy, E., &
Smith, B. (2006). Childhood ADHD predicts risky sexual
behavior in young adulthood. Journal of Clinical Child
and Adolescent Psychology,35(4), 571577.
Ford, J. D., & Blaustein, M. E. (2013). Systematic self-regu-
lation: A framework for trauma-informed services in resi-
dential juvenile justice programs. Journal of Family
Violence,28(7), 665677. doi:10.1007/s10896-013-9538-5
Gudjonsson, G. H., Sigurdsson, J. F., Sigfusdottir, I. D., &
Young, S. (2012). An epidemiological study of ADHD
symptoms among young persons and the relationship
with cigarette smoking, alcohol consumption and illicit
drug use. Journal of Child Psychology and Psychiatry,
53(3), 304312. doi:10.1111/j.1469-7610.2011.02489.x
Haro, J. M., Arbabzadeh-Bouchez, S., Brugha, T. S., de
Girolamo, G., Guyer, M. E., Jin, R., Kessler, R. C.
(2006). Concordance of the Composite International
Diagnostic Interview Version 3.0 (CIDI 3.0) with standar-
dized clinical assessments in the WHO World Mental
Health Surveys. International Journal of Methods in
Psychiatric Research,15(4), 167180. doi:10.1002/mpr.196
Hosain, G. M., Berenson, A. B., Tennen, H., Bauer, L. O., &
Wu, Z. H. (2012). Attention deficit hyperactivity symp-
toms and risky sexual behavior in young adult women.
Journal of Womens Health,21(4), 463468. doi:10.1089/
jwh.2011.2825
Hurmic, H., Debrabant, R., Kervran, C., Serre, F.,
Auriacombe, M., & Fatseas, M. (2015). ADHD and sub-
stance use disorders: Subtype and gender differences.
Drug and Alcohol Dependence,156, e100e101. doi:10.
1016/j.drugalcdep.2015.07.1190
Jensen, C. M., & Steinhausen, H. C. (2015). Comorbid men-
tal disorders in children and adolescents with attention-
deficit/hyperactivity disorder in a large nationwide study.
ADHD Attention Deficit and Hyperactivity Disorders,
7(1), 2738. doi:10.1007/s12402-014-0142-1
Kaye, S., Ramos-Quiroga, J. A., van de Glind, G., Levin,
F. R., Faraone, S. V., Allsop, S., Franck, J. (2016).
Persistence and subtype stability of ADHD among sub-
stance use disorder treatment seekers. Journal of
Attention Disorders. doi:10.1177/1087054716629217
Kessler, R. C., Abelson, J., Demler, O., Escobar, J. I.,
Gibbon, M., Guyer, M. E., Zheng, H. (2004). Clinical
calibration of DSM-IV diagnoses in the World Mental
Health (WMH) version of the World Health
Organization (WHO) Composite International Diagnostic
Interview (CIDI). International Journal of Methods in
Psychiatric Research,13(2), 122139. doi:10.1002/mpr.169
Kessler, R. C., Avenevoli, S., Green, J., Gruber, M. J., Guyer,
M., He, Y., Merikangas, K. R. (2009). National
comorbidity survey replication adolescent supplement
(NCS-A): III. Concordance of DSM-IV/CIDI diagnoses
with clinical reassessments. Journal of the American
Academy of Child & Adolescent Psychiatry,48(4),
386399. doi:10.1097/CHI.0b013e31819a1cbc
Kessler, R. C., Wittchen, H.-U., Abelson, J. M., McGonagle,
K. A., Schwarz, N., Kendler, K. S., Zhao, S. (1998).
Methodological studies of the Composite International
Diagnostic Interview (CIDI) in the US National
Comorbidity Survey. International Journal of Methods in
Psychiatric Research,7(1), 3355. doi:10.1002/mpr.33
Kessler, R. C., Wittchen, H.-U., Abelson, J., & Zhao, S.
(2000). Methodological issues in assessing psychiatric dis-
order with self-reports. In A. A. Stone, J. S. Turrkan,
C. A. Bachrach, J. B. Jobe, H. S. Kurtzman, & V. S. Cain
(Eds.), The science of self-report: Implications for research
and practice (pp. 229255). Mahwah, NJ: Lawrence
Erlbaum Associates.
Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011).
Patterns of comorbidity, functioning, and service use for
US children with ADHD, 2007. Pediatrics,127, 462470.
doi:10.1542/peds.2010-0165.[21300675]
Lee, S. S., Humphreys, K. L., Flory, K., Liu, R., & Glass, K.
(2011). Prospective association of childhood attention-
deficit/hyperactivity disorder (ADHD) and substance use
and abuse/dependence: A meta-analytic review. Clinical
Psychology Review,31(3), 328341. doi:10.1016/j.cpr.2011.
01.006
Levy, F., Hay, D. A., Bennett, K. S., & McStephen, M.
(2005). Gender differences in ADHD subtype comorbid-
ity. Journal of the American Academy of Child &
Adolescent Psychiatry,44(4), 368376. doi:10.1097/01.chi.
0000153232.64968.c1
Liebrenz, M., Gamma, A., Ivanov, I., Buadze, A., & Eich, D.
(2015). Adult attention-deficit/hyperactivity disorder:
Associations between subtype and lifetime substance
useA clinical study. F1000Research,4, 407. doi:10.12688/
f1000research.6780.2
Matthys, F., Stes, S., van den Brink, W., Joostens, P.,
M
obius, D., Tremmery, S., & Sabbe, B. (2014). Guideline
for screening, diagnosis and treatment of ADHD in
adults with substance use disorders. International Journal
of Mental Health and Addiction,12(5), 629647. doi:10.
1007/s11469-014-9496-z
Molina, B. S. G., Howard, A. L., Swanson, J. M., Stehli, A.,
Mitchell, J. T., Kennedy, T. M., Hoza, B. (2018).
Substance use through adolescence into early adulthood
after childhood-diagnosed ADHD: Findings from the
MTA longitudinal study. Journal of Child Psychology and
Psychiatry,59(6), 692702. doi:10.1111/jcpp.12855
OHare, T. (2001). Substance abuse and risky sex in young
people: The development and validation of the Risky Sex
Scale. Journal of Primary Prevention,22,89101. doi:10.
1023/A:1012653717412
Oshri, A., Tubman, J. G., Wagner, E. F., Leon-Morris, S., &
Snyders, J. (2008). Psychiatric symptom patterns, prox-
imal risk factors, and sexual risk behaviors among youth
in outpatient substance abuse treatment. American
12 T. REGAN AND J. TUBMAN
Journal of Orthopsychiatry,78(4), 430. doi:10.1037/
a0014326
Poulin, C., Hand, D., Boudreau, B., & Santor, D. (2005).
Gender differences in the association between substance
use and elevated depressive symptoms in a general ado-
lescent population. Addiction,100(4), 525535. doi:10.
1111/j.1360-0443.2005.01033.x
Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C.,
& Rohde, L. A. (2014). ADHD prevalence estimates
across three decades: An updated systematic review and
meta- regression analysis. International Journal of
Epidemiology,43(2), 434442. doi:10.1093/ije/dyt261
Pingault, J. B., C^
ot
e, S. M., Gal
era, C., Genolini, C.,
Falissard, B., Vitaro, F., & Tremblay, R. E. (2013).
Childhood trajectories of inattention, hyperactivity and
oppositional behaviors and prediction of substance abuse/
dependence: A 15-year longitudinal population-based
study. Molecular Psychiatry,18(7), 806812. doi:10.1038/
mp.2012.87
Ramtekkar, U. P., Reiersen, A. M., Todorov, A. A., & Todd,
R. D. (2010). Sex and age differences in attention-deficit/
hyperactivity disorder symptoms and diagnoses:
Implications for DSM-V and ICD-11. Journal of the
American Academy of Child & Adolescent Psychiatry,
49(3), 217228. doi:10.1016/j.jaac.2009.11.011
Ritchwood, T. D., Ford, H., DeCoster, J., Sutton, M., &
Lochman, J. E. (2015). Risky sexual behavior and sub-
stance use among adolescents: A meta-analysis. Children
and Youth Services Review,52,7488. doi:10.1016/j.child-
youth.2015.03.005
Sarver, D. E., McCart, M. R., Sheidow, A. J., & Letourneau,
E. J. (2014). ADHD and risky sexual behavior in adoles-
cents: Conduct problems and substance use as mediators
of risk. Journal of Child Psychology and Psychiatry,
55(12), 13451353. doi:10.1111/jcpp.12249
Schoenfelder, E. N., & Kollins, S. H. (2014). Prevention of
health risk behaviors in ADHD youth: Is ADHD treat-
ment enough? The ADHD Report,22(4), 18. doi:10.
1521/adhd.2014.22.4.1
Shadur, J. M., & Lejuez, C. W. (2015). Adolescent substance
use and comorbid psychopathology: Emotion regulation
deficits as a transdiagnostic risk factor. Current Addiction
Reports,2(4), 354363. doi:10.1007/s40429-015-0070-y
Sibley, M. H., Kuriyan, A. B., Evans, S. W., Waxmonsky,
J. G., & Smith, B. H. (2014). Pharmacological and psy-
chosocial treatments for adolescents with ADHD: An
updated systematic review of the literature. Clinical
Psychology Review,34(3), 218232. doi:10.1016/j.cpr.2014.
02.001
Sihvola, E., Rose, R. J., Dick, D. M., Korhonen, T.,
Pulkkinen, L., Raevuori, A., Kaprio, J. (2011).
Prospective relationships of ADHD symptoms with devel-
oping substance use in a population-derived sample.
Psychological Medicine,41(12), 26152623. doi:10.1017/
S0033291711000791
Soendergaard, H. M., Thomsen, P. H., Pedersen, E.,
Pedersen, P., Poulsen, A. E., Winther, L., Soegaard,
H. J. (2016). Associations of age, gender, and subtypes
with ADHD symptoms and related comorbidity in a
Danish sample of clinically referred adults. Journal of
Attention Disorders,20(11), 925933. doi:10.1177/
1087054713517544
Storr, C. L., Pacek, L. R., & Martins, S. S. (2012). Substance
use disorders and adolescent psychopathology. Public
Health Reviews,34(2), 10. doi:10.1007/BF03391678
Tamm, L., Adinoff, B., Nakonezny, P. A., Winhusen, T., &
Riggs, P. (2012). Attention-deficit/hyperactivity disorder
subtypes in adolescents with comorbid substance-use dis-
order. The American Journal of Drug and Alcohol Abuse,
38(1), 93100. doi:10.3109/00952990.2011.600395
Tamm, L., Trello-Rishel, K., Riggs, P., Nakonezny, P. A.,
Acosta, M., Bailey, G., & Winhusen, T. (2013). Predictors
of treatment response in adolescents with comorbid sub-
stance use disorder and attention-deficit/hyperactivity
disorder. Journal of Substance Abuse Treatment,44(2),
224230. doi:10.1016/j.jsat.2012.07.001
Tapert, S. F., Aarons, G. A., Sedlar, G. R., & Brown, S. A.
(2001). Adolescent substance use and sexual risk-taking
behavior. Journal of Adolescent Health,28(3), 181189.
doi:10.1016/S1054-139X(00)00169-5
Tubman, J. G., Des Rosiers, S. E., Schwartz, S. J., & OHare,
T. (2012). The use of the Risky Sex Scale among adoles-
cents receiving treatment services for substance use prob-
lems: Factor structure and predictive validity. Journal of
Substance Abuse Treatment,43(3), 359365. doi:10.1016/j.
jsat.2012.01.002
Tubman, J. G., Oshri, A., Taylor, H., & Morris, S. L. (2011).
Maltreatment clusters among youth in outpatient sub-
stance abuse treatment: Co-occurring patterns of mal-
adaptive health behaviors. Archives of Sexual Behavior,
40(2), 301309. doi:10.1007/s10508-010-9699-8
van Emmerik-van Oortmerssen, K., van de Glind, G., van
den Brink, W., Smit, F., Crunelle, C. L., Swets, M., &
Schoevers, R. A. (2012). Prevalence of attention-deficit
hyperactivity disorder in substance use disorder patients:
A meta-analysis and meta-regression analysis. Drug and
Alcohol Dependence,122(12), 1119. doi:10.1016/j.dru-
galcdep.2011.12.007
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook,
J. R., Kogan, M. D., Ghandour, R. M., Blumberg, S. J.
(2014). Trends in the parent-report of health care pro-
vider- diagnosed and medicated attention-deficit/hyper-
activity disorder: United States, 20032011. Journal of
the American Academy of Child & Adolescent Psychiatry,
53,3446. doi:10.1016/j.jaac.2013.09.001
Wechsberg, W. M., Deren, S., Myers, B., Kirtadze, I., Zule,
W. A., Howard, B., & El-Bassel, N. (2015). Gender-spe-
cific HIV prevention interventions for women who use
alcohol and other drugs: The evolution of the science
and future directions. Journal of Acquired Immune
Deficiency Syndromes,69(01), S128S139. doi:10.1097/
QAI.0000000000000627
Wilens,T.E.,&Biederman,J.(2006).Alcohol,drugs,and
attention-deficit/hyperactivity disorder: A model for the
study of addictions in youth. Journal of Psychopharmacology,
20(4), 580588. doi:10.1177/0269881105058776
Wilens, T. E., Biederman, J., Faraone, S. V., Martelon, M.,
Westerberg, D., & Spencer, T. J. (2009). Presenting
ADHD symptoms, subtypes, and comorbid disorders in
clinically referred adults with ADHD. The Journal of
Clinical Psychiatry,70(11), 15571562. doi:10.4088/JCP.
08m04785pur
Wilens, T. E., & Morrison, N. R. (2012). Substance-use dis-
orders in adolescents and adults with ADHD: Focus on
SUBSTANCE USE & MISUSE 13
treatment. Neuropsychiatry,2(4), 301312. doi:10.2217/
npy.12.39
Wilens, T. E., & Zulauf, C. A. (2015). Attention deficit
hyperactivity disorder and substance use disorders. In Y.
Kaminer (Ed.), Youth substance abuse and co-occurring
disorders (pp. 103129). Arlington, VA: American
Psychiatric Association Publishing.
Yoshimasu, K., Barbaresi, W. J., Colligan, R. C., Voigt,
R. G., Killian, J. M., Weaver, A. L., & Katusic, S. K.
(2012). Childhood ADHD is strongly associated with a
broad range of psychiatric disorders during adolescence:
A population-based birth cohort study. Journal of Child
Psychology and Psychiatry,53(10), 10361043. doi:10.
1111/j.1469-7610.2012.02567.x
Zaso, M. J., Park, A., & Antshel, K. M. (2015). Treatments
for adolescents with comorbid ADHD and substance use
disorder: A systematic review. Journal of Attention
Disorders. doi:10.1177/108705471556928
14 T. REGAN AND J. TUBMAN
... Adolescent boys with ADHD and SUD consumed more alcohol, with male sex being a risk factor for these behaviors [60]. However, adolescent girls with more hyperactive-impulsive symptoms consumed more alcohol [45] and suffered more frequently from SUD than boys with ADHD [46,55]. In contrast, boys receiving pharmacological treatment for ADHD consumed less alcohol than those in the control group although this finding was not the same for adolescent girls with and without ADHD [53]. ...
... Our review synthesizes the literature on sex differences in substance use, substance use disorder, prevalence, pharmacological therapy, and mental health in adolescents with ADHD. Our results show that ADHD was associated with SUD in adolescence and that girls with ADHD were at an increased risk for some types of SUD, including tobacco, alcohol, marijuana, and cannabis [43][44][45][46]52,55,59]. Indeed, the body of research suggesting that girls with ADHD may be at increased risk for SUD is growing [29,32,34,[61][62][63][64]. ...
... In contrast, other studies emphasized that the association between ADHD and SUD is greater in adolescent boys [51] and considered male sex to be a risk factor for this comorbidity [33,60,66]. Yildiz et al. (2020) [60] found that alcohol consumption in adolescents with ADHD was associated with a SUD comorbidity in boys and with hyperactivity-impulsivity in girls [45], with girls presenting greater SUD [55]. However, the two studies with participants with severe childhood ADHD, found no sex differences: both sexes started drinking alcohol earlier, and the consumption was more frequent than in individuals without the disorder [45,59]. ...
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Sex differences are poorly studied within the field of mental health, even though there is evidence of disparities (with respect to brain anatomy, activation patterns, and neurochemistry, etc.) that can significantly influence the etiology and course of mental disorders. The objective of this work was to review sex differences in adolescents (aged 13–18 years) diagnosed with ADHD (according to the DSM-IV, DSM-IV-TR and DSM-5 criteria) in terms of substance use disorder (SUD), prevalence, pharmacological therapy and mental health. We searched three academic databases (PubMed, Web of Science, and Scopus) and performed a narrative review of a total of 21 articles. The main conclusions of this research were (1) girls with ADHD are more at risk of substance use than boys, although there was no consensus on the prevalence of dual disorders; (2) girls are less frequently treated because of underdiagnosis and because they are more often inattentive and thereby show less disruptive behavior; (3) together with increased impairment in cognitive and executive functioning in girls, the aforementioned could be related to greater substance use and poorer functioning, especially in terms of more self-injurious behavior; and (4) early diagnosis and treatment of ADHD, especially in adolescent girls, is essential to prevent early substance use, the development of SUD, and suicidal behavior.
... The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) enlists the criteria that are used for ADHD diagnosis [4]. ADHD diagnosis primarily depends on the information collected from the child's parents, school, and health professionals (if consulted), accompanied by an interview and an examination [5][6]. 1 2 3 4 5 5 6 5 5 Previous studies have reported a 4%-12% ADHD incidence among children aged six to 12 years [6][7]. Other studies have reported an ADHD prevalence of 4%-8%, 7.6%-9.5%, ...
... The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) enlists the criteria that are used for ADHD diagnosis [4]. ADHD diagnosis primarily depends on the information collected from the child's parents, school, and health professionals (if consulted), accompanied by an interview and an examination [5][6]. 1 2 3 4 5 5 6 5 5 Previous studies have reported a 4%-12% ADHD incidence among children aged six to 12 years [6][7]. Other studies have reported an ADHD prevalence of 4%-8%, 7.6%-9.5%, ...
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Abstract Background Globally, attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder that affects children. In 2011, there was an ADHD diagnosis prevalence of around 8% among children (4-17 years) in the US. ADHD-affected children are more prone to physical injuries such as physical trauma, accidental poisoning, burns, etc. This study was aimed to evaluate the association of ADHD with severe injuries, the influence of age and gender on this association, and the impact of ADHD medications on the frequency of such injuries. Methodology This study was conducted in three governmental and three private settings in Aseer region. The files of children who were diagnosed with ADHD in the study settings were reviewed for a 12-month time period. Data were extracted from the medical files using a pre-structured data extraction sheet to avoid errors and inter-rater bias. The extracted data included child gender, age, duration of disease, and injury-related data. A brief questionnaire had been applied to mothers regarding mothers' attitudes towards injuries among their children, adherence to medications, as well as the reasons for non-adherence to medications and clinical visits in a non-adherent group during the clinic visit. Results One hundred and sixty-three children with a diagnosis of ADHD completed the study. The affected children were aged between two and 15 years (mean: 7.8 ± 2.9 years). An exact of 116 (71.2%) children were males. An exact of 70 (42.9%) affected children had trauma. The most-reported traumas were superficial injuries (84.3%), burns (48.6%), fractures (37.1%), deep injuries (31.4%), and broken or lost teeth (28.6%). About 52% of the children were adherent to medications and their clinical visits. Among the non-adherent group, the most reported reasons were parents’ care and attention (20.5%), followed by the COVID-19 pandemic and delay in visits times (16.7%). Regarding mothers' attitudes towards injuries among children with ADHD, 49.1% of the mothers agreed that there is an association between a child with ADHD and being traumatized while 22.7% said there was no relation. Conclusions In our cohort, the majority of the children with ADHD were boys at primary school age. Association of the history of the disease with trauma was not uncommon, and most injuries were not severe, but burns and deep injuries were reported among considered portions.
... Current data indicate an ADHD prevalence of 21.5% in SUD populations [16]. However, there were many attempts to estimate the prevalence of ADHD among SUD populations over the last decades, with inconsistent data ranging from 5.22% [17] to 62% [18]. ...
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(1) Background: Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of age-inappropriate levels of inattention and/or hyperactivity/impulsivity that results in functional impairment at work, education, or hobbies and affects family life, social contacts, and self-confidence. ADHD is a comorbid condition associated with a prognosis of severe substance use disorder (SUD) and the early onset of such. The aim of this meta-analysis was to obtain the best estimate of the prevalence of ADHD in SUD populations. (2) Methods: A literature research was conducted using PUBMED® and Web of Science®. The following search terms were used: [ADHD], [prevalence], and [substance use disorder]. RStudio® was used for meta-analysis methods. (3) Results: In total, 31 studies were included. We estimate the prevalence of ADHD among SUD patients at 21%.
... Likewise, ADHD has been shown to be a stronger risk factor for alcohol-related diagnoses in girls than in boys. Both in adolescents with a clinical diagnosis and in those without a clinical diagnosis, but who screen positive for ADHD, the association to alcohol problems has been shown to be stronger in girls [57]. In girls and boys treated for SUDs in out-patient facilities, the picture has been clearer; self-reported mental health symptoms, as well as self-reported mental health disorders diagnosed, were significantly more common in girls than in boys [58]. ...
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The current study aimed to explore the multimodal differences between the inattentive ADHD (ADHD-I) subtype and the combined ADHD (ADHD-C) subtype. A large sample of medication-naïve children with pure ADHD (i.e., without any comorbidity) (145 with ADHD-I, 132 with ADHD-C) and healthy controls (n = 98) were recruited. A battery of multiple scales and cognitive tests were utilized to assess the clinical and cognitive profiles of each individual. In addition, structural and diffusion magnetic resonance imaging (MRI) were acquired for 120 subjects with ADHD and 85 controls. Regional gray matter volume, white matter volume, and diffusion tensors, e.g., axial diffusivity (AD), were compared among the three groups in a whole-brain voxel-wise manner. Compared with healthy controls, both ADHD groups exhibited elevated levels of behavioral and emotional problems. The ADHD-C group had more behavioral problems and emotional liability, as well as less anxiety, than the ADHD-I group. The two ADHD groups were equally impaired in most cognitive domains, with the exception of sustained attention. Compared with healthy controls, the ADHD-C group showed a high gray matter volume (GMV) in the bilateral thalamus and a high white matter volume in the body of the corpus callosum, while the ADHD-I group presented an elevated GMV mainly in the left precentral gyrus and posterior cingulate cortex. Compared with participants with ADHD-C and healthy controls, subjects with ADHD-I showed increased AD in widespread brain regions. Our study has revealed a distinct, interconnected pattern of behavioral, cognitive, and brain structural characteristics in children with different ADHD subtypes.
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Children who experience maltreatment are at well-documented risk for the development of problematic substance use and disorder in adolescence and beyond. This review applies a developmental psychopathology framework to discuss the complex multilevel probabilistic pathways from child maltreatment to substance use and substance use disorder (SUD). We begin with an overview of the myriad vulnerabilities associated with child maltreatment, including the development of substance use and SUD. Prominent pathways that may potentiate liability for SUD are discussed. Specifically, we highlight the robust empirical support for the prominent externalizing pathway of risk, and also discuss the state of the research regarding the internalizing pathway. Consistent with the developmental psychopathology perspective, we then review biological processes such as neuroendrocrine mechanisms, allostatic load, and neurobiological pathways that may underlie child maltreatment risk, as well as discuss broader contextual issues. Elucidating the processes underlying the development of substance use and disorder among children exposed to this form of early adversity is paramount for not only informing developmental theories, but also designing effective prevention and intervention programs. Thus, implications for preventive interventions are provided. Finally, critical next steps for research within the area of child maltreatment and the developmental psychopathology of substance use and SUD are proffered.
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ADHD is the one of the most prevalent childhood disorders and has been associated with impairments persisting into adulthood. Specifically, childhood ADHD is an independent clinical risk factor for the development of later substance use disorders (SUD). Moreover, adults who meet diagnostic criteria for ADHD have shown high rates of comorbid SUDs. Few studies, however, have reported on the relationship between ADHD subtypes and SUD in adult samples. The purpose of this study was to characterize a clinical sample of adults with ADHD and to identify possible associations between ADHD subtypes, lifetime substance use, and if ADHD subtypes may be preferentially associated with specific substances of abuse. We recruited 413 adult ADHD patients, performed an evaluation of their ADHD and conducted an interview on their use of psychotropic substances. Complete data was obtained for 349 patients. Lifetime substance abuse or dependence was 26% and occasional use was 57% in this sample. The inattentive subtype was significantly less likely to abuse or be dependent on cocaine than the combined subtype. Our findings underscore the high rate of comorbidity between substance use and ADHD in adults. The more frequent abuse/dependence of cocaine by adult patients with hyperactive-impulsive symptoms should be kept in mind when treating this patient group.
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Background We examined whether increased risk for adolescent tobacco and marijuana problems associated with childhood ADHD is explained by key intermediary influences during adolescence and differs by gender. Methods Longitudinal structural equation models examined mediating effects on problems with both substances (or each substance separately) through age‐14 peer impairment, internalizing, and adolescent ADHD symptoms in two twin samples, prospectively assessed since age 11 (N = 2,164). Whether these mediators contributed beyond mediating effects of early‐adolescent substance use was also considered. Twin difference analyses further illuminated which mediators might be potentially causal. Results Direct effects of childhood ADHD on age‐17 tobacco and marijuana problems (i.e., independent of included mediators) as well as effects of adolescent ADHD symptoms were significant only for females. By contrast, mediation by peer impairment, evident particularly for marijuana, was relatively stronger for males than females. Depression and anxiety were not prospectively associated with age‐17 substance problems when earlier substance problems were considered. Consistent with causal influence of early substance use on later problems, monozygotic twins with more severe tobacco or marijuana problems at age 14 than their co‐twins were also more likely to have substance problems later in adolescence. Conclusions Mediation through peer impairment, continued presence of ADHD symptoms, and early substance use may alter development so that childhood ADHD indirectly contributes to problems with tobacco and marijuana. Targeting gender‐sensitive interventions prior to mid‐adolescence, before these patterns become established, is essential.
Article
Background: Inconsistent findings exist regarding long-term substance use (SU) risk for children diagnosed with attention-deficit/hyperactivity disorder (ADHD). The observational follow-up of the Multimodal Treatment Study of Children with ADHD (MTA) provides an opportunity to assess long-term outcomes in a large, diverse sample. Methods: Five hundred forty-seven children, mean age 8.5, diagnosed with DSM-IV combined-type ADHD and 258 classmates without ADHD (local normative comparison group; LNCG) completed the Substance Use Questionnaire up to eight times from mean age 10 to mean age 25. Results: In adulthood, weekly marijuana use (32.8% ADHD vs. 21.3% LNCG) and daily cigarette smoking (35.9% vs. 17.5%) were more prevalent in the ADHD group than the LNCG. The cumulative record also revealed more early substance users in adolescence for ADHD (57.9%) than LNCG (41.9%), including younger first use of alcohol, cigarettes, marijuana, and illicit drugs. Alcohol and nonmarijuana illicit drug use escalated slightly faster in the ADHD group in early adolescence. Early SU predicted quicker SU escalation and more SU in adulthood for both groups. Conclusions: Frequent SU for young adults with childhood ADHD is accompanied by greater initial exposure at a young age and slightly faster progression. Early SU prevention and screening is critical before escalation to intractable levels.
Article
Background: We report whether the etiology underlying associations of childhood ADHD with adolescent alcohol and marijuana involvement is consistent with causal relationships or shared predispositions, and whether it differs by gender. Methods: In three population-based twin samples (N = 3762; 64% monozygotic), including one oversampling females with ADHD, regressions were conducted with childhood inattentive or hyperactive-impulsive symptoms predicting alcohol and marijuana outcomes by age 17. To determine whether ADHD effects were consistent with causality, twin difference analyses divided effects into those shared between twins in the pair and those differing within pairs. Results: Adolescents with more severe childhood ADHD were more likely to initiate alcohol and marijuana use earlier, escalate to frequent or heavy use, and develop symptoms. While risks were similar across genders, females with more hyperactivity-impulsivity had higher alcohol consumption and progressed further toward daily marijuana use than did males. Monozygotic twins with more severe ADHD than their co-twins did not differ significantly on alcohol or marijuana outcomes, however, suggesting a non-causal relationship. When co-occurring use of other substances and conduct/oppositional defiant disorders were considered, hyperactivity-impulsivity remained significantly associated with both substances, as did inattention with marijuana, but not alcohol. Conclusions: Childhood ADHD predicts when alcohol and marijuana use are initiated and how quickly use escalates. Shared familial environment and genetics, rather than causal influences, primarily account for these associations. Stronger relationships between hyperactivity-impulsivity and heavy drinking/frequent marijuana use among adolescent females than males, as well as the greater salience of inattention for marijuana, merit further investigation.
Article
Objectives: The aim of this study is to understand how early cigarette use might predict subsequent illicit drug use, especially among individuals with attention-deficit hyperactivity disorder (ADHD) symptoms during childhood. Data were drawn from the National Longitudinal Study of Adolescent Health (Waves I-IV). The analysis sample involves participants who had not used illicit drugs at Wave I, with no missing responses for studied predictors ( N = 7,332). Smoking status at Wave I (ever regular vs. never regular) and childhood ADHD symptoms predicted subsequent illicit drug use at Waves II to IV. No interaction effect of smoking status at Wave I and childhood ADHD symptoms was found. However, an indirect effect from childhood ADHD symptoms on illicit drug use was identified, through smoking status at Wave I. Similar results were observed for predicting illicit drug dependence. The findings support the notion that smoking status during early adolescence may mediate the association between childhood ADHD symptoms and risk of later adult drug use. Interventions to prevent smoking among adolescents may be particularly effective at decreasing subsequent drug use, especially among children with ADHD symptoms.
Article
Objective: The primary purpose of this study was to investigate the impact of attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy on the risk of substance use within each ADHD subtype. Methods: The study used data from the National Comorbidity Survey-Adolescent supplement, a nationally representative sample of US adolescents (ages 13-18) collected from 6,483 adolescent-parent interviews conducted between 2001 and 2004. ADHD was categorized into three subtypes: ADHD-predominantly hyperactive-impulsive type (ADHD-H); ADHD-predominantly inattentive type (ADHD-I); and ADHD-combined type (ADHD-C) using Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Substance use information was obtained from the adolescents' interview. The impact of ADHD-pharmacotherapy on substance use was examined using multivariable logistic regression analysis. Results: Among the adolescents with ADHD, ADHD pharmacotherapy significantly associated with reduced risk of substance use (OR = 0.53, 95%CI [0.31-0.90]); with regards to ADHD subtypes, ADHD pharmacotherapy is negatively associated with substance use in adolescents with ADHD-C (OR = 0.53, 95%CI [0.24-0.97]) and those with ADHD-H (OR = 0.23, 95% CI [0.07-0.78]), but it did not have statistically significant effect on risk of substance use in those with ADHD-I subtype (OR = 0.49, 95%CI [0.17-1.39]). Among the group who never received ADHD-pharmacotherapy before the interview, individuals with ADHD-H and ADHD-C had a similar risk of substance use compared to adolescents with ADHD-I (ADHD-C: OR = 1.5, 95%CI [0.77-2.95] and ADHD-H: OR = 2.10, 95%CI [0.87-4.95]). Conclusions: Adolescents with ADHD were equally susceptible to future substance use disregard their ADHD subtypes. Receipt of pharmacotherapy could decrease risk of substance use in adolescents with ADHD-H and ADHD-C, but it may not affect risk of substance use among individuals with ADHD-I.
Article
Background: The developmental pathways associated with an enhanced risk for future alcohol use disorders (AUDs) continue to be a topic of both interest and debate. In this research, internalizing and externalizing disorders were evaluated as prospective predictors of the index AUD episode onset, separately within three developmental periods: early-to-middle adolescence (age 13.0-17.9), late adolescence (18.0-20.9), and early adulthood (21.0-30.0). Methods: Participants (N=816) were initially randomly selected from nine high schools in western Oregon and subsequently interviewed on four separate occasions between ages 16 and 30, during which current and past AUDs were assessed as well as a full range of psychiatric disorders associated with internalizing and externalizing psychopathology domains. Results: In adjusted analyses for each of the three developmental periods investigated, externalizing domain psychopathology from the most proximal adjoining developmental period predicted AUD onset. Distal externalizing psychopathology also predicted AUD onset among early adult onset cases. Proximal or distal internalizing psychopathology, in comparison, was not found to be a significant predictor of AUD onset in adjusted analyses for any of the developmental periods examined. Conclusions: Findings overall suggest that externalizing developmental histories are robust predictors of AUD onset within the age range during which index episodes are most likely to occur, and that gender does not moderate this association.
Article
Adolescence is a vulnerable developmental stage where significant changes occur in a youth's body, brain, environment and socialization, which may increase vulnerability to substance use, development of addiction, and psychiatric disorders. A co-occurrence of mental and behavioral disturbances with drug involvement in adolescence is common, as reflected in both a high risk for drug use in youth with mental illness and a high frequency of psychopathology among drug users. In this review we provide a broad and basic overview of some of the research evidence indicating a strong co-occurrence of drug use disorders (abuse and dependence) with externalizing and internalizing disorders, as well as a few other serious mental health conditions among adolescents. Increasing awareness and knowledge of the high probability of the co-occurrence of mental and behavioral disturbances with drug involvement informs the understanding of the etiology, course, and treatment of psychiatric problems among adolescents.
Article
Objective: To examine ADHD symptom persistence and subtype stability among substance use disorder (SUD) treatment seekers. Method: In all, 1,276 adult SUD treatment seekers were assessed for childhood and adult ADHD using Conners' Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; CAADID). A total of 290 (22.7%) participants met CAADID criteria for childhood ADHD and comprise the current study sample. Results: Childhood ADHD persisted into adulthood in 72.8% (n = 211) of cases. ADHD persistence was significantly associated with a family history of ADHD, and the presence of conduct disorder and antisocial personality disorder. The combined subtype was the most stable into adulthood (78.6%) and this stability was significantly associated with conduct disorder and past treatment of ADHD. Conclusion: ADHD is highly prevalent and persistent among SUD treatment seekers and is associated with the more severe phenotype that is also less likely to remit. Routine screening and follow-up assessment for ADHD is indicated to enhance treatment management and outcomes.