ADHD as a Risk Factor for Substance Use Disorder

This research paper explores the correlation between ADHD and substance use disorder, examining the risk factors and potential causes of addiction. The paper reviews longitudinal studies of young children, not diagnosed with ADHD but followed into adolescence and adulthood, providing compelling evidence that early occurring behaviors, of the type that overlap with symptoms of ADHD, are signals of substance disorder risk. The paper also discusses the history, definition, and course of ADHD, as well as its role as a risk factor for substance use disorder.

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Introduction
In the 1960s, substance use among youth in the United States was on the rise and headed
toward its zenith in the late 1970s. In an effort to understand this trend, longitudinal studies of
children and adolescents were launched to uncover the possibility of early dispositional
vulnerabilities to later drug abuse. These studies improved upon the methodology limitations of
their less-compelling cross-sectional predecessors. Theories of drug addiction readily emerged to
emphasize the role of personality and temperament traits as well as the contribution of other
individual difference variables such as differential sensitivity to alcohol, cognitive factors, and
attitudes As studies of these contributing factors rapidly multiplied, findings revealed that drug
abuse vulnerability is multifaceted, with individual factors accounting for additive and
interactive influences on substance use initiation, escalation, and course (including progression
to addiction and sometimes recovery). One of these findings, replicated across many studies, is
the prediction of substance use from a constellation of temperament and personality traits that
overlap almost entirely with the defining symptoms of Attention-Deficit/Hyperactivity Disorder
(ADHD).
ADHD: history, definition, and course
ADHD has been variably named and defined over the past 60 years in which it has been
studied. In the 1960’s the terms “minimal brain damage or dysfunction” were commonly used to
describe the children, who would ultimately be labeled in Diagnostic and Statistical Manual of
Mental However, through the decades of research on diagnosis/identification and in all versions
of the DSM, the core characteristics of the disorder have been the same--levels of inattention,
impulsivity, and hyperactivity that were substantially different from typically developing

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children and that are accompanied by problems in daily living (impairment). Prior to the
publication of DSM III and beginning in the early 1960’s, ADHD was defined with child
behavior rating scales that included items reflecting the core characteristics of ADHD, conduct
problems and aggression, peer relationships, and internalizing problems. These scales included
the early Behavior Problem Checklist, the Connors Teacher Rating Scale (CTRS), and the Child
Behavior Checklist and were typically completed by parents or teachers or both. The developers
of these scales had started in part with item pools that were derived from clinic-based records of
children with behavior or emotional problems, were typically factor analyzed to produce scales,
and had response formats based on frequency or severity of behaviors. With respect to ADHD,
the one that became most commonly employed was the CTRS—particularly the short form or the
Abbreviated Conners.For more than a decade, a score of 15 on the ACTRS was the most
common way of diagnosing ADHD .
A child can meet criteria on the inattention list, the hyperactive/impulsive list, or both,
and be diagnosed with an inattentive (or impulsive) subtype or with a combined subtype. There
is debate regarding whether structured interviews with parents are needed to buttress parent and
teacher ratings, but the procedures for symptom counting are similar for interviews and rating
scales. It turns out that DSM symptom scales and the empirically derived scales that predated
DSM III are very highly correlated and identify the same children – particularly the combined
subtype, the most common diagnosis.
It is now well established that ADHD is a chronic condition that begins in early
childhood and continues through life. Indeed, the vast majority of children diagnosed with
ADHD continue to have symptoms of ADHD and related impairments into adulthood .There has
been debate about this point for some time, but recent longitudinal studies have made it clear that

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if symptoms are assessed appropriately, the majority of children with ADHD become teenagers
with ADHD and the majority of teenagers with ADHD become adults with ADHD. Further, even
when symptoms of ADHD necessarily decline, the problems of daily living that characterize the
disorder do not decline and often worsen. We review in sections below a number of domains in
which impairment continues to be present for individuals with ADHD as they grow up.
ADHD as a risk factor for substance use disorder
Childhood Traits that Predict Substance Use in Non ADHD Studies
Longitudinal studies of young children, not diagnosed with ADHD but followed into
adolescence and adulthood, provide compelling evidence that early occurring behaviors, of the
type that overlap with symptoms of ADHD, are signals of substance disorder risk. In one of the
first demonstrations of adolescent substance use predicted from nursery school-age behavior,
Block and colleagues predicted adolescent substance use from nursery school teacher ratings of
behavior that clearly included difficulties with self-regulation in multiple behavioral, emotional,
and social respects .From a large sample of kindergarten boys in Montreal, predicted early
adolescent substance use from “novelty-seeking” measured as teacher-ratings of restlessness, not
keeping still, fidgety, etc. In New Zealand, the well-known large Dunedin Health and
Development study found increased adult alcohol dependence by age 21 from observations of
“behavioral under control” at age 3 and increased substance dependence by age 32 from a
composite measure of “self-control” through childhood (aggregated across childhood
observations and ratings of impulsive aggression, hyperactivity, lack of persistence, inattention,
and impulsivity. Other prospective longitudinal studies have reported similar. Collectively, these
studies identify a constellation of traits variously identified in the addiction literature, such as

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behavioral under control. Their occurrence in early childhood predicts later ADHD diagnosis and
also substance use .Thus, theoretical models of ADHD that discuss the disorder for some
children as a reflection of extreme temperament traits dovetails nicely with theoretical models of
substance disorder that posit these aspects of temperament vulnerability as contributors to
addiction.
Other Types of Studies Demonstrating ADHD-Substance
There is ample indirect evidence of an association between ADHD and substance
disorder vulnerability from other types of studies. Alcohol and other substance disorders occur at
greater rates among the parents of children with ADHD .Children of parents with substance
disorders are more likely to have ADHD or ADHD symptoms or to score higher on temperament
or personality traits that include dimensional expressions of ADHD symptoms such as
impulsivity Approximately two-thirds of adolescents in treatment for substance disorders are
diagnosable with ADHD. Further, genetic and neurobiological models of addiction and ADHD
share strikingly similar overlap in targeted regions of interest. Finally, studies of parent-child
interactions have validated the possibility that ADHD behaviors in children cause stress-
mediated increases in parent alcohol use and that parent alcohol use causes parenting styles that
are ineffective with ADHD-affected children .Thus, a transactional, dynamic relationship
between problematic child and parent behavior may involve alcohol in families affected by
ADHD.

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