Attention Deficit/Hyperactivity Disorder and Global Severity Profiles in Treatment-Seeking Patients with Substance Use Disorders

Introduction: Comorbid attention deficit/hyperactivity disorder (ADHD) is present in 15-25% of all patients seeking treatment for substance use disorders (SUDs). Some studies suggest that comorbid ADHD increases clinical severity related to SUDs, other psychiatric comorbidities, and social impairment, but could not disentangle their respective influences. Objectives: To investigate whether comorbid adult ADHD in treatment-seeking SUD patients is associated with more severe clinical profiles in these domains assessed altogether. Methods: Treatment-seeking SUD patients from 8 countries (N = 1,294: 26% females, mean age 40 years [SD = 11 years]) were assessed for their history of DSM-IV ADHD, SUDs, and other psychiatric conditions and sociodemographic data. SUD patients with and without comorbid ADHD were compared on indicators of severity across 3 domains: addiction (number of SUD criteria and diagnoses), psychopathological complexity (mood disorders, borderline personality disorder, lifetime suicidal thoughts, or behavior), and social status (education level, occupational and marital status, and living arrangements). Regression models were built to account for confounders for each severity indicator. Results: Adult ADHD was present in 19% of the SUD patients. It was significantly associated with higher SUD severity, more frequent comorbid mood or borderline personality disorder, and less frequent "married" or "divorced" status, as compared with the absence of comorbid ADHD. ADHD comorbidity was independently associated with a higher number of dependence diagnoses (OR = 1.97) and more psychopathology (OR = 1.5), but not marital status. Conclusions: In treatment-seeking SUD patients, comorbid ADHD is associated with polysubstance dependence, psychopathological complexity, and social risks, which substantiates the clinical relevance of screening, diagnosing, and treating ADHD in patients with SUDs

Onset and severity of early sisruptive eehavioral disorders in treatment-seeking substance use disorder patients with and without attention-deficit/hyperactivity disorder

$\bf Aims:$ This study addressed the age of onset of conduct disorder (CD) and oppositional defiant disorder (ODD) in treatment-seeking substance use disorder (SUD) patients with and without adult attention-deficit/hyperactivity disorder (ADHD) and its association with early onset of SUD. $\bf Methods:$ We examined data from the 2nd $\textit {International ADHD in Substance Use Disorders Prevalence Study}$, including 400 adults in SUD treatment from Puerto Rico, Hungary, and Australia. ADHD, SUD, and CD/ODD were assessed with the $\textit {Conners Adult ADHD Diagnostic Interview for DSM-IV}$, the $\textit {MINI International Neuropsychiatric Interview}$, and the K-SADS, respectively. Cox regression analyses modeled time to emergence of CD/ODD separately for SUD patients with and without adult ADHD. Linear regression models examined associations between age of onset of SUD and presence of ADHD and adjusted for sex, age, and country. To assess the mediating role of CD/ODD on the association of ADHD with onset of SUD, adjusted regression models were estimated. $\bf Results:$ Treatment-seeking SUD patients with ADHD presented an earlier onset of CD/ODD compared with those without ADHD. CD/ODD symptom loads were higher among the SUD and ADHD group. Age of first substance use and SUD were significantly earlier in SUD patients with ADHD, and these findings remained significant after adjustment for demographics and coexisting CD/ODD. $\bf Conclusions:$ ADHD is associated with earlier onset of SUD as well as with an earlier onset of more frequent and more severe disruptive behavioral disorders. These findings may inform preventive interventions to mitigate adverse consequences of ADHD

International consensus statement for the screening, diagnosis, and treatment of adolescents with concurrent attention-deficit/hyperactivity disorder and substance use disorder

Introduction. – Le trouble du déficit de l’attention/hyperactivité chez l’enfant (TDAH) est un facteur derisque de mésusage et de troubles de l’usage de substances (TUS) chez l’adolescent et le jeune adulte. LeTDAH et le TUS coexistent également fréquemment chez les adolescents en demande de soins, compli-quant le diagnostic et le traitement et étant associé à de mauvais résultats thérapeutiques. Les recherchesconcernant l’effet du traitement du TDAH chez l’enfant sur la prévention du TUS à l’adolescence sontpeu concluantes et les études sur le diagnostic et le traitement des adolescents atteints de TDAH etde TUS comorbides sont rares. Ainsi, les preuves disponibles ne sont pas suffisantes pour justifier desrecommandations de traitement solides.Objectif. – Le but de cette étude était d’aboutir à une déclaration de consensus basée sur une combinaisonde données scientifiques et d’expérience clinique.Méthode. – La méthode Delphi modifiée a été utilisée pour parvenir à un consensus basé sur la combinai-son de données scientifiques et d’expérience clinique, avec un groupe multidisciplinaire de 55 expertsprovenant de 17 pays. Les experts ont été invités à évaluer un ensemble d’énoncés portant sur l’effet dutraitement du TDAH de l’enfant sur le TUS à l’adolescence ainsi que sur le dépistage, le diagnostic et letraitement des adolescents souffrant de TDAH et de TUS comorbides.Résultats. – Après trois tours de cotation et d’adaptation de 37 énoncés, un consensus a été atteint sur36 d’entre eux, représentant six domaines : généralités (n = 4), risque de développer un TUS (n = 3),dépistage et diagnostic (n = 7), prise en charges psychosociales (n = 5), traitement pharmacologique(n = 11) et traitements complémentaires (n = 7). Le dépistage systématique du TDAH est recommandéauprès des patients adolescents vus en addictologie et du TUS auprès des patients adolescents souffrantde TDAH vus en santé mentale. Les stimulants à action prolongée sont recommandés comme traitementde première intention du TDAH chez les adolescents souffrant de la comorbidité TDAH-TUS et la phar-macothérapie doit de préférence être incluse dans une prise en charge psychosociale (psychoéducation,entretien motivationnel, thérapies comportementales et cognitives, prise en charge familiale). L’uniquedéclaration non consensuelle restante concerne l’exigence d’abstinence avant l’initiation d’un traite-ment pharmacologique chez les adolescents atteints de TDAH et de TUS concomitants. Contrairementà la majorité des experts, certains exigent une abstinence complète avant de débuter tout traitementpharmacologique, certains se positionnent contre l’utilisation de stimulants dans le traitement de cespatients (indépendamment de l’abstinence), tandis que d’autres n’approuvent pas l’utilisation alternativedu bupropion.Conclusion. – Cette déclaration de consensus internationale peut être utilisée par les cliniciens et lespatients dans un processus collaboratif de prise de décision partagée pour sélectionner les meilleuresinterventions et obtenir des résultats optimaux chez les patients adolescents souffrant de TDAH et deTUS comorbides

International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder

frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations. Objective: The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. Method: A modified Delphi study to reach consensus based upon the combination of scientific data and clinical experience with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. Results: After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11), and complementary treatments (n = 7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimulants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining no-consensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimulants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. Conclusion: This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD