|Year : 2015 | Volume
| Issue : 1 | Page : 9-13
The prevalence and characteristics of attention-deficit hyperactivity disorder among a sample of Egyptian substance-dependent inpatients
Ahmed Abdelkarim, Hoda Salama, Soha Ibrahim, Osama Abou El Magd
Department of Neuropsychiatry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
|Date of Web Publication||23-Mar-2015|
Neuropsychiatry Department, El Hadra University Hospital, El Hadra, 26125 Alexandria
Source of Support: None, Conflict of Interest: None
Attention-deficit hyperactivity disorder (ADHD) affects not only children, but persists in up to 4.4% of the general population. Comorbidity is common among adults with ADHD, including substance abuse. To our knowledge, the relation between ADHD and substance-use disorder (SUD) has not been studied in Arab countries thoroughly.
Aim of the work
The aim of this study was to estimate the prevalence rate of adult ADHD among substance-use inpatients and to compare substance use in patients with and without adult ADHD with regard to the onset, the severity, and the type of substance of abuse.
Participants and methods
This cross-sectional comparative study was conducted at the Addiction Treatment Center at El Maamoura psychiatric hospital. One hundred and two adult male inpatients were recruited and assessed using a semistructured interview questionnaire to collect sociodemographic data, substance-use history, and medical and psychiatric history. The psychiatric interview was applied, and psychometric assessment was performed using the Arabic version of the Wender Utah Rating Scale, which examined retrospectively the symptoms of childhood ADHD, and the Arabic version of the Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist for screening for adult ADHD.
Thirty-six (35.3%) patients were diagnosed as having adult ADHD according to DSM-IV-TR criteria. The presence of adult ADHD was associated with an earlier mean age of onset of SUD (15.58 vs. 13.22 years). It was also associated with a larger number of hospital admissions (6.83 vs. 3.39 times). Individuals with ADHD achieved a shorter mean period of abstinence (124.53 vs. 209.82 days).
This study confirmed the presence of adult ADHD among substance-use patients with a considerable prevalence rate. Also, the presence of adult ADHD was associated with a more complicated course of SUD.
Keywords: adult ADHD self-report scale, adult attention-deficit hyperactivity disorder, prevalence, substance-use disorders, Wender Utah Rating Scale
|How to cite this article:|
Abdelkarim A, Salama H, Ibrahim S, El Magd OA. The prevalence and characteristics of attention-deficit hyperactivity disorder among a sample of Egyptian substance-dependent inpatients. Egypt J Psychiatr 2015;36:9-13
|How to cite this URL:|
Abdelkarim A, Salama H, Ibrahim S, El Magd OA. The prevalence and characteristics of attention-deficit hyperactivity disorder among a sample of Egyptian substance-dependent inpatients. Egypt J Psychiatr [serial online] 2015 [cited 2017 Aug 23];36:9-13. Available from: http://new.ejpsy.eg.net/text.asp?2015/36/1/9/153771
| Introduction|| |
Attention-deficit hyperactivity disorder (ADHD) is one of the most frequent psychiatric disorders experienced by children and, according to epidemiological studies, can be persistent and affect between 35 and 80% of adults with at least one or more symptoms of ADHD. Prevalence of adult ADHD in a recent epidemiological study was reported to be 4.4% among adults in the USA (Barkley et al., 1997; Kessler et al., 2006). Comorbidity with ADHD is present among ~75% of adults with this condition and includes several psychiatric disorders, including substance-use disorders (SUD) at rates reaching 15-45% (Biederman et al., 1993). Different models of comorbidity are generally proposed to link different psychiatric illnesses to SUD. First, psychiatric disorders may occur in the context of withdrawal from SUD or as a result of chronic intoxication. Psychiatric disorders may be considered as a risk factor for SUD or substances of abuse may be used as a self-medication to reduce symptoms of the psychiatric disorder. Also, both the psychiatric disorder and SUD may have either a common genetic predisposition or a common environmental risk factor. Finally, SUD may act as a modifying factor through the course of an already present psychiatric disorder (Biederman et al., 1993; Charach et al., 2011). A recent prospective study on ADHD children has provided evidence that ADHD itself is a risk for later cigarette smoking and SUDs (Charach et al., 2011). Other authors propose a more complicated causal relation between ADHD and SUD, with conduct disorder and then antisocial personality disorder as mediating factors in this relation (Brook et al., 2010). Also, the dopaminergic system is implicated in the pathophysiology of both ADHD and SUD. Studies reported an abnormal dopamine transporter density in the striatum. These studies postulated that alteration in dopamine release, with lower than normal release, characterized individuals with ADHD (Volkow et al., 2007; Frodl, 2010). The dopamine system is also involved in reward and in the prediction of reward and shows dysfunctions in SUD. PET studies in abstinent cocaine addicts have shown decreased D2 receptor availability and extracellular dopamine in the striatum, which correlated with reductions of neural activity in the orbitofrontal and the cingulate cortex (Schultz et al., 1997). Such a shared pathophysiology has led to comorbidity between both ADHD and SUD (Wilens et al., 2003; Wilens, 2004; Wilens and Morrison, 2011); however, the relation in Egypt needs further elucidation.
Aim of the work
The current work aimed to estimate the prevalence rate of adult ADHD among substance-dependent inpatients and also to compare substance-dependent inpatients with and without adult ADHD regarding the course of SUD.
| Participants and methods|| |
This study was designed to be a cross-sectional study that included 102 male inpatients with SUD chosen randomly from the Addiction Treatment Center at El Maamoura psychiatric hospital during the period of 6 months starting on 1 January 2011 to 30 June 2011. Inclusion criteria were age between 18 and 60 years, male sex, Diagnostic and Statistical Manual for Mental Disorders, 4th ed., Text Revised (DSM-IV-TR) diagnosis of SUD (American Psychiatric Association, 2000), and patients' informed written consent given after their detoxification therapy. Exclusion criteria included any psychiatric disorder other than ADHD, physical and neurological diseases, and patients in their detoxification period. All recruited individuals were subjected to the following examinations:
The Wender Utah Rating Scale for the retrospective assessment of symptoms of childhood attention-deficit hyperactivity disorder
- A semistructured interview questionnaire to collect sociodemographic data, history of substance use, and medical and psychiatric history;
- Physical and neurological examination;
- Psychiatric interview using the DSM-IV-TR diagnostic criteria;
- The Arabic-translated and validated version of the Wender Utah Rating Scale (WURS), which retrospectively assesses ADHD-relevant childhood behaviors and symptoms in adults (Wender, 1995); and
- The Arabic-translated and validated version of the adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was used for screening for adult ADHD symptoms (Daigre et al., 2009).
The 61 questions were answered by the adult patient recalling his or her childhood behavior with five possible responses scored from 0 to 4 points. The minimum score for 25 questions was 0 and the maximum score was 100. If a cut-off score of 46 was used, 86 of the patients with ADHD, 99 of the normal persons, and 81% of depressed individuals were classified correctly. The Arabic version was subjected to a jury with five professionals to assess its acceptance to the Arabic culture. The reliability of the scale in its Arabic format was tested using Cronbach's a through the following process:
The adult ADHD self-report scale Symptom Checklist
- A pilot study using the Arabic version was conducted on 30 patients.
- Cronbach's a was calculated to be 0.847 (significant if >0.7)
The Symptom Checklist is an instrument consisting of 18 DSM-IV-TR criteria. Six of the eighteen questions were found to be the most predictive of symptoms consistent with ADHD. These six questions are the basis for the ASRS-v1.1 Screener and are also Part A of the Symptom Checklist. Part B of the Symptom Checklist contains the remaining twelve questions. If four or more marks appear in the darkly shaded boxes within Part A, then the patient has symptoms highly consistent with ADHD in adults, and further investigation is warranted. The frequency scores on Part B provide additional cues and can serve as further probes into the patient's symptoms. No total score or diagnostic likelihood is utilized for the 12 questions. It has been found that the six questions in Part A are the most predictive of the disorder and are best for use as a screening instrument. The Arabic version was subjected to a jury with five professionals to assess its acceptance to the Arabic culture. The reliability of the scale in its Arabic format was tested using Cronbach's a through the following process:
- A pilot study using the Arabic version was conducted on 30 patients.
- Cronbach's a was calculated to be 0.717 (significant if >0.7)
Data were fed into a computer using the Predictive Analytics Software (PASW Statistics 18, Wadsworth, Cengage Language, Belmont, California, USA). Qualitative data were described using the number and percent. Association between categorical variables was tested using the c2 -test. Quantitative data were described using the median, the minimum, and the maximum as well as the mean and SD. Significance of the obtained results was judged at the 5% level.
| Results|| |
The age range was 25-53 and 19-42 years among the ADHD patients and the non-ADHD patients, respectively. The two groups had no statistically significant difference regarding education, residence, and marital status; however, they differed statistically regarding the occupation (P = 0.017) ([Table 1]). The prevalence of ADHD in the recruited sample was as follows: 64 (63.7%) patients had a positive history of childhood ADHD according to the Arabic version of WURS, 44 (43.1%) patients had positive results for adult ADHD symptom by applying the ASRS-v1.1 Symptom Checklist, and 36 (35.3%) patients were diagnosed as having adult ADHD according to the DSM-IV-TR. Regarding the distribution of different subtypes of adult ADHD in the total studied sample (n = 102), it was found that 16 patients (15.7%) met the criteria for adult ADHD, predominantly the inattentive type (ADHD-I), two patients (2.0%) met the criteria for adult ADHD, predominantly the hyperactive-impulsive type (ADHD-H), and 18 patients (17.6%) met the criteria for adult ADHD, combined type (ADHD-C) ([Figure 1]).
|Table 1 Demographic data of the non-attention deficit hyperactivity disorder group (group I) and the|
attention-defi cit hyperactivity disorder group (group II)
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On comparing clinical data of SUD among the ADHD and the non-ADHD patients, it was found that the mean age of onset of substance abuse in the ADHD patient group was about 2 years earlier, ranging from 8 to 18 years, with a mean of 13.22 ± 2.63 years, whereas in the non-ADHD patients, the age of onset ranged from 10 to 31 years, with a mean of 15.58 ± 3.84 years, and the difference was statistically significant (P = 0.001). Regarding the number of substances of abuse, in the non-ADHD group, the number of substances ranged from three to six, with a mean of 4.47 ± 0.98, whereas in the ADHD patients, the number of substances ranged from four to seven, with a mean of 4.67 ± 0.89; however, there was no statistical difference (P = 0.565). Patients with adult ADHD had almost double mean times of hospital admissions for substance use, ranging between 1 and 30, with a mean of 6.83 ± 8.05, whereas in the non-ADHD group, numbers ranged between one and 20 times, with a mean of 3.39 ± 3.95 times, and the difference was statistically significant (P = 0.049). In view of the longest period of abstinence, in the non-ADHD group, the period ranged between 14 and 1200 days, with a mean of 209.82 ± 282.0 days, whereas in the ADHD group, the period was shorter, ranging from 14 to 700 days, with a mean of 124.53 ± 171.86 days, and the difference was statistically significant (PMW = 0.045) ([Table 2]).
|Table 2 Clinical data of substance-use disorder among the studied samples|
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| Discussion|| |
In the present study, the prevalence of adult ADHD was 43.1 and 35.3 according to ASRS-v1.1 Symptom Checklist and DSM-IV-TR, respectively. In concordance with the results of the current study, Tims et al. (2002) found a prevalence rate of 38% ADHD among 600 clients, aged 12-18 years, admitted to outpatient substance-abuse treatment programs for cannabis problems. Also, Latimer et al. (2002) found similar rates of ADHD among adolescents with SUD. Recently, Kaufmann and colleagues (2011) studied the prevalence of ADHD among substance-abuse patients, and found that 34% of the 97 adult patients showed features of adult ADHD after the application of both WURS and WHO self-report screening scales for ADHD (ASRS-v1.1) (Khantzian, 1985). The comorbidity between both ADHD and SUD has been explained by the common biological etiology and/or a model of self-medication for ADHD (Khantzian, 1985; Schubiner et al., 2000; Latimer et al., 2002; Tims et al., 2002; Cobos et al., 2011; Seitz et al., 2011). In contrast, higher rates were reported by Schubiner et al., 2000, in their cross-sectional study that was carried on a sample of 201 patients. They found that 48% of the participants met DSM-IV criteria for ADHD (Schubiner et al., 2000). Further higher rates were found in two other studies examining the prevalence of ADHD among patients with SUD (Cobos et al., 2011; Seitz et al., 2011). The different prevalence rates may be explained by the different study populations: sex, age, number, ethnicity, and culture. The difference in methodology and study designs may also have led to the differences in results.
As for the clinical data for SUD in the present work, ADHD patients had an earlier age of onset of SUD, more substance abuse, longer hospital admission, and lesser periods of abstinence. The literature reports that substance-use problems are typically more substantial in adolescents and adults with ADHD than in those without ADHD. Individuals with both diagnoses have been reported to have an earlier onset, a longer course, and greater severity, with more relapses and greater difficulty with remaining abstinent (Schubiner et al., 2000; Wilens, 2004; Kim et al., 2006; Ohlmeier et al., 2007). In accordance to our findings, Kim et al. (2006) reported that the mean age of onset of pathological drinking was significantly earlier in alcoholics with ADHD compared with alcoholics without ADHD (26.6 and 30.1 years, consecutively; P < 0.05). Similarly, Ohlmeier et al. (2007) found that alcohol addiction started at an earlier age in patients with comorbid ADHD [exceeding the critical level of alcohol consumption at 27.2 years (± 9.52) with existing ADHD against 30.6 years (± 10.6)]; however, this result was not significant (Ohlmeier et al., 2007).
| Conclusion|| |
From the previous data, we concluded that adult ADHD is not a rare condition among substance-use inpatients. The presence of adult ADHD significantly affects the course of SUD. Adult ADHD patients have an earlier age of onset of substance use, shorter periods of remaining abstinent, and much higher rates of relapse in the form of more frequent hospital admissions for substance-use problems. Hence, a better management for SUD should include screening for ADHD symptoms and their inclusion in treatment plans. Further studies should be conducted on SUD patients to overcome our limitations with regard to female patients and outpatient samples.
| Acknowledgements|| |
Conflicts of interest
| References|| |
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, text rev. 4th ed. Washington, DC: American Psychiatric Association.
Barkley RA, Murphy KR, Fischer M (1997). Advancing age, declining ADHD. Am J Psychiatry 154:1323-1325.
Biederman J, Faraone SV, Spencer T (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry 150:1792-1798.
Brook DW, Brook JS, Zhang C, et al.
(2010). The association between attention deficit/hyperactivity disorder in adolescence and substance use disorders in adulthood. Arch Pediatr Adolesc Med 164:930-934.
Charach A, Yeung E, Climans T, et al.
(2011). Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta analyses. J Am Acad Child Adolesc Psychiatry 50:9-21.
Cobos JP, Siñol N, Puerta C (2011). Features and prevalence of patients with probable adult attention deficit hyperactivity disorder who request treatment for cocaine use disorders. Psychiatry Res 185:205-210.
Daigre BC, Ramos-Quiroqa JA, Valero S, Bosch R, Roncero C, et al.
(2009). Adult ADHD Self Report Scale-V1.1 (ASRS-V1.1) symptom checklist in patients with substance use disorders. Actas Eso Psiquiatr 37:299-305.
Frodl T (2010). Comorbidity of ADHD and substance use disorder (SUD): a neuroimaging perspective. J Atten Disord 14:109-120.
Kaufmann YA, Bavarel JG, Khan R, et al
. (2011). Substance Use Disorders with comorbid Attention Deficit Hyperactivity Disorder. Attention D eficit Hyperactivity Disorder 3:113.
Kessler RC, Adler L, Barkley R, et al.
(2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 163:716-723.
Khantzian EJ (1985). The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry 142:1259-1264.
Kim JW, Park CS, Hwang JW, et al.
(2006). Clinical and genetic characteristics of Korean male alcoholics with and without attention deficit hyperactivity disorder. Alcohol Alcohol 41:407-411.
Latimer WW, Stone AL, Voight A, et al.
(2002). Gender differences in psychiatric comorbidity among adolescents with substance use disorders. Exp Clin Psychopharmacol 10:310-315.
Ohlmeier MD, Peters K, Kordon A, et al.
(2007). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyp-eractivity disorder (ADHD). Alcohol Alcohol 42:539-543.
Schubiner H, Tzelepis A, Milberger S, et al.
(2000). Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers. J Clin Psychiatry 61:244-251.
Schultz W, Dayan P, Montague PR (1997). A neural substrate of prediction and reward. Science 275:1593-1599.
Seitz A, Allemann P, Klingemann H, et al.
(2011). Association between attention deficit/hyperactivity disorder (ADHD) and craving among patients with alcohol use disorders (AUD) 'Poster'. Attention Deficit Hyperactivity Disorder 3:114.
Tims FM, Dennis ML, Hamilton N, et al.
(2002). Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction 97 (Suppl 1):46-57.
Volkow ND, Wang GJ, Newcorn J, et al.
(2007). Depressed dopamine activity in caudate and preliminary evidence of limbic involvement in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 64:932-940.
Wender PH (1995). Attention-deficit hyperactivity disorder in adults
. New York, NY: Oxford University Press.
Wilens T (2004). Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. Psychiatr Clin North Am 27:283-301.
Wilens TE, Morrison NR (2011). The intersection of attention-deficit/hyperactivity disorder and substance abuse. Curr Opin Psychiatry 24:280-285.
Wilens TE, Faraone SV, Biederman J, et al.
(2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 111:179-185.
[Table 1], [Table 2]