Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
An in-depth analysis of the research on Attention Deficit Hyperactivity Disorder (ADHD) and its relationship to substance abuse. how symptoms of ADHD persist into adulthood and impact social functioning, mortality rates, and the risk of substance abuse. It also explores possible vulnerabilities that contribute to substance abuse in individuals with ADHD, such as impulsivity, conduct disorder, peer rejection, and a desire to self-medicate. The document also examines the effectiveness of various treatment options, including stimulant and non-stimulant medication and Cognitive Behavioural Therapy (CBT), in reducing the likelihood of substance abuse.
Typology: Exams
1 / 61
This page cannot be seen from the preview
Don't miss anything!
“Institute of Psychiatry, Psychology and Neuroscience Department of Forensics and Neurodevelopmental Sciences
Page 2 of 61
Childhood and Adulthood Diagnoses of ADHD and the Prevalence of Substance Abuse: Exploring the SLaM CRIS database
Acknowledgements I would like to thank everyone at the Biomedical Research Centre Nucleus, who had supported me in this project. I would also like to thank my supervisor for her kindness, guidance and encouragement in enabling me to complete this project. I am and will continue to be very grateful for her support. Lastly a special thank you to the outpatients who had consented for their data to be included within South London and Maudsley Clinical Records Interactive Search Database. This project will not be what it is without them.
- Page 4 of Page 5 of 61
List of Tables
Table 1 - Sample Characteristics......................................................................................................... Table 2 - Associations between Substance Abuse and Adult Outpatients........................................ Table 3 - Motives for Substance Abuse and Diagnosis Age ............................................................. Table 4 - Association of Major Life Events, Self-harm and Suicidal Ideation and Substance Abuse: ..........................................................................................................................
Page 7 of 61
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with an estimated worldwide prevalence rate of 5.3% (Polanczyk, Silva de Lima, Horta, Biederman & Rohde, 2007) and more recently 7.2% in children alone (Thomas, Sanders, Doust, Beller & Glasziou, 2015). The core symptoms of ADHD include inattention, hyperactivity, impulsivity, distractibility and often mood lability (American Psychiatric Association [APA], 2013). These symptoms have been found to impair daily functioning (Harpin, 2005; Wehmeier, Schacht & Barkley, 2010), self-esteem (Harpin, Mazzone, Raynaud, Kahle & Hodgkins, 2016; Newark, Elässer & Stieglitz, 2016) and life satisfaction (Gudjonsson, Sigurdsson, Eyjolfsdottir, Smari & Young, 2009; Pitts, Mangle, Asherson, 2015). As symptoms persist throughout development (Barbaresi et al. 2013; Moffitt et al. 2015; Sibley et al. 2016) social functioning is also affected in adult life (Wasserstein, 2005; Kessler et al. 2006; Gibbins, Toplak, Flora, Weiss & Tannock, 2012; Voigt et al. 2017), and mortality rates identified to be increased over time (Dalsgaard, Østergaard, Leckman, Mortensen & Pederson, 2015). Though many individuals go undiagnosed (Taylor, 2017), those in contact with health services can be diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (2013), or the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (1993), as F90. As diagnostic rates continue to rise (Pulcini et al. 2015; Young, Moss, Sedgwick, Fridman & Hodgkins, 2015; Bachmann, Philipsen & Hoffman, 2017) the National Institute for Health and Care Excellence Guidelines (2008) recommends psychological treatment for children and young people, whilst drug treatment is advised for both children with severe impairment as well as adults.
Despite treatment options available, a growing field of research has illustrated ADHD as a risk factor for substance abuse (West, Mulsow & Arredondo, 2007; Dunne, Hearne, Rose & Latimer,
Page 8 of 61
(Kessler et al. 2006), with the adult-diagnosed reported as having double the lifetime risk of developing a substance use disorder otherwise known as dependence (Fatséas et al. 2016). Recent research has identified that dependence on substances is greater in individuals with ADHD compared to individuals without (Bierderman et al., 2006; Charach, Yeung, Climans & Lillie, 2011; Vitulano et al. 2014). For example, studies which have focused on susceptibility to substance dependence, compared clinically referred individuals to controls, and had used semi- structured interviews in allowing only specified responses that illustrated a form of dependence on substances. In consideration of methods used, influence of comorbidity or diagnosis in childhood or as an adult were not acknowledged (Whitmore et al., 1997; Levy et al. 2014; García-Carretero, Novalbos-Ruiz, Robles-Martínez, Jordan-Quintero & O’Ferrall-González, 2017).
In opposition to research identifying substance abuse as an increased risk for individuals with ADHD, Flory and Lynam (2003) reviewed previous literature and reported that ADHD as a condition is not a major risk factor of substance abuse. Studies which had illustrated this had regularly recruited child diagnosed participants in order to follow development. As participants were followed up, it was observed that individuals were likely to receive treatment early (Mannuzza et al. 2008; Dalsgaard, Mortensen, Frydenberg & Thomson, 2014), experienced lower levels of externalizing problems (Chilcoat & Breslau, 1999) and had an absence of conduct problems and comorbidities (Fergusson, Horwood & Lynskey, 1993). Due to these developmental experiences, continuous treatment for ADHD symptoms were more tolerable, and had contributed to minimising ADHD as a risk for pertaining to subsequent substance abuse (Muld, Jokinen, Bölte & Hirvikoski, 2015).
As previous research has shown evident discrepancy regarding ADHD as an increased risk to substance abuse, possible reasoning for this may be due to the differences in methodological approaches applied within studies. This includes the difference in characteristics of participants
Page 10 of 61
2008). For individuals with ADHD, they may begin self-medicating with cigarette smoking, from a moderate start to a more progressive and excessive state, as an attempt to manage deficits in attention and concentration (Glass & Flory, 2010; Sullivan & Rudnik-Levin, 2001; Liebrenz, 2016). However, it is necessary to consider the likelihood that individuals with ADHD who choose to smoke may do so simply due to a ‘thrill-seeking’ tendency, and may not intend to manage deficits (Downey, Pomerleau & Pomerleau, 1996). In recognition of this individual difference, it has regularly been illustrated in research that early nicotine use has led to dependence and abuse of additional substances in individuals with ADHD, due to the amelioration of ADHD symptoms when using (Liebrenz, 2016; Sousa et al. 2011; Lambert & Hartsough, 1998) therefore, providing further support for the self-medication theory.
As the self-medication hypothesis asserts that the deficits and psychological suffering that comes with ADHD is ‘treated’ by self-medicating (Wender, 1979; Huessy, Cohen & Blair, 1979; Mariani, Khantzian & Levin, 2014), recent studies have shown support for this by examining individuals with ADHD who had reported substance abuse with the aim of moderating symptomology (Rabiner et al. 2009; Peles, Schreiber, Linzy, Domani & Adelson, 2015; Odell et al. 2017). However, as ADHD symptoms are not suitably treated with substance abuse, symptoms are likely to alleviate (Potter & Newhouse, 2004; Kollins, McClernon & Fuemmeler, 2005; Librenz et al. 2016) along with the need to abuse substances also.
It is essential to acknowledge that not all individuals with ADHD seek substances to self-medicate and/or moderate their symptoms. As treatment options are widely available and have shown to provide effective results, many individuals continue to seek pharmaceutical support. According to an annual report by the Care Quality Commission, from 2007 to 2013, methylphenidate, had become the most commonly administered stimulant medication for the primary care of ADHD (Care Quality Commission, 2013). Providing support to the conception that methylphenidate is the
Page 11 of 61
first-line and most effective approach in treating symptomology, if taken as prescribed (Szobot et al. 2008; Kolar et al. 2008; Chang, D’Onofrio, Quinn, Lichtenstein & Larsson, 2016). Naturalistic studies carried out with the aim of observing behaviour closely for a prolonged period within its natural setting, have followed children diagnosed with ADHD complying with stimulant medication. Findings had shown that being treated with methylphenidate during childhood, had prevented substance abuse in adulthood (Dalsgaard, Mortensen, Frydenberg & Thomson, 2014). Though additional research has found that stimulant as well as non-stimulant treatment has no significant effect on later substance abuse in child-diagnosed (Molina et al. 2013) and adult- diagnosed individuals (Schubiner et al. 2002; Levin et al. 2009). Recent research has since argued that stimulant medication should be used in addition to behaviour therapies, such as Cognitive Behavioural Treatment (CBT), in order to effectively treat ADHD and reduce likelihood of substance abuse (Azami et al. 2016; Maier et al. 2016; Pelham Jr et al. 2017).
Nonetheless, as stimulant medication is available in either short-acting, intermediate or sustained release forms of managing ADHD symptoms (Weyandt et al., 2016), it is more commonly prescribed (Bonati & Clavenna, 2005; Chai et al. 2012) and preferred alone (Faraone, Biederman, Spencer & Aleardi, 2006) in acknowledgment of behaviour therapies. In consideration of this, it is likely that frequent and possible obsessive compliance of stimulant medication, can lead to prescription abuse (Volkow et al. 1995) in an attempt to maintain pharmacological effects of medication on symptoms. Sepúlveda et al. (2011) recruited college students’ who were prescribed ADHD medication and were currently misusing their prescription to aid concentration. These students were more likely to endorse multiple substance use behaviours, as found in prior research (Wilens, Gignac, Swezey, Monuteaux & Biederman, 2006; Upadhyaya et al. 2005; Rabiner et al.
Page 13 of 61
using survey responses, selection bias remains an issue along with, inability to explore confounding factors contributing to results, in addition to examination of internal effects of cannabis use on individuals. Additional methods used in measuring cannabis abuse in individuals with ADHD had been illustrated by Kelly et al. (2017), with the use of magnetic reasoning imaging, alongside surveys. Findings showed cannabis use had no effect on abnormalities within the brain though they only recruited a small sample of child-diagnosed participants. Additionally, Tamm et al. (2013) had also focused on a small sample of child-diagnosed individuals yet used neuropsychological assessments and found cannabis was associated with executive dysfunction.
To examine the conflicting results on separate child and adult diagnosed individuals, recent research has studied comparisons of both child and adult diagnosed individuals who are may be abusing substances such as cannabis. Therefore, more information on health outcomes can be drawn from the studies. A study that has done this by Chan, Dennis and Funk (2008) recruited a large sample of child and adult ADHD diagnosed individuals entering treatment for substance abuse. Measuring internalizing and externalizing problems within individuals as well as confirming ADHD diagnosis and substance abuse, they found adult-diagnosed individuals were more likely to experience more internalizing and externalizing problems that contributed to their need to abuse substances, despite ADHD symptoms increasing due to cannabis use (Fergusson & Boden, 2008).
Unfortunately, psychoactive drugs like cannabis provide the ability to induce strong habits towards further use of other drugs (Edwards, Arnif & Jaffe, 1983; Fergusson & Boden, 2008), such as amphetamines (Konstenius, Jayaram-Lindtröm, Beck & Franck, 2010), opioids and cocaine (Arias et al., 2008). Cocaine being one of the most prohibited drugs around the world (United Nations Office on Drugs and Crime, 2015), has been found in a recent study to be frequently used by adult diagnosed patients due to high impulsiveness early use of other substances (de los Cobos, Siñol,
Page 14 of 61
Puerta, Cantillano, Zurita, & Trujols, 2011). Dependence on additional illicit substances such as heroin (Lugoboni et al. 2017) has also been identified due to high levels of ADHD symptoms not responding well to ADHD medication in adults. With continued use of illicit substances such as cocaine and heroin, individuals with ADHD are likely to struggle with stronger impairments as a side effect, in comparison to non-ADHD controls (Wunderli et al. 2016). Therefore, as individuals with ADHD may potentially engage in more than one method of substance abuse, they are more likely to be in contact with health services primarily for their ADHD (Nylander, Holmqvist, Gustafson & Gillberg, 2016) in an attempt to understand/control impulsions to abuse. Research is necessary to consider child and adult diagnosed ADHD individuals in treatment, to examine likelihood of substance abuse and factors potentially contributing to ongoing substance abuse while being treated.
In addition to frequency literature, a study which has utilized a double-blind placebo-controlled trial enabled child and adult ADHD diagnosed patients, with comorbid cocaine dependence, to enter strict outpatient treatment for a course of three months (Schubiner et al. 2002). This trial ensured patients had been administered methylphenidate, provided urine specimens, completed cocaine craving scales and complete assessments on problems in functioning. Beneficially, participants were given weekly individual and group CBT sessions to work on their ADHD and how it related to their cocaine dependence. Findings showed that methylphenidate had helped relieve ADHD symptoms though had no effect on cocaine use, despite cocaine abuse being associated with ADHD symptoms. This suggests additional contributing factors that affect substance abuse in treatment. Essentially, they had used a small sample in their study due to telephone screening methods in sample selection. Potentially affecting reliability, introducing bias as well as enabling researchers to conduct multiple statistical tests, increasing the possibility of a type I error. In contrast, a different study had recruited a wider sample by using clinic referrals and advertisements in multiple media outlets within three states, inviting participants with cocaine
Page 16 of 61
regulate feelings and filter unwanted sensations, illustrating that treatment provided for them as outpatients were not esteemed. In comparison to this, Bozkurt, Evren Umut, Agachanli and Evren (2017) looked at adult ADHD inpatients with a comorbidity of alcohol dependency and found that severity of ADHD symptoms predicted severe alcohol use. Suggesting an association between ADHD symptoms and alcohol use (Wilens et al. 2011b; Huntley & Young, 2014), as patients with ADHD have higher alcohol cravings when comparing withdrawal severity to individuals without ADHD (Seitz, Wapp, Burren, Stutz, Schläfli et al. 2013). As findings from Bozkurt, Evren Umut, Agachanli and Evren (2017) were reported from medical charts, they may have therefore been subjected to observer bias and potential confounders within patient backgrounds were not adequately evaluated. In addition, female adolescents were only included within the sample, thus results from adult diagnosed individuals who are also males, may have shown differing outcomes. Findings by Kolla et al. (2016) supported results in finding an association with alcohol use and symptoms when controlling for sex differences, adding that externalizing psychopathology also predicted alcohol use. Though this did not explore differences in males and females who had been diagnosed as children and adults.
With increasing findings on the likelihood of ADHD being associated with substance abuse, and continuous substance abuse when in treatment, it is not clear on the risks associated with child and adult diagnosed individuals who are currently accessing treatment. In addition, risk factors preluding to substance abuse that are susceptible to both child and adult diagnosed individuals such as comorbidity, major life events, self-harming (Chou, Lin, Sung & Kao, 2014; Allely, 2014; Swanson, Owens & Hinshaw, 2014) and suicidal ideation (Impey & Heun, 2012; Balazs, Miklósi, Keresztény, Dallos & Gádoros, 2014; Stickley, Koyanagl, Ruchkin & Kamlo, 2016; Van Eck et al. 2015), may contribute to why individuals feel the need to abuse substances (Kelly, Cornelius & Clark, 2004) though research considering this for patients currently receiving treatment in ADHD is limited. By utilising electronic health records, data cannot be manipulated, risks and patterns of
Page 17 of 61
substance abuse can be explored and the effects of substance abuse on symptomology and treatment for child and adult diagnosed individuals can be understood.
Moreover, electronic health records from the South London and Maudsley (SLaM) National Health Service (NHS) Foundation Trust, has enabled use of clinical documents for researching reported risks and patterns of substance abuse in ADHD individuals ever in treatment. For this study, approval was sought in accessing the Clinical Record Interactive Search (CRIS) an information process whereby SLaM electronic health records were searched for relevant substance abuse related information on ADHD outpatients within South London. Records were made available in a way that respects the legal and ethical rights of patients as on a weekly basis, the Electronic Patient Journey System (ePJS) maintains patient confidentiality, by being fed through a de-identification pipeline removing patient identifiers from structured forms and free text fields such as clinical notes and letters. Natural Language Processing (NLP) along with its sub discipline of Information Extraction (IE) is a programme commonly used in electronic data to gather information from large quantities of unstructured text authored by individuals (Nikiforou, Ponirou, Diomidous, 2013; Jackson et al. 2017). With the use of NLP and IE, structured information and its meaning, can be extracted in regard to specified factors that influence risks of disease and outcomes of interest around a given time period.
With the use of NLP, IE and the ability to search clinical documents in free text, information is gathered for the research aim of this dissertation. This aim is to examine the prevalence of substance abuse in child and adult diagnosed outpatient’s currently and prior to receiving treatment. By attaining all clinical data the main hypothesis of the study will examine whether being diagnosed with ADHD as an adult, increases the likelihood of engaging in substance abuse compared to child diagnosed outpatients. Due to not having access to treatment at a young age, there may be an increased need to self-medicate symptoms. Additional explanatory hypothesis
Page 19 of 61
factual month and year that a patient was born, but a false day of birth. The year that the primary F90 diagnosis was made was subtracted from the cleaned year of birth to ascertain which individuals were diagnosed in childhood (under the age of 18) and as an adult (over the age of 18). These output was then filtered for individuals on whether they were outpatients from an index date of January 1st 2017. This date was chosen to get the most recent information regarding current prevalence of substance abuse in response to treatment. Eligibility was assessed by reviewing patient history and correspondence between the outpatient service and prior health care professionals involved in the care of the patient. An inclusion criteria was applied for outpatients who would be aged at least 18 or over from the index date to measure current substance abuse as an adult outpatient. Therefore, younger patients from the index date were not included in the search extraction. Outpatients should have also been currently exhibiting ADHD symptoms as highlighted in previous research thus, were eligible for medication or psychological treatment from their outpatient episode. In order to be certain of symptomology, a search for recorded concerns of ADHD symptoms was done where terms used included ‘‘hyperactive,’’ ‘‘distraction,’’ ‘‘distracted,’’ ‘‘impulsive,’’ ‘‘impulsiveness,’’ ‘‘inattentive,’’ ‘‘inattention,’’ ‘‘procrastination,’’ ‘‘procrastinates,’’ ‘‘disorganised,’’ ‘‘disorganisation,’’ and ‘‘anxious’’. To avoid missing symptoms not previously highlighted as a term, mental health records on previous hospital admissions was identified and read through to classify other common ADHD symptoms such as mood lability and difficulty with sleep. Individuals excluded from the sample were found to have missing data, in the case of, being inactive as an outpatient by not seeing their clinician during their outpatient episode or within the past year of being admitted. Also, if individuals had made no disclosure of any information regarding their mental state, behaviour and response to treatment, they were excluded from the sample (N=16). Sociodemographic characteristics were extracted from CRIS including month and year of birth, along with ethnicity, coded with the UK Office for National Statistics: NHS ethnic category codes, to maintain anonymity.
Page 20 of 61
Measures of Alcohol and Substance Abuse To ensure valid information was recorded on current and history of alcohol and substance abuse, patient records were searched for substance abuse related assessments completed within a mental health service. Assessments found included; a Urine Screen which tested for traces of misused substances, SLaM National Drug Treatment Monitoring System (NDTMS) in which patients had to list problem substances, an audit answering ‘How often do you have a drink containing alcohol?’, single assessments pertaining to substance abuse such as the ‘‘Current Drug and Alcohol Assessment,’’ ‘‘Current Substance Abuse Assessment,’’ ‘‘Child and Adolescent Mental Health Services (CAMHS) Drug and Alcohol Assessment,’’ and ‘‘CAMHS Risk to Self Substance Misuse Assessment’’. These assessments required individuals to state whether they were currently abusing substances of any kind, how often and list what substances they were.
For the entire sample, clinical reports of patients expressing experience of substance abuse were searched with terms ‘‘substance misuse,’’ ‘‘substance abuse,’’ ‘‘substance dependence,’’ ‘‘substance abuse disorder,’’ ‘‘alcohol,’’ ‘‘cannabis,’’ ‘‘weed,’’ ‘‘marijuana,’’ ‘‘opiates,’’ ‘‘cocaine,’’ and ‘‘self-medicate,’’ highlighted. Where these terms were not highlighted, historic and recent events made on each patient were searched and read through for any report from the patient expressing consistent and excessive use of alcohol and/or prescribed substances, as well as, different types of illicit substances abused. A specified definition of substance abuse, was defined by cross referencing self-reports made by outpatients, of instances of substance abuse similar to two or more of the DSM-5 criteria for substance use disorder or, excessive continuous use as described by at least one of the criterion of the ICD-10, F10 - F19 Mental and behavioural disorders due to psychoactive substance use. Both the DSM-5 and ICD-10 criteria were used due to the variety of definitions for substance abuse, which patients would be to open to display/define in report to clinicians involved in their care. The DSM-5 criteria includes a pattern of substance use that leads to clinically significant impairment, distress or tolerance, addressing implications of