Attention decit hyperactivity disorder (ADHD)

among illicit psychostimulant users: a hidden disorder?

Sharlene Kaye, Shane Darke & Michelle Torok
National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
ABSTRACT
Aims To estimate the prevalence, nature and correlates of symptomatology consistent with adult attention decit
hyperactivity disorder (ADHD) among illicit psychostimulant users. Design Cross-section survey. Setting Sydney,
Australia. Participants 269 regular illicit psychostimulant users. Measurements Structured interview assessing
demographics, drug use and treatment history, psychostimulant dependence and self-reported symptoms consistent
with adult ADHD. Findings Almost half (45%) screened positive for adult ADHD (ADHD
+
). Symptoms of inattention
(90%) were more prevalent than symptoms of hyperactivity/impulsivity (57%). Of those who screened positive for
adult ADHD, only 17% had received a prior diagnosis of ADHD. The ADHD
+
group differed from other participants in
several respects: an earlier initiation of substance use and injecting drug use; more extensive polydrug use; a higher
frequency of recent stimulant use and injecting drug use; a greater likelihood of stimulant dependence; and a greater
likelihood of having received treatment for drug dependence. After controlling for other factors, screening positive for
ADHD was associated independently with fewer years of education, earlier initiation of regular tobacco use and more
extensive life-time polydrug use. Conclusions Clinicians should be aware of the potential for patients of drug and
alcohol treatment services to have undiagnosed and/or untreated ADHD that may impact on their compliance with,
and retention in, treatment.
Keywords ADHD, ASRS, illicit, psychostimulant, substance use disorders.
Correspondence to: Sharlene Kaye, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
E-mail: s.kaye@med.unsw.edu.au
Submitted 7 December 2011; initial review completed 28 March 2012; nal version accepted 3 December 2012
INTRODUCTION
The association between attention decit hyperactivity
disorder (ADHD) and substance use disorders is well
documented [13]. ADHD is a signicant risk factor for
the development of alcohol and illicit drug use disorders
in adolescence and adulthood [1,35], and is over-
represented consistently among substance use disorder
populations [2,6,7]. Moreover, where symptoms are of
greater severity and persist through adolescence into
adulthood, the likelihood of a comorbid substance use
disorder is increased [4,8]. While general population
estimates suggest that 510% of children and 34%
of adults have ADHD [912], the estimated overall
prevalence of ADHD among those with a substance use
disorder is 23% [2].
The relationship between ADHD and substance use
disorders is complicated by the heterogeneity of pre-
senting symptoms, variability in diagnostic methods and
comorbidity with other psychiatric disorders. ADHD may
be characterized by symptoms reecting inattention,
hyperactivity, impulsivity or a combination of these
symptom domains. As such, different symptom proles,
or subtypes, may have a differential contribution to the
risk of developing a substance use disorder [3,5],
although the nature of this contribution is still unclear,
with some studies indicating that the inattentive subtype
is associated more strongly with substance use disor-
ders [8,13] and others suggesting that the hyperactive
impulsive subtype confers greater risk [14,15]. The
current gold standard for diagnosing ADHD, the
Diagnostic and Statistical Manual of Mental Disorders,
fourth edition text revision (DSM-IV-R) [16], uses a
categorical (present or absent) approach, although it
has been argued increasingly that a dimensional
approach to the diagnosis and classication of ADHD
RESEARCH REPORT
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doi:10.1111/add.12086
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
(and other psychiatric disorders) should be considered for
future editions [17]. Accordingly, research suggests that
dimensional measures of ADHD may be just as, if
not more, useful in predicting substance use disorder
outcomes [13,15,18].
The role of ADHD in the development of substance
use disorders is likely to be multi-factorial. Plausible
mechanisms include the self-medication of ADHD symp-
toms via substance use as well as the impairment in aca-
demic and social functioning associated with ADHD
leading to marginalization and consequent involvement
in more deviant behaviour, such as drug use [19,20].
Given the high level of comorbidity between ADHD and
other externalizing disorders (e.g. conduct disorder and
oppositional deant disorder), there has been much
debate about the extent to which the relationship
between ADHD and substance abuse is mediated by
such additional comorbidity [1,3]. Several studies, for
example, suggest that ADHD is associated with substance
abuse through its comorbidity with conduct disorder
[2126], while others have shown that ADHD is associ-
ated independently with substance abuse, even after
controlling for conduct disorder and other psychiatric
comorbidity [6,15,27,28].
Regardless of the causal pathway between ADHD and
substance use disorders, and the issues surrounding how
such disorders are classied, the clinical reality is that
ADHD complicates the course and treatment of sub-
stance use disorders. ADHD is associated consistently
withanearlier onset, greater severity and increased chro-
nicity of substance use and dependence and a greater
level of impairment due to other psychiatric comorbidity
[4,2931]. Accordingly, substance use disorders among
those with ADHD are more difcult to treat, with lower
rates of treatment retention and higher rates of relapse
[3234]. Although the comorbidity between ADHD and
substance use disorders is sufciently high, and the treat-
ment prognosis sufciently poor, to warrant clinical
attention and concern, it is likely that ADHD is under-
identied as a comorbid disorder among those with a sub-
stance use disorder. While there has been increasing
recognition of the comorbidity between substance use
disorders and other psychiatric disorders, there is less rec-
ognition of, and no routine screening for, ADHD among
substance abusers or other clinical populations [33,35].
It has been hypothesized that individuals with undi-
agnosed or untreated ADHD may use illicit psychostimu-
lants as a formof self-medication [36,37]. If this is indeed
the case, the over-representation of ADHD among illicit
drug users may be particularly apparent among psycho-
stimulant users. Whether the underlying aetiology is self-
medication or, rather, a predisposition among those with
ADHD to engage in illicit drug use per se, increased rates
of childhood ADHD have been observed among depend-
ent cocaine [3739] and methamphetamine users
[4042], suggesting an association between ADHD in
childhood and subsequent illicit psychostimulant use.
While adult ADHD has been found to be of a higher than
average prevalence among treatment-seeking cocaine
abusers [38], such samples may not be representative of
psychostimulant users in general. To date, there are no
studies that have examined adult ADHDamong a broader
group of psychostimulant users that includes metham-
phetamine and cocaine users, and that includes users
not in treatment for drug dependence. The aims of the
current study were to:
1 Estimate the prevalence and nature of adult ADHD
symptomatology among regular illicit psychostimu-
lant users; and
2 Examine the demographic, drug use and psychological
correlates of adult ADHD symptomatology.
METHODS
Participants
Participant recruitment took place between August 2009
and September 2010, via advertisements placed in needle
and syringe programmes, residential rehabilitation serv-
ices, street press and by word of mouth. All participants
were volunteers who were paid AUD$30 for participa-
tion. To be eligible for the study, participants must have
used illicit psychostimulants (i.e. methamphetamine
and/or cocaine) at least weekly over the 12 months
preceding interview.
The sample comprised 269 illicit drug users, 69% of
whom were male, with a mean age of 35.6 years [stand-
ard deviation (SD) 8.5; range 1962 years]. The mean
length of school education was 9.7 years (SD 1.4; range
312 years), with 37% having completed a trade or tech-
nical course and 4% a university course. Most partici-
pants (88%) were unemployed at the time of interview,
with 21% reporting that the main source of their income
came from crime. The majority (86%) had received past
treatment for substance dependence, with 65% enrolled
previously in a methadone or buprenorphine mainte-
nance programme and 40% previously in residential
rehabilitation. Half (52%) were in treatment at the time
of interview, with 39%in opioid substitution therapy and
12% in residential rehabilitation.
Procedure
Interested respondents to advertisements for the study
contacted a member of the research team and were
screened for eligibility. Structured interviews were con-
ducted with eligible participants by a member of the
research team and took approximately 30 minutes to
complete. The study had ethical approval from the
924 Sharlene Kaye et al.
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
University of New South Wales and all relevant area
health services, and all participants were guaranteed
anonymity and condentiality.
Structured interview
A structured interview assessing demographics, past
and current drug use and treatment history was
administered. Drug use history was ascertained by
asking about past and recent (last 6 months) use of
heroin, other opioids, methamphetamine, cocaine,
ecstasy, hallucinogens, benzodiazepines, cannabis, anti-
depressants, inhalants, alcohol and tobacco. The age
of onset of rst and regular use of these substances
was obtained, as was the recent frequency of their
use. Psychostimulant dependence was assessed using
DSM-IV [43] criteria for substance dependence. Physi-
cal and mental health status were assessed using the
Short Form 12-Item (SF-12) Health Survey [44],
which is comprised of two summary physical and
mental health scales having a mean of 50 and a stand-
ard deviation of 10, lower scores indicating poorer
health.
Participants were screened for adult ADHD using the
Adult ADHD Self-Report Scale Screener (ASRS, version
1.1) [45]. The ASRS is a widely used and valid instru-
ment, the six-item version of which has been shown
to outperform the original 18-item version [45]. Of
the six ASRS items, four measure inattention and two
measure hyperactivity/impulsivity. Each item is scored
according to symptom frequency, as follows: 0 (never), 1
(rarely), 2 (sometimes), 3 (often) or 4 (very often). The
rst three items are regarded as positively endorsed
when a score of 2 or higher is obtained. The following
three items are regarded as positive when a score of 3 or
4 is obtained. Endorsement of four or more of these six
items is indicative that the respondent has symptoms
highly consistent with adult ADHD, and that further
clinical investigation is warranted [45]. In the general
population, this recommended cut-off of 4 has been
found to best discriminate between clinical cases and
non-cases of ADHD, with a sensitivity of 68.7% and
specicity of 99.5% [45]. The reliability, validity
and utility of the ASRS have also been demonstrated
among people with substance use disorders [46,47].
As the acute effects of drug or alcohol intoxication or
withdrawal may resemble some of the symptoms of
ADHD, such as impulsivity, attention difculties, rest-
lessness and agitation, participants were asked to reect
upon whether the symptoms they endorsed were
related to their drug use, or were typical of their usual
behaviour.
Psychiatric history was assessed by asking partici-
pants if a health professional had ever told themthat they
may have a mental health or behavioural problem [i.e.
anxiety, depression, oppositional deance disorder (ODD),
ADHD, conduct disorder (CD), bipolar disorder, psychotic
disorder, personality disorder].
Analyses
For continuous variables, t-tests were employed. For
dichotomous categorical variables, odds ratios (OR) and
95% condence intervals (CI) were reported. Where dis-
tributions were skewed, medians and interquartile ranges
(IQRs) were reported and non-parametric analyses con-
ducted. In order to identify factors associated independ-
ently with ADHD screening status (positive or negative),
multivariable and logistic regression analyses, with back-
wards eliminationof variables, were conducted. Variables
identied as associated signicantly with ADHD screen-
ing status via univariable analysis were entered as inde-
pendent variables into the regression model. All analyses
were conducted using PASW statistics (version 18.0)
[48].
RESULTS
Drug use history
While eligibility for the study was dependent on at least
weekly use of illicit psychostimulants over the preceding
12 months, the majority (71%) had used more than three
times per week over this period and 88% met criteria for
psychostimulant dependence. In the 6 months preceding
interview, methamphetamine was used more frequently
than cocaine (48 versus 10 median days, W = -7.6,
P < 0.001). Participants reported extensive polydrug use
histories, as indicated by the mean number of drug
classes used over their life-time (9.7 drug classes) and in
the previous 6 months (6.0 drug classes).
Psychiatric history
Previous diagnoses or indications of a mental or behav-
ioural disorder by a health professional were reported by
two-thirds (67%) of participants. The most common dis-
orders reported were depression (53%) and anxiety
(31%). ADHDhad been diagnosed or indicated previously
in 10% of the sample, bipolar disorder in 9%, a psychotic
disorder in 9% and a personality disorder in 4%.
Current adult ADHD symptomatology
Almost half (45%) screened positive on the ASRS, indi-
cating the presence of symptoms highly consistent with
adult ADHD. Of those who screened positive, 88% (40%
of the total sample) reported that their symptoms were
unrelated to drug use and were consistent with their
ADHD among illicit psychostimulant users 925
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
usual behaviour. While the remaining 12% felt that drug
use may have contributed to their symptoms, underlying
ADHD symptomatology could not be discounted. As
such, they were treated as screening positive in subse-
quent analyses.
Of those who screened positive for adult ADHD, only
17% had received a prior diagnosis or indication of
ADHD, and 14% were treated subsequently for ADHD. A
single participant was being treated currently for ADHD
with stimulant medication.
ADHD symptom proles
The overwhelming majority of the sample (90%)
endorsed at least one of the ASRS items measuring inat-
tention, with almost a third endorsing all four items
(Fig. 1). The most commonly endorsed symptoms of inat-
tention were an inability to complete tasks and difculty
in planning and organization (Table 1). More than half
the sample (57%) endorsed at least one of the ASRS items
measuring hyperactivity/impulsivity, but typically only
one such symptom was reported, most commonly an
inability to sit still for long periods.
Comparisons according to ASRS results
Demographic characteristics
There were no signicant differences in mean age, gender
or proportion unemployed between those who screened
positive for adult ADHD(ADHD
+
) and those who screened
negative (ADHD

) (Table 2). The ADHD

+
group, however,
had completed fewer years of formal school education
than the ADHD
-
group.
Drug use and treatment history
The ADHD
+
group were signicantly younger when they
rst became intoxicated by alcohol or other drugs and
whenthey rst injected a drug. They also initiated regular
use of tobacco, alcohol, cannabis, and methampheta-
mine at signicantly earlier ages than the ADHD
-
group
(Table 2).
Life-time and recent (last 6 months) polydrug use, as
indicated by the number of different drug classes used,
was more extensive among the ADHD
+
group (Table 2).
The ADHD
+
group were also more likely to have engaged
in high frequency stimulant use (ve times or more per
week) over the preceding 12 months and daily injecting
drug use over the preceding month. The majority of both
groups met DSM-IV criteria for stimulant dependence,
although there were no signicant between-group
differences.
The ADHD
+
group were more likely to have received
treatment for drug dependence in the past (Table 2).
There were no signicant differences, however, in the
ages at which the two groups rst entered a treatment
programme or in the proportions in treatment at the
time of interview.
Psychopathology
The ADHD
+
group were more likely to have been diag-
nosed previously with a mental or behavioural disorder,
with diagnoses of anxiety, bipolar disorder, ADHD and
psychotic disorders more commonly reported among this
group (Table 2).
10
14
22
25
29
44
39
17
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4
%

o
f

s
a
m
p
l
e
No. of ASRS items endorsed
Inatenton items endorsed
Hyperactvity/impulsivity items
endorsed
Figure 1 Total number of inattention and hyperactivity/impulsivity
items endorsed on Adult ADHD Self-Report Scale Screener (ASRS)
Table 1 Prevalence of Adult attention decit hyperactivity dis-
order (ADHD) Self-Report Scale Screener (ASRS) items endorsed
at a severity indicative of ADHD symptomatology.
ASRS item
% of sample
(n = 269)
1. How often do you have trouble wrapping up
the nal details of a project, once the
challenging parts have been done?
74
2. How often do you have difculty getting
things in order when you have to do a task that
requires organization?
68
3. How often do you have problems remembering
appointments or obligations?
63
4. When you have a task that requires a lot of
thought, how often do you avoid or delay
getting started?
44
5. How often do you dget or squirm with your
hands or feet when you have to sit down for a
long time?
52
6. How often do you feel overly active and
compelled to do things, like you were driven by
a motor?
21
926 Sharlene Kaye et al.
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
While there were no signicant group differences in
SF-12 scores on the physical health scale, the ADHD
+
group scored signicantly lower on the mental health
scale, indicating poorer mental health functioning
(Table 2).
Multivariable analyses revealed that, after controlling
for demographic, drug use and psychopathological corre-
lates, screening positive for adult ADHD was associated
signicantly and independently with fewer years of edu-
cation, an early adolescent onset of regular tobacco use
and more extensive life-time polydrug use (Table 3). The
nal model was signicant (c
2
= 53.33, d.f. = 5,
P < 0.001) and had a reasonable t (HosmerLemeshow
c
2
= 3.83, d.f. = 8, P = 0.87).
DISCUSSION
The current study conrms the high level of comorbid
ADHD symptomatology among illicit drug users demon-
strated in previous research, with almost one in two par-
ticipants screening positive for symptoms consistent with
adult ADHD. In contrast, only 6% of a recent general
Table 2 Demographic, drug use and psychological correlates of attention decit hyperactivity disorder (ADHD) symptomatology.
ADHD
+
(n = 121) ADHD
-
(n = 148)
OR (95% CI), t-statistic or
MannWhitney U-test
Demographics (n = 269)
Age [mean (SD)] 35.9 (8.1) 35.3 (8.8) NS
Gender [n (%) male] 79 (65) 107 (72) NS
Years of school education [median (IQR)] 9 (1) 10 (2) U = 6059.5***
Unemployed [n (%)] 110 (91) 126 (85) NS
Onset of drug use (n = 269)
Age rst intoxicated (alcohol, illicit drugs) [median (IQR)] 13 (3) 15 (3) U = 6065.0***
Age rst regularly used [median (IQR)]
a
Tobacco (n = 262) 14 (3) 17 (3) U = 5029.5***
Alcohol (n = 245) 16 (4) 17 (2) U = 5607.0**
Cannabis (n = 252) 15 (2) 16 (2) U = 5198.5***
Methamphetamine (n = 256) 18 (4) 20 (7) U = 6274.5**
Cocaine (n = 205) 24.5 (9) 25 (9) NS
Heroin (n = 206) 19 (6) 21 (7) NS
Age rst injected a drug (n = 242) [median (IQR)]
b
17 (4) 19 (6) U = 5358.5***
Age rst regularly injected (n = 239) [median (IQR)] 19 (6) 21 (7) NS
Extent of drug use (n = 269)
No. of drug classes used [mean (SD)]
Ever 10.5 (1.6) 9.0 (1.9) t
267
= -6.71***
Last 6 months 6.5 (1.6) 5.6 (1.7) t
267
= -4.32***
Daily injecting (last mth) [n (%)] 56 (46) 39 (26) OR 2.41, CI 1.444.02
Stimulant use 5+ times/week (last 12 months) [n (%)] 56 (46) 42 (28) OR 2.17, CI 1.313.60
Stimulant dependence [n (%)] 112 (93) 125 (84) NS
Treatment history (n = 269)
Past treatment [n (%)] 112 (93) 118 (80) OR 3.16, CI 1.446.96
Current treatment [n (%)] 72 (60) 67 (45) NS
Age rst entered treatment (n = 230) [median (IQR)] 24 (9) 25 (9) NS
Psychopathology (n = 269)
Previous psychiatric diagnoses [n (%)]
ADHD 21 (17) 7 (5) OR 4.23, CI 1.7310.33
Depression 73 (60) 69 (47) NS
Anxiety 52 (43) 31 (21) OR 2.84, CI 1.674.86
Bipolar disorder 19 (16) 5 (3) OR 5.33, CI 1.9314.74
Psychotic disorder 18 (15) 6 (4) OR 4.14, CI 1.5910.78
Personality disorder 3 (2) 7 (5) NS
Any mental health or behavioural disorder 97 (80) 83 (56) OR 3.17, CI 1.825.50
SF-12 score [mean (SD)] (n = 268)
Physical health 43.7 (11.4) 46.2 (10.5) NS
Mental health 32.0 (10.5) 36.9 (12.1) U = 6734.0**
*P < 0.05; **P < 0.01; ***P < 0.001.
a
ns vary by substance based on number of participants with a history of regular use of each substance use;
b
ns
vary according to history of drug injecting. CI = condence interval; NS = not signicant; IQR = interquartile range; OR = odds ratio; SD = standard
deviation.
ADHD among illicit psychostimulant users 927
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
population sample administered the ASRS screened posi-
tive for ADHD [49]. Moreover, consistent with other
studies [33,50], the majority of those with symptoms of
ADHD in adulthood had never been diagnosed formally
with ADHD. This may, in part, reect the fact that the
sample was aged in their mid-30s, and the level of aware-
ness and diagnosis of ADHD in their childhood years was
far lower than it is today. Furthermore, adult ADHD was
not included in the DSM until the most recent edition
(DSM-IV-TR) [16]. As such, many adults with the disor-
der may be undiagnosed or, if diagnosed in childhood,
may be thought to have outgrown the symptoms.
Importantly, these ndings demonstrate the potential for
ADHD to be under-identied and, consequently, under-
managed, among those with substance use disorders and
highlight the need for drug and alcohol treatment serv-
ices to consider screening for this disorder.
Consistent with previous research into ADHD among
substance use disorder populations, symptoms of inat-
tention were more prevalent than those of hyperactivity/
impulsivity [46,51]. This may reect the tendency for
symptoms of hyperactivity and impulsivity present in
childhood and adolescence to remit with increasing age,
andtodosoearlier andmore frequentlythansymptoms of
inattention [52]. The fact that hyperactivity/impulsivity
items were less commonly endorsed than those of inat-
tention also suggests that participants were reecting
on their usual behaviour when responding to the ASRS
items, as requested, rather thanpsychostimulant-induced
behaviour, such as motor hyperactivity. Although inat-
tention may also be an effect of drug intoxication or
withdrawal, the overwhelming majority of participants
reported that their symptoms were consistent with
their usual behaviour and not related to their drug use.
The predominance of inattentive symptoms, which are
less obvious and specic and could be attributed mis-
takenly to the acute or chronic effects of drug use, may
contribute to the under-identication of ADHD among
this group.
While the demographic characteristics of those who
screened positive were mostly similar to those who
screened negative, a positive screen was associated inde-
pendently with a shorter period of formal education. This
is consistent with the impairment in academic function-
ing that symptoms of ADHD are known to cause in child-
hood and that is thought to contribute to the relationship
between childhood ADHD and the later development of
substance use disorders [8].
In accordance with the well-documented association
between ADHD and the course and severity of substance
use disorders [36,53], screening positive for adult ADHD
was associated with an earlier initiation and more prob-
lematic course of drug use. After taking all associated
substance use factors into account, however, the strong-
est predictors were an earlier onset of tobacco use and a
greater extent of past polydrug use. Overall, these nd-
ings indicate that, irrespective of causality, those with
symptoms of ADHD are at the more severe end of the
drug use spectrum and are thus likely to have poorer
health and treatment outcomes.
In keeping with the high rate of comorbidity between
ADHD and other psychiatric disorders [30,54], a history
of diagnosed psychopathology was more prevalent
among the ADHD
+
group. Although such a history did
not remain a statistically signicant predictor of ADHD
screening status after education and drug use history
were taken into account, the presence of such comorbid-
ity is likely to complicate the course and treatment of
substance use disorders [55].
As with all research, there are methodological limita-
tions to be acknowledged. First, diagnostic interviews to
assess childhood and adult ADHD were not conducted.
The aimof this study was to screen for adult ADHDsymp-
tomatology as a means of estimating the proportion of
psychostimulant users for whom further diagnostic
assessment of ADHD is warranted. While a positive
screening result on the ASRS is strongly indicative of the
presence of adult ADHD, subsequent assessment is
required in order to achieve diagnostic certainty. Sec-
ondly, this study employed a cross-sectional design. As
such, causal inferences as to the role of ADHD in the
development and course of substance use disorder in this
sample, other than as a comorbid disorder, are unable to
be made. Nevertheless, the ndings indicate clearly that
symptoms of ADHDwere associated with a greater extent
Table 3 Multivariable model predicting a positive screen for
attention decit hyperactivity disorder (ADHD).
Independent variables OR (95% CI) P-value
Years of school education 0.73 (0.580.92) 0.009
Age rst intoxicated 0.93 (0.791.08) 0.338
Age rst injected a drug 0.98 (0.921.04) 0.475
Initiated regular tobacco use
before age 15
2.68 (1.405.12) 0.003
Initiated regular alcohol use
before age 15
0.82 (0.342.00) 0.659
Initiated regular illicit drug
use before age 15
1.06 (0.422.71) 0.898
Life-time polydrug use 1.49 (1.221.82) <0.001
Almost daily stimulant use 1.56 (0.822.99) 0.178
Daily injecting 1.09 (0.552.15) 0.809
Ever in treatment 0.81 (0.252.66) 0.726
Ever mental or behavioural
disorder
1.23 (0.582.62) 0.589
SF-12 mental health scale
scores
0.98 (0.961.01) 0.254
CI = condence interval; OR = odds ratio.
928 Sharlene Kaye et al.
2012 The Authors, Addiction 2012 Society for the Study of Addiction Addiction, 108, 923931
and severity of substance use. Thirdly, the representative-
ness of the sample of illicit psychostimulant users in the
current study should be considered. Although it is not
possible to obtain a random stratied sample of a popu-
lation of unknown parameters, the demographic charac-
teristics of the current sample are similar to those of
other samples of illicit psychostimulant users [56].
Although users of illicit psychostimulants were targeted,
extensive levels of past and recent polydrug use were
reported, particularly among those who screened positive
for ADHD. Polydrug use, however, is the norm among
illicit drug using samples [57] and is an important
marker for severity of substance abuse. Fourthly, the
above ndings were based on self-report. The ASRS was
designed to be a self-report measure and has been
validated among substance use disorder populations
[45,46,58]. More broadly, the use of self-report in recall-
ing childhood and current symptoms of ADHD has been
shown to be reliable [59]. Furthermore, among those
receiving treatment for substance use disorders, self-
reported symptoms of ADHD have been shown to remain
stable over time despite a reduction in substance abuse,
indicating that such symptoms are not merely substance-
induced [35]. Self-reported data have also been found to
be sufciently reliable and valid to inform about drug use
patterns and associated problems [60,61]. Finally, while
it is true that symptoms of substance intoxication and
withdrawal can mimic the presentation of ADHD,
leading potentially to overdiagnosis [54], users were
asked to consider whether the symptoms that they
reported were related to their drug use or reected their
typical behaviour. As mentioned above, the majority
reported that the endorsed symptoms were not induced
by drug use or withdrawal. Moreover, the purpose of
using a screening instrument is to identify those for
whom further clinical evaluation is warranted. It is
during such an evaluation that the presence and poten-
tially confounding effects of other disorders, such as sub-
stance use disorder, should be taken into account.
The recognition of adult ADHD as a comorbid and
complicating disorder among those with a substance use
disorder has major implications for the planning and
implementation of treatment responses to ADHD and
substance abuse. While the rst line of treatment for
ADHD is usually stimulant medication (e.g. methylpheni-
date), such medications may be contraindicated among
substance abusers and extended-release formulations
or non-stimulant medications more appropriate [7].
Identication of comorbid ADHD may assist in planning
appropriate forms of substance abuse treatment that will
reduce the risk of non-compliance with treatment regi-
mens and protocols due to symptoms such as inattention,
impulsivity and disorganization which may, in turn, com-
promise treatment retention and treatment outcome [7].
In conclusion, screening for adult ADHD symptoma-
tology among illicit psychostimulant users yielded a high
number of positive results, indicating that the prevalence
of adult ADHDamong this group is likely to be sufciently
high to warrant clinical concern and further investiga-
tion. At present, screening for adult ADHD on intake
is not common practice in drug and alcohol treatment
services [33]. The results of the current study, however,
suggest that a substantial proportion of psychostimulant
users will have comorbid ADHD. Given that such comor-
bidity is associated with a poorer prognosis for treatment,
clinicians should be aware of the potential for those
seeking treatment for substance use disorders to have
undiagnosed and/or untreated ADHD that may impact
on treatment compliance, retention and outcome.
Declarations of interest
None.
Acknowledgements
This research was funded by the National Health and
Medical Research Council. The authors wish to thank the
staff at the participating agencies for their assistance.
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