Childhood trauma exposure in substance use disorder patients with and without ADHD
Introduction
It has been known for decades that substance use disorder (SUD) patients frequently suffer from comorbid psychiatric disorders, especially internalizing disorders such as anxiety and mood disorders (Chan et al., 2008, Chen et al., 2011, Karam et al., 2015). More recently, there is a growing in interest of SUD and comorbid externalizing disorders, including attention deficit hyperactivity disorder (ADHD). ADHD is a prevalent childhood neurodevelopmental disorder, that often persists into adulthood e.g. (Faraone et al., 2006, Groenman et al., 2013) and adult ADHD is currently seen as one of the most frequent psychiatric comorbidities both in general population subjects with SUD and in treatment seeking SUD patients (Kessler et al., 2006, van Emmerik-van Oortmerssen et al., 2014).
ADHD affects 2.6–4.5% of the children worldwide (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015) and 2.1–3.1% of the adults (Simon, Czobor, Bálint, Mészáros, & Bitter, 2009), and the presence of ADHD is associated with risk behaviors (Kaye et al., 2014) negative life events (Bernardi et al., 2012), academic underachievement (Frazier, Youngstrom, Glutting, & Watkins, 2007), and higher mortality (Dalsgaard, Ostergaard, Leckman, Mortensen, & Pedersen, 2015). Although ADHD symptoms may wane with time or change character, e.g. the overt hyperactivity in childhood may be present as an inner restlessness in adults, functional impairments frequently persist into adulthood (Faraone et al., 2006). The association between ADHD and SUD is well-established (Groenman et al., 2013, Charach et al., 2011, Lee et al., 2011, van de Glind et al., 2014) and a recent meta-analysis of 29 studies has shown that ADHD is present in 25% of the adolescents and 21% of the adults with SUD (Emmerik-van Oortmerssen et al., 2012).
The clinical presentation of comorbid SUD and ADHD is complex; comorbidity with other psychiatric disorders is high (Carpentier et al., 2011; van van Emmerik-van Oortmerssen et al., 2014, Wilens et al., 2005), and individuals with ADHD frequently have more severe SUD and poorer prognosis of SUD treatment (Kaye et al., 2013, Rounsaville et al., 1991). Adding to this complexity, both disorders are associated with childhood trauma exposure (CTE) including sexual, physical and emotional abuse, physical and emotional neglect, and family violence is associated with a higher incidence of psychiatric disorders such as mood disorders, anxiety disorders (including post-traumatic stress disorder: PTSD), and SUD (Elliott et al., 2014, Fenton et al., 2013, Green et al., 2010, Kendler et al., 2000, Magnusson et al., 2012, Scott et al., 2003, Weich et al., 2009, Whittle et al., 2013). High rates of CTE are found in clinical samples with alcohol use disorder (55%–73%) (Huang et al., 2012, Schwandt et al., 2013, Windle et al., 1995), and drug use disorders (44–74%) (Darke and Torok, 2013, Oviedo-Joekes et al., 2011). CTE has also been associated with a wide range of adverse outcomes such as behavioral problems (De Sanctis et al., 2012, Gilbert et al., 2009), lower educational achievements (Jonson-Reid et al., 2004, Perez and Widom, 1994), and abnormalities in the neurobiology of the brain (Lim et al., 2014, Teicher et al., 2014). CTE in treatment seeking SUD patients is associated with elevated rates of other psychiatric disorders and suicide (Huang et al., 2012, Darke and Torok, 2013, Banducci et al., 2014). Similarly, CTE is associated with increased psychiatric comorbidity in patients with ADHD (Bernardi et al., 2012, Antshel et al., 2013, Biederman et al., 2014, McLeer et al., 1994, Rucklidge et al., 2006). Taken together, CTE has been shown to have a negative impact a variety of outcomes in different populations and it is therefore important to understand more about the role of CTE in clinically complex groups of patients with ADHD and SUD.
Although both ADHD and SUD have been associated with CTE and although CTE has a potentially negative effect on the prognosis of both disorders, the role of CTE in SUD-ADHD comorbidity has not yet been studied. In the present study we utilize data from a large European sample of treatment seeking substance users to investigate the role of CTE in SUD-ADHD comorbidity.
Section snippets
Objective
First, we investigate the effect of CTE on the prevalence of childhood and adult ADHD in treatment seeking SUD patients. Second, we investigate whether CTE in SUD patients is associated with a higher severity of ADHD symptoms and whether CTE in SUD patients affects the persistence of ADHD from childhood to adulthood.
Materials and methods
The data in the present study was collected between 2009 and 2011 as part of the International ADHD in Substance Abuse Prevalence (IASP) study (van de Glind et al., 2013) consisting of two phases: a screening phase and a full assessment phase. IASP is an international multi-center study in treatment seeking SUD patients from 10 countries. Patients form Australia, Belgium, France, Hungary, Netherlands, Norway, Spain, Sweden, Switzerland and the United States) participated in the screening phase
Prevalence of CTE
The prevalence rates for the different types of CTE in the total sample were: sexual abuse 13.2%, physical abuse 28.6%, emotional abuse 38.3%, violence in the family 27.7%, and neglect (emotional or physical) 22.4%. Among the CTE types, only ‘neglect’ was significantly associated with the primary substance of abuse: more drug than alcohol use disorder patients reported neglect (26.4% and 19.3% respectively; p = 0.004).
Of the total sample 649 (53.6%) reported at least one CTE. Table 1 presents
Discussion
The findings from this international multi-center study show a high frequency of childhood trauma (53.6%) in treatment seeking SUD patients consistent with earlier findings in SUD populations (Huang et al., 2012, Oviedo-Joekes et al., 2011). SUD patients with childhood trauma show increased rates (19.5%) of ADHD compared to those without trauma (8.5%); this was true for majority of single type (emotional and sexual abuse, violence in the family and neglect) and multiple types of trauma. This
Conclusions
To conclude, this combination of findings suggest that the increased rate of adult ADHD in SUD patients with childhood trauma is not the consequence of a negative effect of CTE on the persistence of childhood ADHD into adulthood, but a direct expression of the high rate of childhood ADHD in SUD patients with CTE. The high prevalence of childhood maltreatment in treatment seeking substance users with ADHD calls for early interventions in children and adolescents with ADHD. Also, in adult
Role of funding sources
In the period of development of the study, the ICASA network received unrestricted grants from the following pharmaceutical companies: Janssen Cilag, Eli Lilly & Company and Shire. Since becoming a formal foundation (September 2010), the ICASA network has operated independently from pharmaceutical funding, obtaining funding via the following sources. Participating institutes: the Noaber Foundation, the Waterloo Foundation and the Augeo Foundation. The local institutes report the following
Author contributions
MK was involved in the project coordination, data collection, management and analyses, and wrote the final version of the manuscript.
AF analyzed the data and wrote the first draft of the manuscript together with MK.
GvdG, wrote the proposal, coordinated the IASP study, was involved in the data management and data analyses, KvE-vO, AS, JF, E-TB, FM, ZD, CB, MF, JAR-Q, SVF, SA, SK, GD, coordinated the local data collection, KvE-vO, SV, MF, SC, BJ, AS, MK, SK, SV, IASP research group collected data
Author disclosure
G. van de Glind was free consultant for Shire at one occasion. 2013 he received an unrestricted travel grant from Neurotech and he is a member (unpaid) of the advisory board of Neurotech. In 2011 P.-J. Carpentier received a fee for speaking at a conference organized by Eli Lilly. F.R. Levin reports study medication provided by US World Meds and is a consultant to GW Pharmaceuticals. The ICASA Foundation has reimbursed her for air fare and hotel to attend the Annual Meeting as a speaker. S. Kaye
Acknowledgements
The following people participated in this study: Atul Beniwal, Geert Bosma, Joanne Cassar, Therese Dahl, Constanza Daigre, Romain Debrabant, Louisa Degenhardt, Rutger-Jan. van der Gaag, David Hay, Kari Lossius, Eva Karin Løvaas, Marion Malivert, Merete Möller, Carlos Roncero, Laura Stevens, Sara Wallhed, Anneke van Wamel and JesseYoung. The authors would like to thank all patients who participated in the IASP study.
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