Comorbidity of Alcohol and Substance Dependence With Attention-Deficit/Hyperactivity Disorder (ADHD)

From Alcohol and Alcoholism

Comorbidity of Alcohol and Substance Dependence With Attention-Deficit/Hyperactivity Disorder (ADHD)

Medscape News

Martin D. Ohlmeier; Karsten Peters; Bert T. Te Wildt; Markus Zedler; Marc Ziegenbein; Birgitt Wiese; Hinderk M. Emrich; Udo Schneider

Posted: 06/23/2008; Alcohol and Alcoholism. 2008;43(3):300-304. © 2008
Oxford University Press

Abstract and Introduction


Aims: Attention-deficit/hyperactivity disorder (ADHD) is of great clinical importance not only because of its high prevalence but also due to the frequent comorbid illnesses that are connected with this disorder. Several studies were able to demonstrate that ADHD constitutes a significant risk factor for the exacerbation of habit-forming illnesses, i.e. addictions.

Methods: We conducted a study on 152 adult patients with alcohol dependence (n = 91) or multiple substance addiction (n = 61) to determine whether or not these patients were affected by ADHD. For retrospective assessment of childhood ADHD, the WURS-k was used as well as the DSM-IV symptom checklist for ADHD. The CAARS was used to assess the persisting symptoms of ADHD in adults.

Results: 20.9% (WURS-k) or 23.1% (DSM-IV diagnostic criteria) of the alcohol-dependent patients showed evidence of retrospective ADHD affliction in childhood. With the help of CAARS, ADHD was proved to be persistent in 33.3% of the adult patients. In the group of substance-addicted patients 50.8% (WURS-k) and 54.1% (DSM-IV) presented with diagnostic criteria for ADHD in childhood and 65.5% (CAARS) showed evidence of ADHD persisting in adulthood.

Conclusions: These results reveal that habit-forming illnesses can be associated with a high comorbidity with ADHD, expressed in the form of alcohol abuse and also in consumption of illegal drugs. The results underline the great importance of early and adequate diagnostics and therapy of ADHD for the prevention of habit-forming illnesses.


Attention-deficit/hyperactivity disorder (ADHD) is one of the most frequent afflictions 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 (Barkley, 1997). Wender (1995) describes a prevalence of ADHD in adulthood of 2%-6%. In a recent epidemiological study conducted in 2006, Kessler et al. found a prevalence of 4.4% among adults in the USA. The focal symptoms of this affliction include attention deficit, increased impulsiveness, hyperactivity, disorganization, and emotional instability stemming from childhood days (American Psychiatric Association, 1994).

Several studies have already demonstrated that ADHD, which nowadays is a term understood as a genetically determined dysfunction of the dopamine and noradrenergic catecholamine system (Ernst et al., 1998; Faraone et al., 1998; Dougherty et al., 1999; Dresel et al., 1999; Krause et al., 2003), indeed represents a risk factor for the exacerbation of addictive illnesses. Wilens et al. (1997, 2004) and other authors (Goodwin et al., 1975; Tarter et al., 1977) found a comorbidity of ADHD and alcoholism or substance abuse in 35%-70%.

Patients with ADHD and drug addiction showed a tendency to commence early and to experiment more freely with substance abuse than those addicted patients without ADHD (Caroll and Rounsaville, 1993; Levin FR and Kleber, 1995; Wilens et al., 1997; Biederman et al., 1998). In a study conducted by Wilens et al. (1997), the average age of ADHD patients at onset of substance abuse was found to be 19 years, whereas the addictive illness did not start on average until the age of 22 years in a control group of addictive patients without ADHD.

Other research groups have described a doubled lifetime risk of addictive illness for ADHD patients and concluded that ADHD in combination with a comorbid disorder (depression, anxiety disorder, etc.) additionally increases the risk of developing an addiction (Biederman et al., 1995; Disney et al., 1999). In this connection, it has also been reported that a personality disorder can be diagnosed in up to 71% of those with a comorbidity of ADHD and addictive illness (Schubiner et al., 2000).

A high incidence of alcohol abuse in ADHD patients was found in several studies. For example, Biederman et al. (1998) described a markedly higher incidence of alcohol abuse or dependence among 239 adults with ADHD, at 44%, compared to a control population of 268 persons, 24% of whom were affected. In their investigation on 78 adult ADHD patients, Downey et al. (1997) determined an incidence of 33.3% for alcohol abuse or dependence. Rasmussen and Gilberg (2000) found an increased incidence of alcohol abuse in a controlled longitudinal study on 55 22-year-old patients, in whom ADHD had been diagnosed at the age of seven years and who had never received drug treatment, compared with 46 control subjects. Krause et al. (2002a) investigated 153 adult patients with alcohol dependence and found evidence of ADHD in childhood in 65 of them, 28 also showing persistent symptoms in adulthood.

With regard to cocaine dependence, it was shown that there is a prevalence of 35% in ADHD in combination with addictive illnesses and that the cocaine consumption is much more prominent and commences earlier in this patient group than in cocaine addicts without ADHD (Caroll and Rounsaville, 1993). Also, in studies conducted by Volkow et al. (2003), it was shown that there is more cocaine abuse in ADHD patients and that those affected report a marked reduction in symptoms after taking cocaine.

The risk of nicotine dependence also appears to be higher in ADHD patients. The coincidence of nicotine dependence in adults with ADHD is reported as 40%-75% (Pomerleau et al., 1995). In our own investigations, we were also able to demonstrate a markedly higher percentage of severe nicotine dependence in alcohol-dependent patients with comorbid ADHD than in patients without the additional diagnosis of ADHD (Ohlmeier et al., 2007).

The studies available at present clearly show a connection between ADHD and addictive illnesses, which leads to the supposition that a high percentage of alcoholics and drug addicts are also suffering from a — possibly as yet undiagnosed — ADHD. The aim of this study was to examine retrospectively how many patients with alcohol and multiple substance dependence had in fact suffered ADHD in childhood and whether or not these symptoms persisted into adulthood. Furthermore, the question was raised as to the possible effects of ADHD with regard to commencement, type, and severity of addiction.

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