ADD/ADHD relationship to drug and alcohol use

ADD/ADHD is a common and disabling disorder. It starts at birth, is usually a life-long disorder and occurs in 4% of the adult population. It is associated with drug and alcohol abuse, depression, anxiety disorders, and bipolar disorder. It has also been recently observed that about one third of the morbidly obese have ADD/ADHD. It is also associated with lower rates of educational attainment, lower income, more unemployment and higher rates of divorce/separation and arrests. It is highly heritable at about 75%. It is under-diagnosed and under-treated.

The diagnosis is based on the observation of the following characteristics: impulsivity (poor money management, interrupting others while talking, making inappropriate comments in social situations), easy distractibility (poor listening, forgetting instructions moments after they are given, poor driving), ability to focus only on subjects of high interest to the subject (uneven performance at school), poor organization (handing assignments in late, messy notebooks and desk, failure to pay bills on time, being late for or forgetting appointments, being late for work), and easily bored (change jobs frequently, seek out fast paced activities, risk taking behaviour). This is not an exhaustive list and each person does not necessarily have every one of these characteristics. Elementary school report cards will say things like not performing up to potential, needs to work more carefully, not handing assignments in on time, daydreaming, disruptive in class.

Cognitive testing can be very helpful although it is not the sole basis for the diagnosis. This can provide quantitative comparison to a control group matched for age and education. This is helpful because many of these symptoms are subjective and it is very difficult to assess them on interview. I frequently find that the results of specific testing are at odds with my clinical impression based only on what I have observed or been told.

In childhood the major problem is at school while in adulthood the major problem areas are employment and relationships. Partners get tired of unpaid bills, poor money management, unfinished projects, unreliability, procrastination, lying (usually in an attempt to avoid criticism and preserve self-esteem). Employers become aware of frequent mistakes, low productivity, late attendance, and the need for more supervision and repetition of instructions.

When looking at the families of patients with ADD/ADHD we observe the following:

  • There will be a much higher risk for ADD/ADHD in the relatives' parents, siblings, children
  • There will be more drug dependence (cannabis) in the relatives
  • In a group selected for drug dependence (cannabis) rather than ADD/ADHD, there will be more ADD/ADHD among the relatives
  • Alcohol dependence in relatives is predicted only by ADD/ADHD plus alcohol dependence in the patients
  • Alcohol dependence and drug dependence (cannabis) breed true in families without evidence of a common risk between these disorders.

The fact that alcohol dependence seems to be independently transmitted while cannabis dependence seems to be transmitted with the ADD/ADHD is a somewhat unexpected recent finding. Whether this will hold true for other types of drug dependence has yet to be determined.

 

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