Elsevier

Drug and Alcohol Dependence

Volume 160, 1 March 2016, Pages 97-104
Drug and Alcohol Dependence

Cognition and impulsivity in adults with attention deficit hyperactivity disorder with and without cocaine and/or crack dependence

https://doi.org/10.1016/j.drugalcdep.2015.12.040Get rights and content

Highlights

  • We compared ADHD + cocaine dependence and ADHD controls with a neurocognitive battery.

  • ADHD controls: slower responses, deficits in visual search and psychomotor speed.

  • ADHD + cocaine group: deficits in vigilance, in implicit learning in decision making.

  • ADHD + cocaine group: lower IQ, verbal inability and higher motor impulsivity.

  • Discussion of differences according to the integrative model from Nigg, Casey (2005).

Abstract

Background

Substance use disorder (SUD) is a common comorbidity in adults with attention deficit-hyperactivity disorder (ADHD). However,there have been few studies on cognitive profiles of these patients. Impulsivity is also commonly increased in both disorders. The central aim of this study was to compare cognition and impulsivity in subjects who had ADHD and cocaine dependence (ADHD + COC group) to those with ADHD only (ADHD-noSUD group). We hypothesized that the ADHD + COC group would show more marked cognitive dysfunction and greater impulsivity than their counterparts with ADHD only.

Methods

A total of 70 adult patients diagnosed with ADHD according to (DSM-IV-TR) criteria were enrolled; 36 with ADHD + COC and 34 with ADHD-noSUD. All study participants were evaluated with a sociodemographic questionnaire; the Mini International Neuropsychiatric Interview; the Adult ADHD Self-Report Scale; the Addiction Severity Index; the Alcohol, Smoking and Substance Involvement Screening Test; the Barratt Impulsiveness Scale; and a comprehensive neurocognitive battery.

Results

Compared to individuals with ADHD-noSUD, ADHD + COC individuals had significantly lower mean IQ and higher motor impulsivity. On average, the ADHD + COC group also performed more poorly on tasks assessing verbal skills, vigilance, implicit learning during decision making, and ADHD-noSUD performed more poorly on selective attention, information processing, and visual search.

Conclusions

Our results support the integrative theory of ADHD based on the cognitive and affective neuroscience model, and suggests that ADHD-noSUD patients have impairments in cognitive regulation, while ADHD + COC patients have impairments in both cognitive and affective regulation.

Introduction

Attention deficit-hyperactivity disorder (ADHD) and substance use disorder (SUD) are common and often coexist in adults. The risk of developing cocaine (COC) abuse is two times higher in individuals with (vs. without) ADHD (Lee et al., 2011). The prevalence of ADHD is high among patients with COC dependence, reaching 23.1% (Van-Emmerick-Van Oortmerssen, 2012). Two recent studies of adults with COC dependence demonstrated considerable frequencies of comorbid ADHD: 20.5% (Pérez de los Cobos et al., 2011) and 25.0% (Daigre et al., 2013). Compared to their counterparts without ADHD, COC-dependent adults with ADHD are more severe in different aspects of the disorder: they initiated drug use at a younger age, were younger at first hospitalization, used COC more frequently or intensely, and were more likely to abandon treatments (Carroll and Rounsaville, 1993, Arias et al., 2008, Pérez de los Cobos et al., 2011).

Both patients with ADHD or SUD show deficits in executive function and high impulsivity and preference for immediate (versus delayed) rewards can promote drug addiction among individuals with ADHD (de Wit, 2009).

Studies of patients with both ADHD and SUD demonstrated cognitive impairments compared to those with ADHD alone or healthy controls. These include lower intelligence-quotient (IQ) scores, fewer years of education, as well as more marked deficits in working memory, verbal comprehension, perceptual organization, processing speed, and attention (Ginsberg et al., 2010, Bihlar Muld et al., 2013). On the other hand, COC-dependent patients with ADHD did not show differences in interference control (Stroop Test), time reproduction (visual time reproduction paradigm), attentional set-shifting (Trail Making Tasks A and B) and working memory (n-back Task) compared to their counterparts with ADHD only or healthy controls. Nevertheless, they had higher motor impulsivity with lower response inhibition (Stop Signal Task) and cognitive impulsivity (Delayed Discounting Test; Crunelle et al., 2013). Using the Barratt Impulsiveness Scale (BIS-11) Crunelle et al. (2013) also demonstrated higher attention impulsivity in the COC-dependent patients with ADHD compared to ADHD-only and healthy-control groups. Pérez de los Cobos et al. (2011), who compared patients with probable adult ADHD and concomitant COC dependence with COC dependence patients, reported that the former group had higher scores in the BIS-11 than the latter.

Two other studies investigated the impact of ADHD in COC use or dependence. Vonmoos et al. (2013), using a neuropsychological battery, observed that the presence of ADHD as a comorbidity either to recreational cocaine users or to dependent cocaine users worsened the scores of a global cognitive index in comparison to their counterparts without ADHD. Vergara-Moragues et al. (2011) used Barkley’s Current Behavior Scale Self-Report to measure executive function in patients with COC dependence and ADHD, compared to COC dependence without ADHD.

The neuropsychological model proposed by Nigg and Casey (2005), considers that children with the ADHD-combined subtype have deficits in cognitive and affective control. This model posited that they have impairments in cognition related to executive control, in tasks that require prolonged effort and concentration. Such disruptions could weaken self-control (i.e., impaired cognitive regulation). In fact, a study showed that patients with ADHD or with SUD had deficits in executive function (Martínez-Raga and Knecht, 2012).

Nigg and Casey (2005) also suggested, however, that impairments in affective regulation, reward expectation, and delay aversion are observed in children with ADHD. These disruptions could lead to enhanced impulsivity and more marked emotional dysregulation (i.e., impaired affective regulation) in ADHD (Martel et al., 2009).

Although Nigg and Casey (2005) proposed their model in the context of childhood development, it seems to accommodate observations on adults with ADHD as well as SUD. One study has evaluated deficits in cognition and impulsivity in patients with both ADHD and COC dependence; but the study involved relatively small patient sample of ADHD and COC dependence (n = 11; Crunelle et al., 2013).

In order to address this knowledge gap, we undertook the present study to evaluate potential differences in executive function, verbal memory, and impulsivity between adults with ADHD and COC dependence (i.e., ADHD + COC group) or ADHD without substance use disorder (i.e., ADHD-noSUD group). We hypothesized that cognitive and emotional profiles would differ between the two groups, with the ADHD-noSUD group showing marked impairments in cognitive control and the ADHD + COC group exhibiting greater deficits in cognitive as well as emotional and motivational control.

Section snippets

Participants

From May, 2010 through October, 2012, we included 70 patients with ADHD according to criteria from the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (Text Revision; DSM-IV-TR; American Psychiatric Association (APA), 2000). Cocaine-dependent patients with ADHD (designated the ADHD + COC group) were recruited from among those under treatment at a therapeutic community (Associação para Promoção da Oração e do Trabalho − APOT [Association for Promotion of Prayer and Work]) in

Participants

Of 242 individuals screened, 70 subjects were included in the study: 36 in the ADHD + COC group and 34 in the ADHD-noSUD group (Fig. 1).

Sociodemographic characteristics

More than 70% of patients in each group were men. There were no statistically significant between-group differences in gender, age, or race. All subjects in the ADHD-noSUD group had ≥8 years of education, compared to 75% of those in the ADHD + COC group. A significantly higher proportion of subjects in the ADHD + COC group were married, whereas educational attainment

Discussion

These findings support our hypothesis that there are significant differences in executive function and impulsivity between patients with ADHD + COC compared to the ADHD-noSUD patients. Subjects in our ADHD + COC group had significantly lower verbal IQ, verbal skills, vigilance, and poorer implicit learning in an affective decision making task, as well as greater motor impulsivity as measured by both neuropsychological tasks and the BIS-11. On the other hand, subjects in our ADHD-noSUD group showed

Role of funding sources

This study was funded by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP, Grant no. 2009/15106-3) and the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, no. 161097/2011-1), Brazil.

Conflict of interest

No competing interests.

Contributors

C.S. Miguel designed the study, collected the data, interpreted the results, and wrote the first draft, M. R. Louzã contributed to designing the study, collected the data, analyzed the data, and participated in writing the manuscript. P. A. Martins, N. Moleda, M. Klein, M. A. Gobbo, T. Chaim-Avancini, T. M. Alves, and M. A. Silva collected the data. All authors contributed to and approved the final manuscript.

Acknowledgements

We thank the patients for participating in the present study and for sharing their time and experience. We also thank the Association for the Promotion of Prayer and Work (Associação para Promoção da Oração e do Trabalho—APOT), Detoxification Unit of Taipas General Hospital and Interdisciplinary Group for Alcohol and Drug Studies Clinic for collaboration. Editorial assistance in manuscript preparation was provided by Stephen W. Gutkin, (Rete Biomedical Communications Corp., Wyckoff, NJ, USA).

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      The individual GMA categories and their prevalences are listed in Table 1. We identified 55 studies on GMA, motor impulsivity and inhibitory control in BD (Bas et al., 2015; Chrobak et al., 2016; Goswami et al., 1998, 2007; Goswami et al., 2006; Minichino et al., 2015; Mrad et al., 2016; Negash et al., 2004; Owoeye et al., 2013; Rigucci et al., 2014; Sagheer et al., 2018; Sharma et al., 2016; Udal et al., 2009; Whitty et al., 2006; Zhao et al., 2013b; Mukherjee et al., 1984; Scappa et al., 1993; Mazzarini et al., 2010; Medda et al., 2015a; Nivoli et al., 2014; Fein and McGrath, 1990; Perugi et al., 2017; Gupta et al., 2007; Lage et al., 2013; Bauer et al., 2017; Fleck et al., 2011; Fortgang et al., 2016; Gilbert et al., 2011; Henry et al., 2013; Hidiroglu et al., 2013; Izci et al., 2016; Karakus and Tamam, 2011; Leibenluft et al., 2007; Lijffijt et al., 2015; Lombardo et al., 2012; Mahon et al., 2012; Mathias de Almeida et al., 2013; Matsuo et al., 2009, 2010; Nandagopal et al., 2011; Nery et al., 2013; Passarotti et al., 2010; Ponsoni et al., 2018; Rote et al., 2018; Saunders et al., 2016; Swann et al., 2008; Fears et al., 2015; Ramirez-Bermudez et al., 2016; Ajilore et al., 2015; Altshuler et al., 2005; Diler et al., 2014; Elvsashagen et al., 2013; Poldrack et al., 2016; Singh et al., 2010; Strakowski et al., 2008), 45 studies on GMA in OCD (Anderson and Savage, 2004; Aylward et al., 1996; Bolton et al., 1998, 2000; Caramelli et al., 1996; Dhuri and Parkar, 2016; Focseneanu et al., 2015; Guz and Aygun, 2004; Hollander et al., 2005, 1990; Karadag et al., 2011; Malhotra et al., 2017; Mataix-Cols et al., 2003; Mergl and Hegerl, 2005; Nickoloff et al., 1991; Ozcan et al., 2016; Peng et al., 2012; Poyurovsky et al., 2007; Sevincok et al., 2006, 2004; Stein et al., 1997, 1993; Stein et al., 1994; Tapanci et al., 2018; Thienemann and Koran, 1995; Towey et al., 1993; Tripathi et al., 2015; Tumkaya et al., 2012; Kruger et al., 2000; Lim, 2006; Benatti et al., 2014; Bersani et al., 2013; Blaszczynski, 1999; Chamberlain et al., 2006, 2007; Melca et al., 2015; Mersin Kilic et al., 2016; Voon et al., 2017; Blum et al., 2018; Carlisi et al., 2017; Heinzel et al., 2018; Menzies et al., 2007; Bari and Robbins, 2013a; de Wit et al., 2012; Fan et al., 2017), 23 studies on GMA, motor impulsivity and inhibitory control in ASD (Hirjak et al., 2014, 2016b; Mayoral et al., 2010; Tani et al., 2006; Breen and Hare, 2017; Ohta et al., 2006; Stoppelbein et al., 2005; Wing and Shah, 2006; Floris et al., 2016; Travers et al., 2015b, 2013; Gulsrud et al., 2018; Papadopoulos et al., 2013; Morrison et al., 2018; De Jong et al., 2011; Brasic et al., 2000; Fink et al., 2006; Halayem et al., 2009; Carlisi et al., 2017; Daly et al., 2014; Karten and Hirsch, 2015; Duerden et al., 2013; Kenet et al., 2012), 85 studies on GMA, motor impulsivity and inhibitory control in ADHD (Abdel Aziza et al., 2016; Bari and Robbins, 2013b; Brossard-Racine et al., 2012; Cardo et al., 2008; Cavanna et al., 2008a; Chan et al., 2010; Chiang et al., 2017; Crosbie and Schachar, 2001; Cubillo et al., 2010; Curatolo et al., 2010; Czerniak et al., 2013; D’Agati et al., 2010; Depue et al., 2010; Di Tommaso, 2012; Dibbets et al., 2009; Dillo et al., 2010; Edebol et al., 2013; Fan et al., 2014; Feng et al., 2005; Ferrin and Vance, 2012; Fontenelle and Mendlowicz, 2008; Freeman and Tourette Syndrome International Database, 2007; Gong et al., 2015; Goulardins et al., 2017; Gustafsson et al., 2000; Hart et al., 2014; Hovik et al., 2017; Huisman-van Dijk et al., 2016; Janssen et al., 2015a; Kaneko et al., 2016; Klimkeit et al., 2005; Kofman et al., 2008; Krain and Castellanos, 2006; Lei et al., 2015; Liotti et al., 2005; Lipkin et al., 2003; Lisdahl et al., 2016; Liu et al., 2017; Lo-Castro et al., 2011; Mahajan et al., 2016; Mahone, 2012; Mahone et al., 2006; Makris et al., 2008; Mao et al., 2014; Mersin Kilic et al., 2016; Miguel et al., 2016; Morein-Zamir et al., 2014; Newman et al., 2016; Niedermeyer, 2001; Niedermeyer and Naidu, 1997; O’halloran et al., 2017; Pan et al., 2009; Papadopoulos et al., 2013; Passarotti et al., 2010; Patankar et al., 2012; Pitcher et al., 2002; Pitzianti et al., 2016b, a; Pitzianti et al., 2017; Poblano et al., 2014; Qiu et al., 2009; Rickson, 2006; Roessner et al., 2007; Rubia et al., 1999, 2005; Sagvolden et al., 2005; Schachar et al., 2005; Schneider et al., 2006; Shaw et al., 2011; Sheppard et al., 2000; Shilon et al., 2012; Slaats-Willemse et al., 2005; Smith et al., 2006; Stray et al., 2010; Suskauer et al., 2008a, b; Szekely et al., 2017; Tuisku et al., 2003; Udal et al., 2009; Uslu et al., 2007; van Rooij et al., 2015; Wodka et al., 2007; Wu et al., 2014b; Yurtbasi et al., 2018; Ziereis and Jansen, 2016) and 22 studies on GMA, motor impulsivity and inhibitory control in TS (Semerci, 2000; Cavanna et al., 2008b; Kerbeshian et al., 2009; Janik et al., 2007; Kompoliti and Goetz, 1998; Comings and Comings, 1987; Frank et al., 2011; Laverdure et al., 2013; Draper et al., 2015; Eddy et al., 2014; Eichele et al., 2010; Ganos et al., 2014; Heise et al., 2010; Hovik et al., 2017; Johannes et al., 2001, 2003; Jung et al., 2013; Mahone et al., 2018; Orth et al., 2005; Ozonoff et al., 1998; Wylie et al., 2013; Plessen et al., 2007). We acknowledge the possibility that we were not able to identify all relevant studies on GMA in BD, OCD, and ND because the information regarding GMA, motor impulsivity and inhibitory control in the abstract was missing.

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