Cognition and impulsivity in adults with attention deficit hyperactivity disorder with and without cocaine and/or crack dependence
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).
References (47)
- et al.
Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders
Addict. Behav.
(2008) - et al.
History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers
Compr. Psychiatry
(1993) - et al.
Impulsivity in adult ADHD patients with and without cocaine dependence
Drug Alcohol Depend.
(2013) - et al.
Neuropsychological performance deficits in adults with attention deficit/hyperactivity disorder
Arch. Clin. Neuropsychol.
(2001) - et al.
Schedule for Affective Disorders and Schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data
J. Am. Acad. Child Adolesc. Psychiatry
(1997) - et al.
Relationship between impulsivity and decision making in cocaine dependence
Psychiatry Res.
(2010) - et al.
Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review
Clin. Psychol. Rev.
(2011) - et al.
The impact of impulsivity on cocaine use and retention in treatment
J. Subst. Abuse Treat.
(2001) - et al.
Features and prevalence of patients with probable adult attention deficit hyperactivity disorder who request treatment for cocaine use disorders
Psychiatry Res.
(2011) - et al.
Implicit emotional biases in decisión making: the case of the Iowa Gambling task
Brain Cogn.
(2008)
Propensity for risk taking and trait impulsivity in the Iowa Gambling Task
Pers. Individ. Dif.
An examination of the impact of attention-deficit hyperactivity disorder on IQ: a large controlled family-based analysis
Can. J. Psychiatry
Impact of executive function deficits and attention-deficit/hyperactivity disorder (ADHD) on academic outcomes in children
J. Consult. Clin. Psychol.
Attention deficit/hyperactivity disorders with co-existing substance use disorder is characterized by early antisocial behaviour and poor cognitive skills
BMC Psychiatry
Decisions under ambiguity and decisions under risk: correlations with executive functions and comparisons of two different gambling tasks with implicit and explicit rules
J. Clin. Exp. Neuropsychol.
Children and young people’s mental health
Attention deficit hyperactivity disorder in cocaine-dependent adults: a psychiatric comorbidity analysis
Am. J. Addict
Impulsivity as a determinant and consequence of drug use: a review of underlying processes
Addict. Biol
Relations between Continuous Performance Test performance measures and ADHD behaviors
J. Abnorm. Child Psychol.
Attention Deficit Hyperactivity Disorder (ADHD) among longer-term prison inmates is a prevalent, persistent and disabling disorder
BMC Psychiatry
Validação da versão brasileira do teste de triagem do envolvimento com álcool, cigarro e outras substâncias (ASSIST) [Validation of the Brazilian version of Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)]
Rev. Assoc. Med. Bras.
Cited by (24)
ADHD and addictive behavior in crack-cocaine users
2023, EncephaleCitation Excerpt :Due to stringent inclusion criteria, the sample size of the present study was low. Other studies including exclusively crack users published thus far included also low sample sizes (< 100 patients) [10,13,45]. The prevalence of both C-ADHD and A-ADHD are high in crack users.
Association between adult ADHD, self-report, and behavioral measures of impulsivity and treatment outcome in cocaine use disorder
2020, Journal of Substance Abuse TreatmentCitation Excerpt :Adult attention deficit and hyperactivity disorder (ADHD), in particular, frequently co-occurs among individuals with CUD with higher levels of impairment (Pérez de los Cobos et al., 2011). Cocaine users with ADHD represent a different subtype of cocaine users (Crunelle, Veltman, van Emmerik-van Oortmerssen, Booij, & van den Brink, 2013; Wunderli et al., 2016) and experience significant impairments in both cognitive and affective domains (Cunha et al., 2013; Miguel et al., 2016), have frequent psychiatric comorbidity, and a more severe course of illness (Arias et al., 2008; Fatséas et al., 2016; Lambert, 2005). For these reasons, several studies have tested whether specific treatments for ADHD can be useful to decrease cocaine use in patients with ADHD (Levin et al., 2009; Levin et al., 2015; Schubiner et al., 2002).
Motor dysfunction as research domain across bipolar, obsessive-compulsive and neurodevelopmental disorders
2018, Neuroscience and Biobehavioral ReviewsCitation Excerpt :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.
A systematic review of the utility of continuous performance tests among adults with ADHD
2024, Clinical Neuropsychologist