ABSTRACT
Childhood attention deficit hyperactivity disorder (ADHD) is a risk factor for substance misuse and substance use disorder (SUD) in adolescence and (early) adulthood. ADHD and SUD also frequently co-occur in treatment-seeking adolescents, which complicates diagnosis and treatment and is associated with poor treatment outcomes. Research on the effect of treatment of childhood ADHD on the prevention of adolescent SUD is inconclusive, and studies on the diagnosis and treatment of adolescents with ADHD and SUD are scarce. Thus, the available evidence is generally not sufficient to justify robust treatment recommendations.
The aim of the study was to obtain a consensus statement based on a combination of scientific data and clinical experience. To reach a consensus based on the combination of scientific data and clinical experience, a modified Delphi study was conducted with a multidisciplinary group of 55 experts from 17 countries. The experts were asked to rate a set of statements on the effect of treatment of childhood ADHD on adolescent SUD and on the screening, diagnosis, and treatment of adolescents with comorbid ADHD and SUD. After 3 iterative rounds of rating and adapting 37 statements, consensus was reached on 36 of these statements representing 6 domains: general (n=4), risk of developing SUD (n=3), screening and diagnosis (n=7), psychosocial treatment (n=5), pharmacological treatment (n=11), and complementary treatments (n=7). Routine screening is recommended for ADHD in adolescent patients in substance abuse treatment and for SUD in adolescent patients with ADHD in mental healthcare settings. Long-acting stimülants are recommended as the first-line treatment of ADHD in adolescents with concurrent ADHD and SUD, and pharmacotherapy should preferably be embedded in psychosocial treatment. The only remaining noconsensus statement concerned the requirement of abstinence before starting pharmacological treatment in adolescents with ADHD and concurrent SUD. In contrast to the majority, some experts required full abstinence before starting any pharmacological treatment, some were against the use of stimülants in the treatment of these patients (independent of abstinence), while some were against the alternative use of bupropion. This international consensus statement can be used by clinicians and patients together in a shared decision-making process to select the best interventions and to reach optimal outcomes in adolescent patients with concurrent ADHD and SUD.
References
1
van Emmerik-van Oortmerssen K, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, Schoevers RA. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug Alcohol Depend. 2012;12:11-9.
2
Wilens TE, Morrison NR. Substance-use disorders in adolescents and adults with ADHD: focus on treatment. Neuropsychiatry (London). 2012;2:301-12.
3
Groenman AP, Oosterlaan J, Rommelse N, Franke B, Roeyers H, Oades RD, Sergeant JA, Buitelaar JK, Faraone SV. Substance use disorders in adolescents with attention deficit hyperactivity disorder: a 4-year follow-up study. Addiction. 2013;108:1503-11.
4
Groenman AP, Janssen TWP, Oosterlaan J. Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2017;56:556-69.
5
Groenman AP, Schweren LJS, Weeda W, Luman M, Noordermeer SDS, Heslenfeld DJ, Franke B, Faraone SV, Rommelse N, Hartman CA, Hoekstra PJ, Buitelaar J, Oosterlaan J. Stimülant treatment profiles predicting co-occurring substance use disorders in individuals with attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry. 2019;28:1213-22.
6
Quinn PD, Chang Z, Hur K, Gibbons RD, Lahey BB, Rickert ME, Sjölander A, Lichtenstein P, Larsson H, D'Onofrio BM. ADHD Medication and Substance-Related Problems. Am J Psychiatry. 2017;174:877-85.
7
Humphreys KL, Eng T, Lee SS. Stimülant medication and substance use outcomes: a meta-analysis. JAMA Psychiatry. 2013;70:740-9.
8
Molina BS, Hinshaw SP, Eugene Arnold L, Swanson JM, Pelham WE, Hechtman L, Hoza B, Epstein JN, Wigal T, Abikoff HB, Greenhill LL, Jensen PS, Wells KC, Vitiello B, Gibbons RD, Howard A, Houck PR, Hur K, Lu B, Marcus S; MTA Cooperative Group. Adolescent substance use in the multimodal treatment study of attention-deficit/hyperactivity disorder (ADHD) (MTA) as a function of childhood ADHD, random assignment to childhood treatments, and subsequent medication. J Am Acad Child Adolesc Psychiatry. 2013;52:250-63.
9
Landelijke Stuurgroep Multidisciplinaire richtlijnontwikkeling in de GGZ. Multidisciplinaire Richtlijn ADHD bij Kinderen en Jeugdigen. Utrecht: Trimbos-Instituut; 2005.
10
The Royal Australasian College of Physicians (RACP). Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder (ADHD). 2009. Available from: https://www.racp.edu.au/docs/default-source/advocacylibrary/pa-australian-guidelines-on-adhddraft.
11
Scottish Intercollegiate Guidelines Network. Edinburgh: Scottish Intercollegiate Guidelines Network (SIGN); Management of attention deficit and hyperkinetic disorders in children and young people: a national clinical guideline [Internet]; 2009. Available from: http://www.sign.ac.uk/.
12
Association of the Scientific Medical Societies in Germany (AWMF) online. Interdisciplinary Evidence- and Consensus-Based Guideline “Attention Deficit/Hyperactivity Disorder in Children, Young People and Adults”. [in German]; 2018. https://www.awmf.org/uploads/tx_szleitlinien/028- 045l_S3_ADHS_2018-06.pdf.
13
Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practice guidelines. 4th ed. Toronto: ON: CADDRA; 2018.
14
Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128:1007-22.
15
National Institute for Health Care Excellence (NICE). Attention defificit hyperactivity disorder: diagnosis and management. NG87; March 2018. Available from: www.nice.org.uk/guidance/ng87.
16
Chan E, Fogler JM, Hammerness PG. Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review. JAMA. 2016;315:1997-2008.
17
Sibley MH, Kuriyan AB, Evans SW, Waxmonsky JG, Smith BH. Pharmacological and psychosocial treatments for adolescents with ADHD: an updated systematic review of the literature. Clin Psychol Rev. 2014;34:218-32.
18
Knight JR, Sherritt L, Harris SK, Gates EC, Chang G. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27:67-73.
19
Babor TF, Robaina K. The alcohol use disorders identification test (AUDIT): a review of graded severity algorithms and national adaptations. Int J Alcohol Drug Res. 2016;5:17-24.
20
DuPaul GJ, Reid R, Anastopoulos AD, Lambert MC, Watkins MW, Power TJ. Parent and teacher ratings of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data. Psychol Assess. 2016;28:214-25.
21
Ustun B, Adler LA, Rudin C, Faraone SV, Spencer TJ, Berglund P, Gruber MJ, Kessler RC. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry. 2017;74:520-7.
22
Evans SW, Serpell ZN, Schultz BK, Pastor DA. Cumulative benefits of secondary schoolbased treatment of students with attention deficit hyperactivity disorder. School Psych Rev. 2007;36:256-73.
23
Evans SW, Langberg JM, Schultz BK, Vaughn A, Altaye M, Marshall SA, Zoromski AK. Evaluation of a school-based treatment program for young adolescents with ADHD. J Consult Clin Psychol. 2016;84:15-30.
24
Langberg JM, Epstein JN, Becker SP, Girio-Herrera E, Vaughn AJ. Evaluation of the Homework, Organization, and Planning Skills (HOPS) Intervention for Middle School Students with ADHD as Implemented by School Mental Health Providers. School Psych Rev. 2012;41:342-64.
25
Schramm SA, Hennig T, Linderkamp F. Training problem solving and organizational skills in adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial. J Cogn Educ Psychol. 2016;15:391-411.
26
Steeger CM, Gondoli DM, Gibson BS, Morrissey RA. Combined cognitive and parent training interventions for adolescents with ADHD and their mothers: A randomized controlled trial. Child Neuropsychol. 2016;22:394-419.
27
Barkley RA, Edwards G, Laneri M, Fletcher K, Metevia L. The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. J Consult Clin Psychol. 2001;69:926-41.
28
Boyer BE, Geurts HM, Prins PJ, Van der Oord S. Two novel CBTs for adolescents with ADHD: the value of planning skills. Eur Child Adolesc Psychiatry. 2015;24:1075-90.
29
Sibley MH, Graziano PA, Kuriyan AB, Coxe S, Pelham WE, Rodriguez L, Sanchez F, Derefinko K, Helseth S, Ward A. Parent-teen behavior therapy + motivational interviewing for adolescents with ADHD. J Consult Clin Psychol. 2016;84:699-712.
30
Sibley MH, Rodriguez L, Coxe S, Page T, Espinal K. Parent-Teen Group versus Dyadic Treatment for Adolescent ADHD: What Works for Whom? J Clin Child Adolesc Psychol. 2020;49:476-92.
31
Sprich SE, Safren SA, Finkelstein D, Remmert JE, Hammerness P. A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents. J Child Psychol Psychiatry. 2016;57:1218-26.
32
Vidal R, Castells J, Richarte V, Palomar G, García M, Nicolau R, Lazaro L, Casas M, Ramos-Quiroga JA. Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2015;54:275-82.
33
van Emmerik-van Oortmerssen K, Vedel E, Kramer FJ, Blankers M, Dekker JJM, van den Brink W, Schoevers RA. Integrated cognitive behavioral therapy for ADHD in adult substance use disorder patients: Results of a randomized clinical trial. Drug Alcohol Depend. 2019;197:28-36.
34
Gray SA, Chaban P, Martinussen R, Goldberg R, Gotlieb H, Kronitz R, Hockenberry M, Tannock R. Effects of a computerized working memory training program on working memory, attention, and academics in adolescents with severe LD and comorbid ADHD: a randomized controlled trial. J Child Psychol Psychiatry. 2012;53:1277-84.
35
Bink M, Bongers IL, Popma A, Janssen TW, van Nieuwenhuizen C. 1-year follow-up of neurofeedback treatment in adolescents with attention-deficit hyperactivity disorder: randomised controlled trial. BJPsych Open. 2016;2:107-15.
36
Matsudaira T, Gow RV, Kelly J, Murphy C, Potts L, Sumich A, Ghebremeskel K, Crawford MA, Taylor E. Biochemical and Psychological Effects of Omega-3/6 Supplements in Male Adolescents with Attention-Deficit/Hyperactivity Disorder: A Randomized, Placebo-Controlled, Clinical Trial. J Child Adolesc Psychopharmacol. 2015;25:775-82.
37
Ahmed GM, Mohamed S. Effect of regular aerobic exercises on behavioral, cognitive, and psychological response in patients with attention deficit-hyperactivity disorder. Life Sci J. 2011;8:366-71.
38
Cunill R, Castells X, Tobias A, Capellà D. Pharmacological treatment of attention deficit hyperactivity disorder with co-morbid drug dependence. J Psychopharmacol. 2015;29:15-23.
39
Carpentier PJ, Levin FR. Pharmacological Treatment of ADHD in Addicted Patients: What Does the Literature Tell Us? Harv Rev Psychiatry. 2017;25:50-64.
40
Riggs PD, Winhusen T, Davies RD, Leimberger JD, Mikulich-Gilbertson S, Klein C, Macdonald M, Lohman M, Bailey GL, Haynes L, Jaffee WB, Haminton N, Hodgkins C, Whitmore E, Trello-Rishel K, Tamm L, Acosta MC, Royer-Malvestuto C, Subramaniam G, Fishman M, Holmes BW, Kaye ME, Vargo MA, Woody GE, Nunes EV, Liu D. Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attention-deficit/hyperactivity disorder and substance use disorders. J Am Acad Child Adolesc Psychiatry. 2011;50:903-14.
41
Szobot CM, Rohde LA, Katz B, Ruaro P, Schaefer T, Walcher M, Bukstein O, Pechansky F. A randomized crossover clinical study showing that methylphenidate-SODAS improves attention-deficit/hyperactivity disorder symptoms in adolescents with substance use disorder. Braz J Med Biol Res. 2008;41:250-7.
42
Riggs PD, Hall SK, Mikulich-Gilbertson SK, Lohman M, Kayser A. A randomized controlled trial of pemoline for attention-deficit/hyperactivity disorder in substance-abusing adolescents. J Am Acad Child Adolesc Psychiatry. 2004;43:420-9.
43
Thurstone C, Riggs PD, Salomonsen-Sautel S, Mikulich-Gilbertson SK. Randomized, controlled trial of atomoxetine for attention-deficit/hyperactivity disorder in adolescents with substance use disorder. J Am Acad Child Adolesc Psychiatry. 2010;49:573-82.
44
Findling RL, Turnbow J, Burnside J, Melmed R, Civil R, Li Y. A randomized, double-blind, multicenter, parallel-group, placebo-controlled, dose-optimization study of the methylphenidate transdermal system for the treatment of ADHD in adolescents. CNS Spectr. 2010;15:419-30.
45
Newcorn JH, Nagy P, Childress AC, Frick G, Yan B, Pliszka S. Randomized, Double-Blind, Placebo-Controlled Acute Comparator Trials of Lisdexamfetamine and Extended-Release Methylphenidate in Adolescents With Attention-Deficit/Hyperactivity Disorder. CNS Drugs. 2017;31:999-1014.
46
Pelham WE, Smith BH, Evans SW, Bukstein O, Gnagy EM, Greiner AR, Sibley MH. The Effectiveness of Short- and Long-Acting Stimülant Medications for Adolescents With ADHD in a Naturalistic Secondary School Setting. J Atten Disord. 2017;21:40-5.
47
Wilens TE, McBurnett K, Bukstein O, McGough J, Greenhill L, Lerner M, Stein MA, Conners CK, Duby J, Newcorn J, Bailey CE, Kratochvil CJ, Coury D, Casat C, Denisco MJ, Halstead P, Bloom L, Zimmerman BA, Gu J, Cooper KM, Lynch JM. Multisite controlled study of OROS methylphenidate in the treatment of adolescents with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2006;160:82-90.
48
Findling RL, Childress AC, Cutler AJ, Gasior M, Hamdani M, Ferreira-Cornwell MC, Squires L. Efficacy and safety of lisdexamfetamine dimesylate in adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2011;50:395-405.
49
Spencer TJ, Wilens TE, Biederman J, Weisler RH, Read SC, Pratt R. Efficacy and safety of mixed amphetamine salts extended release (Adderall XR) in the management of attention-deficit/hyperactivity disorder in adolescent patients: a 4-week, randomized, double-blind, placebo-controlled, parallel-group study. Clin Ther. 2006;28:266-79.
50
Bostic JQ, Biederman J, Spencer TJ, Wilens TE, Prince JB, Monuteaux MC, Sienna M, Polisner DA, Hatch M. Pemoline treatment of adolescents with attention deficit hyperactivity disorder: a short-term controlled trial. J Child Adolesc Psychopharmacol. 2000;10:205-16.
51
Atomoxetine ADHD and Comorbid MDD Study Group, Bangs ME, Emslie GJ, Spencer TJ, Ramsey JL, Carlson C, Bartky EJ, Busner J, Duesenberg DA, Harshawat P, Kaplan SL, Quintana H, Allen AJ, Sumner CR. Efficacy and safety of atomoxetine in adolescents with attention-deficit/hyperactivity disorder and major depression. J Child Adolesc Psychopharmacol. 2007;17:407-20.
52
Biederman J, Melmed RD, Patel A, McBurnett K, Konow J, Lyne A, Scherer N; SPD503 Study Group. A randomized, double-blind, placebo-controlled study of guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics. 2008;121:e73-84.
53
Sallee FR, McGough J, Wigal T, Donahue J, Lyne A, Biederman J; SPD503 STUDY GROUP. Guanfacine extended release in children and adolescents with attention-deficit/hyperactivity disorder: a placebo-controlled trial. J Am Acad Child Adolesc Psychiatry. 2009;48:155-65.
54
Wilens TE, Robertson B, Sikirica V, Harper L, Young JL, Bloomfield R, Lyne A, Rynkowski G, Cutler AJ. A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2015;54:916-25.e2.
55
Childress A. The safety of extended-release drug formulations for the treatment of ADHD. Expert Opin Drug Saf. 2017;16:603-15.
56
Liang EF, Lim SZ, Tam WW, Ho CS, Zhang MW, McIntyre RS, Ho RC. The Effect of Methylphenidate and Atomoxetine on Heart Rate and Systolic Blood Pressure in Young People and Adults with Attention-Deficit Hyperactivity Disorder (ADHD): Systematic Review, Meta-Analysis, and Meta-Regression. Int J Environ Res Public Health. 2018;15:1789.
57
Cooper WO, Habel LA, Sox CM, Chan KA, Arbogast PG, Cheetham TC, Murray KT, Quinn VP, Stein CM, Callahan ST, Fireman BH, Fish FA, Kirshner HS, O'Duffy A, Connell FA, Ray WA. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011;365:1896-904.
58
Habel LA, Cooper WO, Sox CM, Chan KA, Fireman BH, Arbogast PG, Cheetham TC, Quinn VP, Dublin S, Boudreau DM, Andrade SE, Pawloski PA, Raebel MA, Smith DH, Achacoso N, Uratsu C, Go AS, Sidney S, Nguyen-Huynh MN, Ray WA, Selby JV. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA. 2011;306:2673-83.
59
Crunelle CL, van den Brink W, Moggi F, Konstenius M, Franck J, Levin FR, van de Glind G, Demetrovics Z, Coetzee C, Luderer M, Schellekens A; ICASA consensus group, Matthys F. International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder. Eur Addict Res. 2018;24:43-51.
60
Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:376-80.
61
Özgen H, Spijkerman R, Noack M, Holtmann M, Schellekens ASA, van de Glind G, Banaschewski T, Barta C, Begeman A, Casas M, Crunelle CL, Daigre Blanco C, Dalsgaard S, Demetrovics Z, den Boer J, Dom G, Eapen V, Faraone SV, Franck J, González RA, Grau-López L, Groenman AP, Hemphälä M, Icick R, Johnson B, Kaess M, Kapitány-Fövény M, Kasinathan JG, Kaye SS, Kiefer F, Konstenius M, Levin FR, Luderer M, Martinotti G, Matthys FIA, Meszaros G, Moggi F, Munasur-Naidoo AP, Post M, Rabinovitz S, Ramos-Quiroga JA, Sala R, Shafi A, Slobodin O, Staal WG, Thomasius R, Truter I, van Kernebeek MW, Velez-Pastrana MC, Vollstädt-Klein S, Vorspan F, Young JT, Yule A, van den Brink W, Hendriks V. International Consensus Statement for the Screening, Diagnosis, and Treatment of Adolescents with Concurrent Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder. Eur Addict Res. 2020;26:223-32.
62
Agabio R, Sinclair JM, Addolorato G, Aubin HJ, Beraha EM, Caputo F, Chick JD, de La Selle P, Franchitto N, Garbutt JC, Haber PS, Heydtmann M, Jaury P, Lingford-Hughes AR, Morley KC, Müller CA, Owens L, Pastor A, Paterson LM, Pélissier F, Rolland B, Stafford A, Thompson A, van den Brink W, de Beaurepaire R, Leggio L. Baclofen for the treatment of alcohol use disorder: the Cagliari Statement. Lancet Psychiatry. 2018;5:957-60.
63
van de Glind G, Brynte C, Skutle A, Kaye S, Konstenius M, Levin F, Mathys F, Demotrovics S, Moggi F, Ramos-Quiroga JA, Schellekens A, Crunelle C, Dom G, van den Brink W, Franck J. The international collaboration on ADHD and substance abuse (ICASA): mission, results, and future activities. Eur Addict Res. 2020;26:173-8.