Executive Functioning, Emotional Control and Functional Impairment in patients screened for Attention-Deficit/Hyperactivity Disorder (ADHD) among treatment-seeking adults with Substance Use Disorder (SUD) Anneke Meyer Corné Coetzee Ilse Truter Judith Regnart
Research Aims Research Aim: To establish whether treatment-seeking patients, screened positively for ADHD, differ from a group of patients without ADHD symptoms on the following aspects: Executive Functions (planning, inhibitory control, learn from past mistakes, mental flexibility). Emotional Control Functional Impairment (Family, Work/School, Life Style, Social Skills, Risk Taking).
PARTICIPATING TREATMENT CENTRES Centre N % Stabilis 77 31.6 SANCA Horizon 64 26.2 SANCA Daveyton 8 3.3 SANCA Castle Carey 43 17.6 Elim 18 7.4 Wedge Gardens 20 8.2 Dora Nginza 14 5.7 Total 244 100
INSTRUMENTS Adult ADHD Self-Report Scale (ASRS-v1.1) Expanded (WHO, 2003) 9 items on Inattention 9 items on Hyperactivity/Impulsiveness 10 items on Executive Functions 4 items on Emotional Control 2 items on DSM-5 Impulsiveness criteria Cronbach α for present sample.92 Weiss Functional Impairment Rating Scale Self-Report (WFIRS-S) (Weiss, 2000) Family Work/School Life Skills Self-Concept Social Risk taking Cronbach α for present sample.87
DIAGNOSTIC CRITERIA I N ATTENTION H YPERACTIVITY/IMPULSIVENESS 30 Inattention and Hyperactivity/Impulsiveness Scores F(2, 239)= 83.61, p = < 0.001, n p 2 = 0.41 No gender effect Vertical bars denote 0.95 confidence intervals 28 26 24 22 20 18 16 14 12 10 ADHD Males NonADHD ADHD Females NonADHD Inatt scale H/I scale
ADHD PREVALENCE 180 ADHD among treatment seeking patients (ARS-6) 160 64% 140 120 100 36% 80 60 40 20 0 ADHD NonADHD
MALE-FEMALE RATIO 140 120 Prevalence of ADHD Males 65% 30 28 26 Prevalence of ADHD Females 60% 24 100 22 80 35% 20 18 16 40% 60 14 12 40 10 8 20 6 4 2 0 ADHD NonADHD 0 ADHD NonADHD
EXECUTIVE FUNCTIONS ADHD is fundamentally a cognitive disorder, a developmental impairment of executive functions (EF), the controlling system of the brain EF are complex cognitive control processes, mainly supported by the prefrontal cortex which enable self-regulation and selfdirected behaviour toward a goal, modifying behaviour in the light of new information. They enable a person to: Make decisions and evaluate risks Plan for the future Prioritise and sequence actions Solve novel problems They guide thought and behaviour and allow purposive action toward a goal
Impaired decision making EF AND SUBSTANCE USE Reduced sensitivity to future outcomes Reduced ability to suppress responses Poor evaluation of consequences Patients with ADHD + SUD may demonstrate intelligence, learning and memory, language and attention in the normal range but may show considerable impairment in decision-making, judgement, self-insight and learning from past mistakes This has been associated with low treatment adherence, poor attendance at outpatient therapy sessions, low willingness to change, denial of abuse, and less abstinence following treatment termination
IMPORTANT BRAIN AREAS INVOLVED IN EF At least four different brain regions are affected in ADHD and may lead to altered functioning of the cortical-striatal-thalamic-cortical loop, impacting executive functioning (Stahl & Mignon, 2010) A dysfunctioning mesocortical dopamine branch may be responsible.
RESULTS EXECUTIVE FUNCTIONS 32 Results: Executive Functions F(1, 238) = 105.88, p < 0.001, n p 2 = 0.31 No gender effect Vertical bars denote 0.95 confidence intervals 30 28 26 EF score 24 22 20 18 16 14 12 ADHD NonADHD Male Female
EMOTIONAL CONTROL Emotional symptoms are common and persistent in youth and adults with ADHD Persons with ADHD are prone to rapid, unusually intense, and disproportionate emotional reactions Specific to ADHD: Emotional impulsiveness (EI) Deficient emotional self-regulation (DESR). Serious impact on patients with the disorder Impaired social living and adaptive skills Increased rates of treatment service utilisation
Emotional impulsiveness: Emotion generation that is highly impulsive, fast rising with unusually high reactivity. This leads to quicker-than-typical emotional responses to provoking stimuli. EMOTIONAL CONTROL Deficient emotional self-regulation: Occurs after emotion generation. It leads to slower than typical return of activated emotions to base line (Faraone et al., 2018)
BRAIN MECHANISMS INVOLVED IN EMOTIONAL CONTROL EI and DESR could be caused by deficits in the biological networks regulating emotions and the cognitive behavioural skills need to cope with such emotions. DA deficiency is involved.
RESULTS: EMOTIONAL CONTROL 15 Results: Emotional Control F(1, 238) = 22.43 p < 0.001, n p 2 = 0.09 Gender effect: p = 0.01 Vertical bars denote 0.95 confidence intervals 14 13 12 EC Score 11 10 9 8 7 6 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT Patients with ADHD present functional impairment Deficiencies in EF (planning, inhibition control, cognitive impulsiveness, working memory, insight, self-judgement) are linked to significant psychosocial impairment and lower levels of competence Emotional symptoms in ADHD causes lower quality of life, worse social adjustment, reduced marital status, unemployment, poor work performance and poor peer relations Functioning in ADHD is usually impaired in more than one area of functioning: Work, social relationships, academic performance, family relations
FUNCTIONAL IMPAIRMENT: FAMILY 17 Functional Impairment: Family F(1, 176)=8.6350, p =.003, n p 2 =.05 No effect of gender Vertical bars denote 0.95 confidence intervals 16 15 14 13 12 score 11 10 9 8 7 6 5 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT: WORK/SCHOOL 20 Functional Impairment: Work/School F(1, 157) = 22.62, p< 0.001, n p 2 = 0.13 No effect of gender Vertical bars denote 0.95 confidence intervals 18 16 14 12 score 10 8 6 4 2 0 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT: LIFE STYLE 26 Functional Impairment: Life Style F(1, 175)=.29.46, p<0.001, n p 2 = 0.14 No gender effect Vertical bars denote 0.95 confidence intervals 24 22 20 18 score 16 14 12 10 8 6 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT: SELF-CONCEPT 15 Functional Impairment: Self-concept F(1, 173)=13.49, p<0.001, n p 2 = 0.07 No effect of gender Vertical bars denote 0.95 confidence intervals 14 13 12 Self-concept score 11 10 9 8 7 6 5 4 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT: SOCIAL SKILLS 16 Functional Impairment: Social skills F(1, 174)=19.25, p<0.001, n p 2 = 0.10 No gender effect Vertical bars denote 0.95 confidence intervals 14 12 Social score 10 8 6 4 2 ADHD NonADHD Male Female
FUNCTIONAL IMPAIRMENT: RISK TAKING 26 Functional Impairment: Risk taking F(1, 174)=8.35, p=.004, n p 2 =.05 Effect of gender: p = 0.046 Vertical bars denote 0.95 confidence intervals 24 22 20 Risk taking score 18 16 14 12 10 8 6 ADHD NonADHD Male Female
CONCLUSION When ADHD is the primary disorder 35 55% of adults have Comorbid SUD When SUD is the primary disorder, 15-25% exhibit symptoms of ADHD. Persons with ADHD + SUD are significantly more severely impaired in Executive Functions and Emotional Control than persons with SUD only This causes psychosocial impairment in all areas. Some symptoms like risk taking and impulsiveness may underlie both disorders, when comorbid, these two disorders can have a huge impact on the treatment of each other, and therefore both need to be addressed Females have more problems with emotional control Males with ADHD take greater risks than females
RECOMMENDATIONS Clinicians must be aware of the complicated nature of diagnosis and treatment of ADHD when comorbid with SUD Individuals with SUD and ADHD do less well on SUD treatment and are less likely to remain in treatment, therefore the diagnosis and treatment of ADHD and in patients with SUD seems to be essential to achieve the best clinical outcome Patients with SUD should be screened for ADHD on admission and if positive, confirmed by a clinician. ADHD treatment is usual with stimulants, but as stimulants may be addictive, not-stimulant therapy is preferred.
THANK YOU FOR YOUR ATTENTION! To be continued
Acknowledgement: Thanks to the enthusiastic and cooperative staff and patients of the Treatment Centres
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