Temporal association between childhood psychopathology and substance use disorders: findings from a sample of adults with opioid or alcohol dependency
Introduction
Clinical and epidemiological samples document a bi-directional overlap between psychopathology and substance use disorders (SUD; alcohol or drug abuse or dependence) (Kessler et al., 1997). While there is general agreement as to the co-occurrence of comorbid psychopathology and SUD (Clark et al., 1997, Kandel et al., 1997), there is much debate about the developmental sequence of these disorders (Buydens-Branchey et al., 1989, Compton et al., 2000, Schuckit et al., 2000). Whereas early-onset SUD has been linked to pre-existing psychopathology, such as attention deficit/hyperactivity disorder (ADHD), conduct disorder, mood disorders, and anxiety (Bukstein et al., 1989, Clark et al., 1999, Costello et al., 1999, Wilens et al., 1997, Buydens-Branchey et al., 1989, Cloninger et al., 1988, Irwin et al., 1990), other studies have shown that psychopathology, such as major depression, follows SUD and may represent complications of substance abuse or genetic influences of abuse (Bukstein et al., 1992, Bukstein et al., 1989, Schuckit et al., 2000). Consequently, mixed findings in the literature do not show clear evidence as to the temporal relationship between childhood psychopathology and SUD.
A methodological shortcoming of previous work is the insufficient attention to the developmental sequence of childhood disorders that have been suggested to precede and increase the risk for SUD. For example, we previously demonstrated that ADHD and related co-morbidity is associated with a higher risk for and earlier onset of SUD in ADHD individuals (Wilens et al., 1997). This finding is consistent with prospectively collected data in a controlled study of ADHD that documented increased risk for early onset SUD (Biederman et al., 1997). Furthermore, emphasis needs to be given to the timing and sequence of multiple disorders that may appear during the childhood years, such as anxiety disorders, dysthymia or childhood depression, conduct and oppositional disorders, and influence the onset of a SUD.
Additionally, few researchers have attempted to establish the developmental sequence of childhood psychopathology and SUD into the adulthood years. In evaluating the relationship between psychopathology and SUD, it would be important to follow children through the full age of risk for late-onset SUD. The researchers who have studied this sequence have failed to agree upon which disorders in fact precede the SUD (Compton et al., 2000, Wilens et al., 1997, Brook et al., 1998, Schuckit et al., 2000, Bukstein et al., 1989). Because of the paucity of longitudinal, prospective studies and the use of dimensional measures of psychopathology (Brook et al., 1998, Block et al., 1988), the existing literature does not provide sufficient data to establish a temporal association between childhood psychiatric disorders and SUD.
The present study utilized a retrospective design and applied clinically valid measures for assessing childhood psychopathology in evaluating adults who had reached the full age of risk for developing SUD. Thus, a developmental sequence of psychopathology and SUD through the lifespan can emerge that would be useful in advancing our understanding of the relationship between psychopathology and SUD.
The delineation of antecedent psychopathology to SUD has important implications. If antecedent disorders emerge in childhood, preventive programs could be developed aimed at affected children years before the onset of SUD. Clinically, practitioners could focus efforts on aggressively treating psychopathology and monitoring SUD development. The purpose of the current study was to evaluate the developmental relationship of SUD and psychopathology, attending to childhood-onset disorders in a well-characterized sample of adults in SUD treatment. We hypothesized that among adults with SUD, psychopathology would have its onset during childhood preceding the initiation of substance use.
Section snippets
Sample
The sample consisted of adults with SUD ascertained from outpatient methadone and outpatient alcohol treatment centers, previously described in a report on the children of these SUD adults (Wilens et al., 2002). The institutional review committee approved this study and written informed consent was obtained for all participants.
Diagnostic information relied on the Structured Clinical Interview for DSM-III-R (SCID) (Spitzer et al., 1992) for adult diagnoses, supplemented by the Kiddie Schedule
Demographic and clinical characteristics
We studied 47 adults with a SUD (27 opioid and 20 alcohol; 53% male; Table 1). The mean age of these adults was 39.3±6.6 years, with no significant difference between the ages of the opioid and alcohol subgroups (t=0.2, P=0.8). The mean socioeconomic status of SUD adults was 3.6±1.5, with a significant difference between the alcohol and opioid subgroups (t=−5.4, P<0.01).
There were no differences between adults with opioid and alcohol dependency in the rates of lifetime psychiatric co-morbidity
Discussion
These results, derived from retrospective reporting, support the hypothesis that adults with SUD frequently had childhood-onset co-morbid disorders that emerged many years prior to SUD. The onset of ADHD, multiple anxiety, and disruptive disorders preceded SUD onset; while mood disorders followed the onset of SUD. These data confirm and extend prior findings (Bukstein et al., 1989, Clark et al., 1999, Costello et al., 1999, Wilens et al., 1997) and suggest that childhood disorders may represent
Acknowledgments
This research was supported by National Institute of Drug Abuse grants to T. Wilens; USPHS grant MH-K2001175A, DA-11929, and DA-12945.
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2011, Psychiatry ResearchCitation Excerpt :Other authors have reported earlier age of onset in anxiety disorders, but no systematic pattern in mood disorders relative to SUD (Merikangas et al., 1998; Kessler et al., 2003). Only one study examined the age at onset in COD among different mental diagnoses, but it failed to identify oncoming age and associated diagnoses (Hahesy et al., 2002). Among 47 SUD patients, Hahesy et al. (2002) reported 62% with early-onset SUD (< 18 years) and 38% with late-onset SUD (> 19 years).