Background: Although substance use disorders (SUD) and attention-deficit/hyperactivity disorder (ADHD) show significant symptomatic overlap, ADHD is often overlooked in SUD patients. Objective: The aim of the present study was to characterize aspects of attention and inhibition (as assessed by a continuous performance test [CPT]) in SUD patients with and without a comorbid diagnosis of ADHD and in healthy controls, expecting the most severe deficits in patients with a combined diagnosis. Methods: The MOXO-CPT version, which incorporates visual and auditory environmental distractors, was administered to 486 adults, including healthy controls (n = 172), ADHD (n = 56), SUD (n = 150), and combined SUD and ADHD (n = 108). Results: CPT performance of healthy controls was better than that of individuals in each of the 3 clinical groups. The only exception was that the healthy control group did not differ from the ADHD group on the Timing index. The 3 clinical groups differed from each other in 2 indices: (a) patients with ADHD (with or without SUD) showed increased hyperactivity compared to patients with SUD only and (b) patients with ADHD showed more responses on correct timing as compared with the SUD groups (with or without ADHD). Conclusion: The CPT is sensitive to ADHD-related deficits, such as disinhibition, poor timing, and inattention, and is able to consistently differentiate healthy controls from patients with ADHD, SUD, or both. Our results are in line with previous research associating both ADHD and SUD with multiple disruptions across a broad set of cognitive domains such as planning, working memory, decision-making, inhibition control, and attention. The lack of consistent differences in cognitive performance between the 3 diagnostic groups might be attributed to various methodological aspects (e.g., heterogeneity in severity, type, and duration of substances use). Our results support the view that motor activity should be considered a significant marker of ADHD.

1.
Groenman AP, Janssen TW, Oosterlaan J. Childhood psychiatric disorders as risk factor for subsequent substance abuse: A meta-analysis.
J Am Acad Child Adolesc Psychiatry
. 2017 Jul;56(7):556–69.
2.
Wilens TE. Impact of ADHD and its treatment on substance abuse in adults.
J Clin Psychiatry
. 2004;65 Suppl 3:38–45.
3.
Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature.
Pediatrics
. 2003 Jan;111(1):179–85.
4.
Lichtenstein P, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, et al. Medication for attention deficit-hyperactivity disorder and criminality.
N Engl J Med
. 2012 Nov;367(21):2006–14.
5.
van de Glind G, Konstenius M, Koeter MW, van Emmerik-van Oortmerssen K, Carpentier PJ, Kaye S, et al.; IASP Research Group. Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria.
Drug Alcohol Depend
. 2014 Jan;134:158–66.
6.
Ohlmeier MD, Peters K, Te Wildt BT, Zedler M, Ziegenbein M, Wiese B, et al. Comorbidity of alcohol and substance dependence with attention-deficit/hyperactivity disorder (ADHD).
Alcohol Alcohol
. 2008 May-Jun;43(3):300–4.
7.
Lee SS, Humphreys KL, Flory K, Liu R, Glass K. Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review.
Clin Psychol Rev
. 2011 Apr;31(3):328–41.
8.
Adisetiyo V, Gray KM. Neuroimaging the neural correlates of increased risk for substance use disorders in attention-deficit/hyperactivity disorder-A systematic review.
Am J Addict
. 2017 Mar;26(2):99–111.
9.
Ortal S, van de Glind G, Johan F, Itai B, Nir Y, Iliyan I, et al. The role of different aspects of impulsivity as independent risk factors for substance use disorders in patients with ADHD: A review.
Curr Drug Abuse Rev
. 2015;8(2):119–33.
10.
Tapert SF, Granholm E, Leedy NG, Brown SA. Substance use and withdrawal: neuropsychological functioning over 8 years in youth.
J Int Neuropsychol Soc
. 2002 Nov;8(7):873–83.
11.
de Wit H. Impulsivity as a determinant and consequence of drug use: a review of underlying processes.
Addict Biol
. 2009 Jan;14(1):22–31.
12.
Groenman AP, Oosterlaan J, Greven CU, Vuijk PJ, Rommelse N, Franke B, et al. Neurocognitive predictors of substance use disorders and nicotine dependence in ADHD probands, their unaffected siblings, and controls: a 4-year prospective follow-up.
J Child Psychol Psychiatry
. 2015 May;56(5):521–9.
13.
McGue M, Slutske W, Iacono WG. Personality and substance use disorders: II. Alcoholism versus drug use disorders.
J Consult Clin Psychol
. 1999 Jun;67(3):394–404.
14.
Stevens L, Roeyers H, Dom G, Joos L, Vanderplasschen W. Impulsivity in cocaine-dependent individuals with and without attention-deficit/hyperactivity disorder.
Eur Addict Res
. 2015;21(3):131–43.
15.
Pérez de Los Cobos J, Siñol N, Puerta C, Cantillano V, López Zurita C, Trujols J. Features and prevalence of patients with probable adult attention deficit hyperactivity disorder who request treatment for cocaine use disorders.
Psychiatry Res
. 2011 Jan;185(1-2):205–10.
16.
Crunelle CL, Veltman DJ, van Emmerik-van Oortmerssen K, Booij J, van den Brink W. Impulsivity in adult ADHD patients with and without cocaine dependence.
Drug Alcohol Depend
. 2013 Apr;129(1-2):18–24.
17.
Miguel CS, Martins PA, Moleda N, Klein M, Chaim-Avancini T, Gobbo MA, et al. Cognition and impulsivity in adults with attention deficit hyperactivity disorder with and without cocaine and/or crack dependence.
Drug Alcohol Depend
. 2016 Mar;160:97–104.
18.
Tamm L, Trello-Rishel K, Riggs P, Nakonezny PA, Acosta M, Bailey G, et al. Predictors of treatment response in adolescents with comorbid substance use disorder and attention-deficit/hyperactivity disorder.
J Subst Abuse Treat
. 2013 Feb;44(2):224–30.
19.
Levin FR, Upadhyaya HP. Diagnosing ADHD in adults with substance use disorder: DSM-IV criteria and differential diagnosis.
J Clin Psychiatry
. 2007 Jul;68(7):e18.
20.
Bastiaens L, Galus J. Comparison of the adult ADHD self report scale screener for DSM-IV and DSM-5 in a dually diagnosed correctional population.
Psychiatr Q
. 2018 Jun;89(2):505–10.
21.
Dakwar E, Mahony A, Pavlicova M, Glass A, Brooks D, Mariani JJ, et al. The utility of attention-deficit/hyperactivity disorder screening instruments in individuals seeking treatment for substance use disorders.
J Clin Psychiatry
. 2012 Nov;73(11):e1372–8.
22.
Luderer M, Kaplan-Wickel N, Richter A, Reinhard I, Kiefer F, Weber T. Screening for adult attention-deficit/hyperactivity disorder in alcohol dependent patients: underreporting of ADHD symptoms in self-report scales.
Drug Alcohol Depend
. 2019 Feb;195:52–8.
23.
Manor I, Vurembrandt N, Rozen S, Gevah D, Weizman A, Zalsman G. Low self-awareness of ADHD in adults using a self-report screening questionnaire.
Eur Psychiatry
. 2012 Jul;27(5):314–20.
24.
Silverstein MJ, Faraone SV, Alperin S, Biederman J, Spencer TJ, Adler LA. How Informative Are Self-Reported Adult Attention-Deficit/Hyperactivity Disorder Symptoms? An Examination of the Agreement Between the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale V1.1 and Adult Attention-Deficit/Hyperactivity Disorder Investigator Symptom Rating Scale.
J Child Adolesc Psychopharmacol
. 2018 Jun;28(5):339–49.
25.
Epstein JN, Erkanli A, Conners CK, Klaric J, Costello JE, Angold A. Relations between Continuous Performance Test performance measures and ADHD behaviors.
J Abnorm Child Psychol
. 2003 Oct;31(5):543–54.
26.
Fasmer OB, Mjeldheim K, Førland W, Hansen AL, Syrstad VE, Oedegaard KJ, et al. Linear and non-linear analyses of Conner’s Continuous Performance Test-II discriminate adult patients with attention deficit hyperactivity disorder from patients with mood and anxiety disorders.
BMC Psychiatry
. 2016 Aug;16(1):284.
27.
Ginsberg Y, Hirvikoski T, Lindefors N. Attention Deficit Hyperactivity Disorder (ADHD) among longer-term prison inmates is a prevalent, persistent and disabling disorder.
BMC Psychiatry
. 2010 Dec;10(1):112.
28.
Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population.
Psychol Med
. 2005 Feb;35(2):245–56.
29.
Adler LA, Guida F, Irons S, Rotrosen J, O’Donnell K. Screening and imputed prevalence of ADHD in adult patients with comorbid substance use disorder at a residential treatment facility.
Postgrad Med
. 2009 Sep;121(5):7–10.
30.
Chiasson JP, Stavro K, Rizkallah É, Lapierre L, Dussault M, Legault L, et al. Questioning the specificity of ASRS-v1.1 to accurately detect ADHD in substance abusing populations.
J Atten Disord
. 2012 Nov;16(8):661–3.
31.
van de Glind G, Van Emmerik-van Oortmerssen K, Carpentier PJ, Levin FR, Koeter MW, Barta C, et al.; Iasp Research Group. The International ADHD in Substance Use Disorders Prevalence (IASP) study: background, methods and study population.
Int J Methods Psychiatr Res
. 2013 Sep;22(3):232–44.
32.
Brown RL, Leonard T, Saunders LA, Papasouliotis O. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: an opportunity for prevention.
Prev Med
. 1998 Jan-Feb;27(1):101–10.
33.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
J Clin Psychiatry
. 1998;59 Suppl 20:22–33.
34.
Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan KH, et al. The Mini International Neuropsychiatric Interview (MINI): A short diagnostic structured interview: Reliability and validity according to the CIDI.
Eur Psychiatry
. 1997;12(5):224–31.
35.
Epstein JN, Kollins SH. Psychometric properties of an adult ADHD diagnostic interview.
J Atten Disord
. 2006 Feb;9(3):504–14.
36.
Ribasés M, Ramos-Quiroga JA, Hervás A, Bosch R, Bielsa A, Gastaminza X, et al. Exploration of 19 serotoninergic candidate genes in adults and children with attention-deficit/hyperactivity disorder identifies association for 5HT2A, DDC and MAOB.
Mol Psychiatry
. 2009 Jan;14(1):71–85.
37.
Ramos-Quiroga JA, Bosch R, Richarte V, Valero S, Gómez-Barrosa N, Nogueira M, et al. Criterion and concurrent validity of Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) Spanish version.
Rev Psiquiatr Salud Ment
. 2012;5(4):229–35.
38.
World Health Organization. Process of translation and adaptation of instruments. Geneva: WHO; [Last accessed on Mar 19, 2017]. Available from: http://www.who.int/substance_abuse/research_tools/translation/en/.
39.
Berger I, Goldzweig G. Objective measures of attention-deficit/hyperactivity disorder: a pilot study.
Isr Med Assoc J
. 2010 Sep;12(9):531–5.
40.
Slobodin O, Cassuto H, Berger I. Age-related changes in distractibility: developmental trajectory of sustained attention in ADHD.
J Atten Disord
. 2018 Dec;22(14):1333–43.
41.
Murray DM, Blistein JL. Methods to reduce the impact of intraclass correlation in group-randomized trials.
Eval Rev
. 2003 Feb;27(1):79–103.
42.
Thoma RJ, Monnig MA, Lysne PA, Ruhl DA, Pommy JA, Bogenschutz M, et al. Adolescent substance abuse: the effects of alcohol and marijuana on neuropsychological performance.
Alcohol Clin Exp Res
. 2011 Jan;35(1):39–46.
43.
Fernández-Serrano MJ, Pérez-García M, Verdejo-García A. What are the specific vs. generalized effects of drugs of abuse on neuropsychological performance?
Neurosci Biobehav Rev
. 2011 Jan;35(3):377–406.
44.
Harstad E, Levy S; Committee on substance abuse. Attention-deficit/hyperactivity disorder and substance abuse.
Pediatrics
. 2014 Jul;134(1):e293–301.
45.
Lis S, Baer N, Stein-en-Nosse C, Gallhofer B, Sammer G, Kirsch P. Objective measurement of motor activity during cognitive performance in adults with attention-deficit/hyperactivity disorder.
Acta Psychiatr Scand
. 2010 Oct;122(4):285–94.
46.
Teicher MH, Polcari A, Fourligas N, Vitaliano G, Navalta CP. Hyperactivity persists in male and female adults with ADHD and remains a highly discriminative feature of the disorder: a case-control study.
BMC Psychiatry
. 2012 Nov;12(1):190.
47.
Edebol H, Helldin L, Norlander T. Objective measures of behavior manifestations in adult ADHD and differentiation from participants with bipolar II disorder, Borderline personality disorder, participants with disconfirmed ADHD as well as normative participants.
Clin Pract Epidemiol Ment Health
. 2012;8(1):134–43.
48.
Bioulac S, Lallemand S, Rizzo A, Philip P, Fabrigoule C, Bouvard MP. Impact of time on task on ADHD patient’s performances in a virtual classroom.
Eur J Paediatr Neurol
. 2012 Sep;16(5):514–21.
49.
Dekkers TJ, Agelink van Rentergem JA, Koole A, van den Wildenberg WP, Popma A, Bexkens A, et al. Time-on-task effects in children with and without ADHD: depletion of executive resources or depletion of motivation?
Eur Child Adolesc Psychiatry
. 2017 Dec;26(12):1471–81.
50.
Tucha L, Fuermaier AB, Koerts J, Buggenthin R, Aschenbrenner S, Weisbrod M, et al. Sustained attention in adult ADHD: time-on-task effects of various measures of attention.
J Neural Transm (Vienna)
. 2017 Feb;124(Suppl 1):39–53.
51.
Tucha O, Walitza S, Mecklinger L, Sontag TA, Kübber S, Linder M, et al. Attentional functioning in children with ADHD - predominantly hyperactive-impulsive type and children with ADHD - combined type.
J Neural Transm (Vienna)
. 2006 Dec;113(12):1943–53.
52.
Huang-Pollock CL, Karalunas SL, Tam H, Moore AN. Evaluating vigilance deficits in ADHD: a meta-analysis of CPT performance.
J Abnorm Psychol
. 2012 May;121(2):360–71.
53.
Liebrenz M, Gamma A, Ivanov I, Buadze A, Eich D. Adult attention-deficit/hyperactivity disorder: associations between subtype and lifetime substance use - a clinical study.
F1000 Res
. 2015 Jul;4:407.
54.
De Alwis D, Lynskey MT, Reiersen AM, Agrawal A. Attention-deficit/hyperactivity disorder subtypes and substance use and use disorders in NESARC.
Addict Behav
. 2014 Aug;39(8):1278–85.
55.
Kaye S, Ramos-Quiroga JA, van de Glind G, Levin FR, Faraone SV, Allsop S, et al. Persistence and subtype stability of ADHD among substance use disorder treatment seekers.
J Atten Disord
. 2019 Oct;23(12):1438–53.
56.
Davidovitch M, Koren G, Fund N, Shrem M, Porath A. Challenges in defining the rates of ADHD diagnosis and treatment: trends over the last decade.
BMC Pediatr
. 2017 Dec;17(1):218.
57.
Crunelle CL, van den Brink W, Moggi F, Konstenius M, Franck J, Levin FR, et al.; ICASA consensus group. International consensus statement on screening, diagnosis and treatment of substance use disorder patients with comorbid Attention Deficit/Hyperactivity Disorder.
Eur Addict Res
. 2018;24(1):43–51.
58.
López-Martín S, Albert J, Fernández-Jaén A, Carretié L. Emotional distraction in boys with ADHD: neural and behavioral correlates.
Brain Cogn
. 2013 Oct;83(1):10–20.
59.
Hagen E, Erga AH, Nesvåg SM, McKay JR, Lundervold AJ, Walderhaug E. One-year abstinence improves ADHD symptoms among patients with polysubstance use disorder.
Addict Behav Rep
. 2017 Sep;6:96–101.
60.
van Emmerik-van Oortmerssen K, Vedel E, Kramer FJ, Koeter MW, Schoevers RA, van den Brink W. Diagnosing ADHD during active substance use: feasible or flawed?
Drug Alcohol Depend
. 2017 Nov;180:371–5.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.