Differential implications of persistent, remitted, and late-onset ADHD symptoms for substance abuse in women and men: A twin study from ages 11 to 24

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Background: Persistence and emergence of ADHD in adulthood are associated with substance problems. We investigate differential implications of ADHD course for tobacco, alcohol, or marijuana problems by sex, then whether substance misuse results from ADHD or contributes to it, through a twin differences design. Methods: A population-based cohort of 998 twins (61 % monozygotic; 52 % female), born in Minnesota from 1988 to 1994, was prospectively assessed from ages 11–24. Childhood ADHD was oversampled. At age 24, 255 had a history of childhood-onset ADHD (160 persistent, 95 remitted); 93 had late-onset ADHD symptoms identified in late-adolescence/adulthood. Persistent, remitted, and late-onset groups were compared to those without ADHD (N = 459) on childhood characteristics and age-24 substance problems. Results: Persistent and late-onset groups differed in childhood; twin concordances suggested greater genetic etiology for persistent ADHD. As adolescents, however, both groups were high in conduct problems; by adulthood, they were comparably high in substance problems. In particular, women whose ADHD persisted were 5 times more likely to develop tobacco use disorder than women without ADHD. Remitted ADHD was associated with less-increased risk, except for alcohol problems among women. Consistent with possible causality, monozygotic female twins with more age-17 ADHD symptoms than co-twins had more age-24 tobacco symptoms; a similar association was found for alcohol. Conclusions: Presence or emergence of ADHD in early adulthood increases substance problems to a greater degree for women than men. While effects of substances on later ADHD were not statistically significant, detection was limited by the relative rarity of late-adolescent substance symptoms.

Original languageEnglish (US)
Article number107947
JournalDrug and alcohol dependence
StatePublished - Jul 1 2020

Bibliographical note

Funding Information:
This work was supported by National Institute on Drug Abuse grants R01DA038065 to Irene Elkins, R01DA013240 and R01DA036216 to William Iacono; National Institute on Alcohol Abuse and Alcoholism grant R37AA009367 to Matt McGue; and K01DA037280 to Sylia Wilson. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Health.

Publisher Copyright:
© 2020 Elsevier B.V.


  • Alcohol
  • Attention deficit hyperactivity disorder
  • Discordant twin design
  • Gender differences
  • Longitudinal
  • Marijuana
  • Tobacco


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