Drug and Alcohol Dependence 54 (1999) 195 – 205
Relationship of ADHD, depression, and non-tobacco substance use
disorders to nicotine dependence in substance-dependent delinquents
Paula D. Riggs *, Susan K. Mikulich, Elizabeth A. Whitmore, Thomas J. Crowley
Addiction Research and Treatment Ser6ice, Box C268 -35, Department of Psychiatry, Uni6ersity of Colorado School of Medicine, Den6er,
CO 80262, USA
Received 2 May 1998; accepted 28 August 1998
Abstract
This study used standardized interviews to examine the relationship of attention deficit hyperactivity disorder (ADHD), major
depression (MDD), and other illicit substance use disorders (SUD) to onset and severity of nicotine dependence in 82 female and
285 male adolescents with conduct disorder (CD) and SUD. Results indicate that both ADHD and MDD significantly contribute
to severity of nicotine dependence in delinquents with SUD. ADHD is further associated with earlier onset of regular smoking
in males. Severity of non-tobacco SUD also was related directly to nicotine dependence severity in both males and females, and
to earlier onset of smoking in males. Our findings illuminate the contribution of comorbidity to nicotine dependence and its
relationship to other SUD severity among adolescents with CD and SUD and highlight the need for coordinated assessment and
treatment of smoking cessation along with concurrent treatment of other drug use and psychiatric comorbidity such as ADHD
and MDD in such youths. © 1999 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Conduct disorder; Attention deficit hyperactivity disorder; Major depressive disorder; Adolescents
1. Introduction
Cigarette smoking is a major public health problem
that almost always begins in adolescence and may
herald the later development of illicit substance abuse
(Newcomb, 1995; Brown et al., 1996; Milberger et al.,
1997). Data from longitudinal studies indicate that
cigarettes are often the first drug used by those who go
on to develop later illicit drug abuse. There is very little
cannabis or other illicit drug experimentation without
preceding cigarette and alcohol use (Kandel and Yamaguchi, 1993; Duncan et al., 1995) except perhaps
among youth with very serious behavior problems
* Corresponding author. Tel.: +1 303 3157652; fax: + 1 303
3155641.
Portions of this paper were presented at the annual meeting of
the College of Problems on Drug Dependence (Nashville, TN, 1997).
(Young et al., 1995). An emerging literature indicates
that those youth at greatest risk for early initiation of
smoking with progression on to other substance use
disorders (SUD) are those with conduct disorder (CD;
Brown et al., 1996; Milberger et al., 1997). A recent
study of a community sample of 1709 adolescents (ages
14–18), found early cigarette use strongly related to
later development of illicit substance abuse (Brown et
al., 1996). In this study, one of the most robust risk
factors for development of non-tobacco SUD in later
adolescence was the early onset of cigarette smoking
(B 13 years of age); 82% of early-onset smokers went
on to develop drug and alcohol abuse (Brown et al.,
1996). In a controlled study of 237 children and adolescents (ages 6–17), the small subsample with CD had
more than double the risk of developing smoking at
4-year follow-up compared to those without CD (Milberger et al., 1997). Thus, although a majority (71%) of
0376-8716/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved.
PII: S0376-8716(98)00155-0
196
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
high-school students try cigarettes (National Center for
Health Statistics, 1996; American Cancer Society, 1997;
Milberger et al., 1997), there appears to be a smaller
subgroup at risk for both early initiation of smoking
and CD who are at highest risk to then go on to
develop further illicit SUD. It is in this group in
particular that smoking has been conceptualized as part
of a ‘generalized deviance syndrome’, which includes
other substance abuse and dependence, delinquency
and poor school performance (Jessor and Jessor, 1977;
Brown et al., 1996).
1.1. What is known about the impact of attention
deficit hyperacti6ity disorder (ADHD) and major
depression (MDD) on smoking in youth with CD and
SUD?
Although current data indicate that most of the risk
for adolescent smoking, as well as the subsequent development of non-tobacco substance involvement, is mediated through CD (Brown et al., 1996; Biederman et al.,
1997), there is some support for the notion that psychiatric disorders other than CD may either independently
impart increased risk for smoking or further increase
the risk of that contributed by CD (Breslau et al., 1993;
Brown et al., 1996; Biederman et al., 1997). Preliminary
evidence indicates that additional comorbidity, such as
ADHD and MDD, may add to the already high risk of
smoking imparted by CD (Milberger et al., 1997;
Brown et al., 1996). This may be a significant issue
since the prevalence of both MDD (15 – 24%) and
ADHD (30–50%) among conduct-disordered youth is
much higher than in adolescents without CD (Zoccolillo, 1992; Moffitt, 1993; Riggs et al., 1995; Thompson
et al., 1996). Milberger et al. (1997) recently showed
that the subsample of adolescents in their study who
had a diagnosis of CD comorbid with ADHD (n = 28)
had especially high rates and earlier onset of cigarette
smoking when compared to the non-CD (ADHD only)
adolescents. However, the numbers in this category
were too small to explore relationships more fully.
Moreover, this study did not report on SUD other than
smoking. Studies of adolescent males with both CD
and SUD have shown that both MDD (Riggs et al.,
1995) and ADHD (Thompson et al., 1996) are also
related to greater severity of multiple substance use
disorders, although the specific relationship to nicotine
dependence in these studies was also not evaluated.
In both adolescent and adult studies, MDD has been
shown to be associated with smoking (Breslau et al.,
1994; Pomerleau et al., 1995; Milberger et al., 1997). It
appears that individuals with depression are not only
more likely to smoke, but also to have greater difficulty
with smoking cessation efforts and to experience depression when they do quit (Covey et al., 1993, 1997;
Pederson et al., 1997). It is speculated that smoking
may even diminish the chances of recurring depression
in some people, since a major depressive episode may
follow smoking cessation in these subjects (Glassman et
al., 1990). However, the relationship between mood and
smoking is not quite clear. In longitudinal studies of
adolescents, smoking status has been found to be the
most important predictor of developing depressive
symptoms for both males and females (Choi et al.,
1997). Two recent longitudinal studies in adolescents
however, suggest that the relationship between smoking
and depression may be reciprocal and bi-directional in
that smoking predicts later onset of MDD, and MDD
predicts later onset of smoking (Brown et al., 1996;
Wang et al., 1996).
Other longitudinal work suggests that much of the
relationship between the two may be due to risk factors
associated with and common to both depression and
smoking (Fergusson et al., 1996). Data gathered during
a 16-year longitudinal study of a birth cohort of 947
New Zealand children found moderate to strong comorbidity between depression and nicotine dependence
at age 16 in that teenagers with depression had 4.6
times the odds of nicotine dependence than those without depression. However, when other risk factors common to both disorders were removed from the model,
the adjusted odds ratio between depression and smoking was reduced to 2.3 (a small to moderate relationship). Thus, much of the relationship between
depression and nicotine may be explained by risk factors common to and underlying both disorders. Nevertheless, the comorbid relationship between depression
and nicotine dependence seems to be established by age
16 (Fergusson et al., 1996). Interestingly, one of the
common risk factors associated with both disorders in
this study was association with delinquent peers (Fergusson et al., 1996). Another strong risk factor for both
disorders is genetic. A large female twin study demonstrated that the relationship between lifetime smoking
and lifetime major depression resulted solely from genes
that predispose to both conditions (Kendler et al.,
1993). These results suggest that the association between smoking and major depression, at least in
women, is not a causal one but arises largely from
familial factors which are probably genetic and which
predispose to both smoking and major depression
(Kendler et al., 1993).
Very few studies of adolescent SUD have included
examination of gender differences in comorbidity and
the relationship of comorbid disorders to nicotine dependence and other SUD. Compared to adolescent
males, adolescent females generally have a lower prevalence of CD, ADHD, and SUD (American Psychiatric
Association, 1987; Szatmari et al., 1989; American Psychiatric Association, 1994) and higher depression rates
(Offord et al., 1987). CD behaviors of younger males
appear to be more strongly associated with later adoles-
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
cent substance use (Windle, 1990) and antisocial personality disorder (Myers et al., 1998) than similar behaviors of adolescent females. Both post-traumaticstress-disorder (PTSD) and major MDD have been
demonstrated to be more strongly associated with alcohol dependence in females than in males (Clark et al.,
1997). Greenbaum et al. (1991) reported that male and
female adolescents with both CD and depression appear to have higher rates of SUD. We previously
conducted similar analyses examining the relationships
of CD, ADHD, and depression in males and females
with both CD and SUD (Whitmore et al., 1997), but we
did not examine differences in the relationship of these
variables with nicotine use, specifically. Nevertheless,
this research suggested that CD, ADHD, and depression were all associated with SUD in males, but for
females, CD and ADHD were less important than
depression in substance dependence. Gender differences
regarding progression of drug abuse have also been
noted. For example, progression to illicit drug use for
males in a general adult population sample was found
to be dependent on prior use of alcohol, whereas for
females ‘either’ cigarette or alcohol use was sufficient to
predict progression to marijuana (Kandel et al., 1992;
Weinberg et al., 1998). There have been no studies; to
our knowledge, examining the relationship of smoking
to other comorbidity in conduct-disordered adolescents
with SUD, who are the adolescents most at risk to
smoke. As a result, there are few data regarding the
relationship of onset and severity of nicotine dependence to other comorbidity (e.g. ADHD and MDD),
few data regarding the relationship of nicotine dependence to other illicit SUD, and virtually no data on
gender differences in such youth. A greater understanding of the relationship of ADHD, MDD, and nicotine
dependence is important in these high risk youth with
CD and SUD because it may illuminate and refine
efforts at prevention and treatment.
We sought to contribute knowledge regarding the
following questions: first, does ADHD in conduct-disordered adolescents contribute to earlier onset of smoking and to greater severity of nicotine dependence? We
hypothesized based on previous literature in adolescents
without CD and adult literature that ADHD severity
would be associated with severity of nicotine dependence and younger age of regular smoking in adolescents with CD and SUD and that these relationships
will be stronger in males than in females (hypothesis 1).
A reason for this is that ADHD is more common and
impairing in males than in females (Barkley, 1990).
Secondly, we also wished to address whether MDD
contributes to severity of nicotine dependence in adolescents with CD and SUD. In both males and females we
hypothesized that MDD would be associated with more
severe nicotine dependence (hypothesis 2). Although the
relationship between smoking and depression has been
197
shown to be stronger in females than in males in most
studies, male and female adolescents with CD and SUD
appear to have similar rates of depression (MDD;
Whitmore et al., 1997). Thus, the relationship between
smoking and MDD in these youth, all of whom have
CD and SUD, is hypothesized to be equivalent in both
males and females. We also wished to explore the
combined impact and possible gender differences of
ADHD and MDD on nicotine dependence. Thirdly, we
hypothesized that severity of nicotine dependence and
earlier onset of smoking would be related to non-tobacco SUD severity in both males and females (hypothesis 3). We hypothesized that both would be so.
2. Method
2.1. Subjects
This sample is the same as that described in Whitmore et al. (1997) and also encompasses those of our
earlier studies (Riggs et al., 1995; Young et al., 1995;
Thompson et al., 1996). Behaviorally disordered, substance-abusing adolescents were recruited from Synergy
treatment programs of the University of Colorado
School of Medicine. Although referral criteria were
identical for males and females, the program for males
was residential and for females was day treatment
because residential treatment is available for males with
CD and SUD in this community but not for females.
Therefore, the treatment format differences were due to
a lack of support, funding, and referrals for residential
treatment for adolescent females, not because we
deemed the females to be less troubled than the males
whom we treat in residence.
Patients were referred by social services and juvenile
justice agencies throughout Colorado. They were 13–19
years old, had at least three CD symptoms during their
lifetime, and had one or more non-tobacco substance
abuse or dependence diagnoses by DSM-III-R criteria
(American Psychiatric Association, 1987). Applicants
for admission to the program were excluded if they
were deemed to be an imminent threat to themselves or
others or were thought to have other primary diagnoses
(e.g. psychoses) which are better treated in a locked,
inpatient psychiatric setting. Assent and consent to be
evaluated were provided by the youth, and their parent
or guardian as part of their consent to treatment.
Research consent was not obtained because federal
regulations do not require it for later analyses of previously collected clinical data. The Colorado Multiple
Institution Review Board approved this plan.
We assessed 100 adolescent females and 404 males
consecutively referred for evaluation and treatment between May 1991 and August 1995. Eighteen females
and 119 males who either did not meet our inclusion
198
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
criteria (n=25) or did not complete all interviews
(n = 112) were excluded, resulting in a sample of 82
females and 285 males.
2.2. Measures
2.2.1. Composite International Diagnostic
Inter6iew —Substance Abuse Module (CIDI-SAM)
DSM-III-R substance use diagnoses and symptom
counts for tobacco and nine other drug categories were
made using the CIDI-SAM (Cottler et al., 1989), a
structured, reliable and valid, 30 – 60 min interview
(Robins et al., 1988; Cottler et al., 1989). As an index of
non-tobacco substance use severity, we examined the
cumulative number (across substances) of non-tobacco
dependence symptoms.
2.2.2. Diagnostic Inter6iew Schedule for Children
(DISC 2.1)
DSM-III-R diagnoses and symptom counts of psychiatric disorders, including CD, ADHD, and MDD
were made using DISC (Fisher et al., 1993), a highly
structured, standardized instrument for children. We
developed and nested supplemental questions (Young
et al., 1995) assessing lifetime symptom occurrence
within the CD section of the DISC, because DISC
bases CD diagnoses on symptoms which occurred
during the past year and many of these adolescents
had been placed in controlled settings in the past year
that controlled their symptoms. As reported previously (Thompson et al., 1996; Whitmore et al., 1997),
self-reports on the DISC may under-diagnose ADHD
in these adolescents. Consequently, we evaluated
ADHD on a continuum of severity (rather than requiring the DISC-based ADHD diagnosis), using in
analyses the number of current ADHD symptoms
which had lasted at least 6 months. Similarly, number
of ‘lifetime’ CD symptoms and number of depression
symptoms were used as severity indices of those disorders. As described by Whitmore et al. (1997),
parental reports were not obtained to confirm diagnoses for several reasons, including the fact that parents of these delinquent adolescents are often
unwilling or unable to provide any information about
their children (Thompson et al., 1996).
2.2.3. Comprehensi6e Addiction Se6erity Index —
Adolescents (CASI-A)
Substance use characteristics were assessed using
CASI-A (Meyers, 1991), a 60-min semi-structured interview which was modeled after the Addiction Severity
Index (McLellan et al., 1983). Specifically, onset age in
years of regular (at least monthly) use of tobacco and
other drugs were obtained.
2.2.4. Social class
We estimated Hollingshead-Redlich two-factor social
class status from the adolescent’s report of the education and occupation of the principal wage earner in the
home (Hollingshead and Redlich, 1958).
2.2.5. Training and administration of the instruments
For both DISC and CIDI-SAM, a psychiatrist received formal training in the administration of these
instruments by their authors and subsequently supervised the training of additional bachelor’s-level and
master’s-level interviewers. Each trainee observed and
scored five interviews given by an experienced interviewer. Then, an experienced interviewer observed and
concurrently scored five of the trainee’s assessments.
Interviewers worked independently only after the last
two joint interviews achieved exact correspondence
(100% inter-rater reliability) with the experienced interviewer. Every interview was cross checked by another
interviewer, and feedback about accuracy was given to
the interviewers following each interview. Administration of the CASI-A and Hollingshead–Redlich were
based upon their training manuals/instructions.
2.3. Data analysis
Gender comparisons were computed using t-tests for
continuous variables (e.g. symptom counts) and x 2-tests
for categorical variables (e.g. diagnoses). Analysis of
covariance (ANCOVA) was used to adjust for differences in age at intake when age was significantly and
linearly related to the dependent variable of interest.
Pearson correlations and multiple regressions were
computed separately for males and females because the
larger male sample provided much more power, and
therefore, male findings could have overwhelmed or
obscured female findings. All hypothesis tests were
two-tailed and P-values of 0.05 or less were considered
statistically significant. All analyses were conducted in
SPSS (1990).
3. Results
3.1. Sample demographics
As reported in Whitmore et al. (1997), 45% of subjects were Caucasian and 42% were Hispanic, with
socioeconomic status (47.0915.6) falling just above the
lowest socioeconomic class. Age at intake was the only
demographic variable that differed by gender (t365 =
4.37, PB 0.001) in that males were significantly older
(16.09 1.3 years) than females (15.3 9 1.4 years); consequently, subsequent analyses were adjusted for age
where it significantly correlated with the outcome variable of interest.
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
Table 1
Gender comparisons in nicotine and other substance dependence and
comorbidity
Males
Females
Gender difference
Nicotine dependence
Symptoms
3.2 92.4
Diagnosis
58.9%
3.492.3
68.3%
t365 = −0.86; PB0.39
x 21 = 2.34; PB0.13
Non-nicotine dependence
Symptoms 14.8 9 9.1
Diagnosis
93.0%
11.79 7.8
89.0%
F1,364 = 4.01; PB0.05
x 21 = 1.37; PB0.24
ADHD
Symptoms
Diagnosis
4.4 9 4.0
10.5%
4.09 3.9
9.8%
t365 = 0.66; PB0.51
x 21 = 0.04; PB0.84
MDD
Symptoms
Diagnosis
1.6 9 2.5
14.4%
2.29 3.0
23.2%
t365 = −1.78; PB0.08
x 21 = 3.59; PB0.06
CD
Symptoms
Diagnosis
7.0 9 2.0
100.0%
5.99 2.1
100.0%
t365 = 4.33; PB0.01
Males began regular tobacco use slightly but significantly younger (12.5 92.2) than females (12.9 91.7)
after adjusting for age at intake (F1,294 =5.04, PB
0.03). However, onset of regular use of other substances
(12.7 92.0) did not differ by gender after adjusting for
intake age (F1,345 =2.20, P B0.14).
Table 1 presents general gender differences in the
sample regarding the mean symptom counts and proportion diagnosed with the comorbid diagnoses of interest. Males and females did not differ significantly in
the number of nicotine dependence symptoms or in the
proportion receiving nicotine or non-nicotine substance
dependence diagnoses. Males averaged three more dependence symptoms accumulated across substances
than females. Inclusion criterion required that all subjects have at least three lifetime symptoms of CD.
Males had significantly more lifetime symptoms than
females (7.0 vs. 5.9, respectively, t365 =4.33, P B 0.01).
There were no gender differences in symptom counts or
diagnoses of ADHD and MDD although there was a
trend for females to have more symptoms and diagnoses of MDD (Table 1).
199
3.2. Relationship of ADHD and depression to nicotine
dependence se6erity
We hypothesized (hypothesis 1) that severity of
ADHD would be associated with severity of nicotine
dependence and younger age of regular smoking in
adolescents with CD and SUD, and that these relationships would be stronger in males compared to females.
We also hypothesized (hypothesis 2) that severity of
MDD would be associated with severity of nicotine
dependence in both males and females. Pearson correlations between tobacco measures and comorbid psychiatric disorders for males and females are reported in
Table 2. For males, severity of CD, ADHD, and MDD
correlated significantly with severity of nicotine dependence (as measured by the number of nicotine dependence symptoms). The younger onset of regular
smoking in males also correlated significantly with CD
and ADHD, but not with MDD symptoms (Table 2).
Similarly, in females, severity of CD, ADHD, and
MDD also correlated significantly with the severity of
nicotine dependence; however, onset of regular smoking
in females was not significantly related to CD, MDD or
ADHD (Table 2). The interrelationships of MDD,
ADHD, and CD are not reported in Table 2, but all of
these pairwise correlations were significant for both
genders as described by Whitmore et al. (1997). Specifically, the correlations between ADHD and MDD in
both males and females exceeds r=0.3.
To assess how the combination of ADHD and MDD
severity jointly related to severity of nicotine dependence, multiple regression of the number of nicotine
dependence symptoms on severity of those comorbid
psychiatric disorders were conducted separately for
each gender. Because of their significant correlation
with nicotine dependence, age at intake and severity of
CD were evaluated as covariates. However, in multiple
regressions including comorbidity, they were found to
be non-significant, and thus were removed from the
final models presented in Table 3. Separately for males
and for females, Tables 3 and 4 include for each
variable: the estimated intercepts, the unstandardized
regression coefficients with their standard errors, the
Table 2
Pearson correlations of nicotine measures with comorbid psychiatric disorders
Onset regular smoking
ADHD Sx
MDD Sx
CD Sx
Non-nicotine dependence Sx
Males
Nicotine dependence Sx
Onset regular smoking
−0.23**
0.20**
−0.17*
0.29**
−0.06
0.18**
−0.15**
0.43**
−0.17*
Females
Nicotine dependence Sx
Onset regular smoking
−0.12
0.25*
−0.05
0.28*
−0.06
0.27*
−0.17
*PB0.05; **PB0.01.
0.34**
0.07
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
200
Table 3
The relationship of ADHD and depression to nicotine dependencea
Intercept
ADHD Sx
MDD Sx
Males: R 2 =0.09
b (se b)
2.51 (0.21)
sr2 (unique)
Partial F
148.02
P-value
0.00005
0.07 (0.04)
0.01
3.36
0.068
0.23 (0.06)
0.05
15.30
0.0001
Females: R 2 = 0.11
b (se b)
2.59 (0.37)
sr2 (unique)
Partial F
48.27
P-value
0.00005
0.11 (0.07)
0.03
2.75
0.100
0.18 (0.09)
0.05
4.02
0.048
a
Multiple regression: nicotine dependence on ADHD and depression.
partial F tests and their significance, and the squared
semipartial correlation coefficients (sr2), which indicate
the amount of unique variability explained in tobacco
dependence severity by each variable after accounting
for the other variables in the model. As an overall
summary of the results of each model, Tables 3 and 4
also include the squared multiple correlation coefficient
(R 2), which indicates the total amount of explained
variability (i.e. the unique variability and the joint
variability) in nicotine dependence severity accounted
for by the independent variables.
For males (Table 3), the severity of depression was
significantly associated with severity of nicotine dependence (F=15.30, P B0.0001). The severity of ADHD
trended toward significance (F = 3.36, P B 0.07) in its
association with nicotine dependence. Depression accounted for more unique variability (5%) in nicotine
dependence than did ADHD (1%). The combination of
ADHD and depression symptoms accounted for a total
of 9% of the variability in severity of nicotine dependence in males (Table 3). Similarly, in the smaller
sample of females (Table 3), the severity of depression
was significantly related to the severity of nicotine
dependence (F =4.02, P B 0.05). Severity of ADHD
trended toward significance in its relation to severity of
nicotine dependence (F = 2.75, P B0.10). Depression
individually accounted for 5% and ADHD accounted
for 3% of the unique variability in severity of nicotine
dependence (Table 3). The combination of ADHD and
depression symptoms accounted for 11% of the variability in severity of nicotine dependence in females
(Table 3).
3.3. Relationship of ADHD, MDD, and non-nicotine
SUD se6erity to nicotine dependence
We hypothesized (hypothesis 3) that non-nicotine
SUD severity would be related to severity of nicotine
dependence and younger age of onset of regular smoking. For both males and females, more severe non-
nicotine SUD was associated with more severe nicotine
dependence. Younger onset of regular smoking was
related to both nicotine and non-nicotine SUD severity,
but only in males (Table 2).
As a final analysis, we examined whether the combination of ADHD, depression, and age of onset of
smoking significantly related to severity of other (nontobacco) substance dependence. Age at intake and CD
severity were included as covariates because they differed significantly for males and females and correlated
with other substance severity. For males the severity of
CD accounted for only a small amount of unique
variability in severity of non-nicotine SUD (5%). Onset
of regular cigarette smoking accounted for only 2% of
unique variability (Table 4). The combination of onset
of smoking with ADHD and depression symptoms
accounted for 27% of the variability in other substance
dependence, after adjusting for intake age and CD
severity in males (Table 4).
When the same model is tested in females (Table 4),
neither ADHD nor onset of cigarette smoking explained significant variability in other substance dependence beyond that explained by depression alone.
Depression accounted for 9% of the unique variability
in other substance dependence in females (F =6.72,
PB 0.012), with the other variables marginally accounting for 1% or less. The combination of onset of smoking with ADHD and depression symptoms accounted
for 15% of the variability in other substance dependence after adjusting for intake age and CD severity in
females (Table 4).
4. Discussion
It is important to understand the relationships
among multiple comorbid disorders, such as depression
and ADHD, commonly present in conduct-disordered
adolescents with substance disorders. The major findings from this study highlight these relationships.
4.1. What is the relationship of early onset smoking,
nicotine dependence se6erity, ADHD and depressi6e
symptoms to other illicit substance dependence-se6erity?
The most significant findings from this study reveal a
gender difference in that the combination of early onset
of smoking with ADHD and depression symptoms
contribute significantly to the severity of other substance dependence in adolescent males with CD and
SUD (27% of the variability) whereas in females, neither ADHD nor onset of cigarette smoking explain
significant variability in other substance dependence
beyond that explained by depression alone. Our hypothesis (3) that severity of nicotine dependence in
adolescents with CD and SUD was associated with
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
201
Table 4
The relationship of non-nicotine substance dependence severity with onset of smoking and comorbid disordersa
Males: R 2 =0.27
b (se b)
sr2 (unique)
Partial F
P-value
Females: R 2 = 0.15
b (se b)
sr2 (unique)
Partial F
P-value
a
Intercept
Age at assessment
−9.8 (7.5)
0.03
1.69
0.195
1.4 (0.46)
0.05
8.86
0.003
1.1 (0.29)
0.02
13.74
0.0003
0.42 (0.71)
0.003
0.361
0.5500
−0.24 (0.50)
0.01
0.233
0.6313
0.22 (12.2)
0.01
0.00
0.9855
CD Sx
Onset smoking
ADHD Sx
MDD Sx
−0.59 (0.26)
0.03
4.98
0.0267
0.44 (0.16)
0.03
7.56
0.0065
0.70 (0.23)
0.33 (0.57)
0.01
0.342
0.5610
0.23 (0.24)
0.09
0.903
0.3457
0.89 (0.34)
9.14
0.0028
6.72
0.0119
Multiple regression: non-nicotine SUD on smoking onset, ADHD, MDD, adjusting for CD and age.
other SUD severity was also supported by our results.
For both males and females, severity of nicotine dependence contributed to a severity of non-nicotine SUD.
For males only, younger onset of regular smoking was
related to later nicotine and non-nicotine SUD severity
which may be partially explained by the males having
more severe CD, since more severe CD has been related
to earlier onset of conduct symptoms as well as earlier
onset of substance involvement (Moffitt, 1993).
4.2. What is the impact of ADHD and MDD on
se6erity of nicotine dependence and onset of smoking?
In addition, both MDD and ADHD contribute significantly to the severity of nicotine dependence in these
youth, all of whom have CD and SUD. This is confirming of hypotheses 1 and 2 predicting that both comorbidities would contribute to severity of nicotine
dependence. For males, but not for females, ADHD
and the severity of their conduct disorder was associated with earlier onset of smoking. For females, both
MDD and ADHD coupled with severity of CD were
associated with more severe nicotine dependence but
not earlier onset of smoking.
4.3. Does ADHD contribute to earlier onset of
smoking and greater se6erity of nicotine dependence?
Our finding that ADHD was related to severity of
nicotine dependence and younger age of onset of regular smoking (in males; hypothesis 1) is consistent with
and extends previous work in predominantly non-CD/
SUD male samples (Milberger et al., 1997). Our own
prior work in a male sub-sample of the present report
showed that ADHD (Thompson et al., 1996) was associated with more severe SUD and to the earlier onset of
both CD and SUD (Thompson et al., 1996). Altogether
our work and that of others seems to support the
notion that ADHD with CD may ‘pull down’ the age
of onset of smoking and CD, at least in males, as well
as contribute to severity of nicotine dependence, as well
as reduce the time of escalation to further SUD.
Since both ADHD and CD are more common in
males and ADHD has onset prior to age 7, very early
smoking prevention efforts may be especially important
in very young preadolescent males with CD and
ADHD. This is also consistent with work by Pomerleau
et al. (1995) demonstrating that male adult smokers
with ADHD have a much lower quit rate compared to
the general population (males with ADHD, 23% quit
successfully, compared to 51.6% in the general population). Whereas females with ADHD have an equivalent
quit rate to non-ADHD females (45% in both ADHD
and non-ADHD). This may also be consistent with
literature on adolescent alcohol dependence supporting
that disruptive behavior disorders, especially ADHD
co-occurring with CD, may be more relevant for males
than females regarding the etiology of alcohol use
disorders (Barkley, 1990; Wilens et al., 1996).
It is somewhat surprising that there were no significant gender differences in the number of ADHD symptoms or in those meeting diagnostic criteria for ADHD
in this sample given that the prevalence of ADHD in
general population studies and most clinical samples is
higher in males than in females (Barkley, 1990). One
possible explanation is that the prevalence of ADHD is
higher among conduct-disordered females with SUD
than in the general population. This would also be
supported by our own previous work (Thompson et al.,
1996). Another possible explanation is that the self-report of ADHD symptoms on DISC (in the current
study) or in studies which rely largely on adult retrospective recall of ADHD symptoms (Pomerleau et al.,
1995) may be assessing overlapping symptoms of depression and/or anxiety in the females compared to
males given that most studies show that MDD and
PTSD are more strongly associated with SUD in females compared to males (Clark et al., 1997). Further
research is needed to clarify this issue.
202
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
4.3.1. Does MDD contribute to se6erity of nicotine
dependence?
Our finding that MDD, in both males and females
with CD and SUD, was related to more severe nicotine
dependence also extends previous research in predominantly non-CD/SUD samples and points to the clinical
importance of early assessment and treatment of depression in children and adolescents who have or who
are at risk to develop CD and SUD (Breslau et al.,
1993; Brown et al., 1996; Milberger et al., 1997). The
onset of MDD is generally later than ADHD, which
may explain why earlier age of onset of regular smoking was not associated with MDD, but was associated
with ADHD (which has onset prior to age seven)
severity in males. Our findings regarding depression
also suggest that for both males and females, it is
important for clinicians to carefully assess conduct-disordered children and adolescents for MDD and to
integrate the treatment of depression with that of CD
and SUD. Moreover, since both MDD and smoking
generally preceed the onset of CD and illicit SUD
(Riggs et al., 1995; Birmaher et al., 1996) in children or
adolescents who later develop these disorders, the early
identification of depressed children and younger adolescents who smoke may provide an important opportunity for possible intervention and prevention of further
CD and SUD. This point is also supported by the
prospective study of Kandel et al. (1992) which assessed
adult sequelae of adolescent depressive symptoms in a
cohort of high school students initially interviewed at
ages 15–16 and then followed 9 years later at ages
24 – 26. When assessed in young adulthood, both current and lifetime cigarette smoking were strikingly
higher in individuals who were depressed as adolescents. Our results also support the notion that MDD
appears to be just as important a contributor to
nicotine severity in males with CD as in females (hypothesis 2).
Our findings are also consistent with Clark et al.
(1997) demonstrating that CD and MDD tend to occur
together in both female and male adolescents with
alcohol dependence and contribute to SUD severity in
both males and females. Other studies, too, have shown
that adolescent MDD predicted onset of cigarette
smoking and that adolescent smokers were twice as
likely to develop episode of MDD and seven times as
likely to develop drug abuse/dependence in ensuing 12
months as non-smokers (Brown et al., 1996). One important conceptualization of this bi-directional relationship is posited by Fergusson et al. (1996), who states
that depression may not be a specific risk factor for
smoking and vice versa, but rather smoking and the
constellation of problems that include problematic use
of substances, problems in school, and conflict with
parents may serve as a trigger for depression. Thus,
they speculate that the specific relationship of smoking
with depression may become less important than the
crises often associated with drug abuse and disruptive
behavior disorder.
4.4. Directions for Future Research
Future research is needed to establish whether: (1)
treatment of ADHD and/or depression assists in smoking cessation or reduces the severity of nicotine dependence; and whether (2) treatment of nicotine
dependence improves ADHD and/or depression. Moreover, the relationship of comorbidities such as ADHD
and MDD with nicotine dependence and other SUD
emphasizes the need to develop and test pharmacotherapies which may target nicotine dependence, ADHD,
and/or depression simultaneously. Although our data
did not bear directly on this issue, one such promising
pharmacotherapy may be bupropion hydrochloride,
which has efficacy for smoking cessation (in adults;
Hurt et al., 1997), treating ADHD (in children and
adolescents; Casat et al., 1987; Clay et al., 1988; Wolfe
et al., 1993; Conners et al., 1996), and as an antidepressant (demonstrated in adults; Abramowicz, 1989). Its
efficacy in all three disorders may be due to its action as
an indirect dopamine agonist (especially in the nucleus
accumbens) coupled with noradrenergic activity, a common neurobiology to all of these disorders (Shea and
Wang, 1985; Conners et al., 1996; Plizka et al., 1996;
Spencer et al., 1996). In an open-label trial of bupropion in a small sample of adolescent males (n=13)
similar to those in the current report, bupropion appeared to be a promising agent in treatment of ADHD
in non-depressed adolescents with CD/SUD (Riggs et
al., in press). These results also offered preliminary
evidence that the treatment of ADHD with bupropion
in these males may also enhance their progress in the
treatment for both CD and substance use disorders.
The smoking outcome with bupropion treatment, however, was not assessed in this study.
In addition to the demonstrated efficacy of nicotine
replacement therapies for smoking cessation (Tonnesen
and Fagerstrom, 1994), there is also new evidence that
nicotine may treat symptoms of both ADHD (Conners
et al., 1996, Levin et al., 1996) and depression (SalinPascua et al., 1998). Thus, pharmacotherapies that
show promise for targeting both nicotine dependence
and other common comorbidities in these youth warrant further investigative work. Psychosocial interventions such as cognitive-behavioral treatment and
behavioral treatments targeting comorbid disorders
such as depression (Brent et al., 1997), ADHD, and
possibly PTSD should also be empirically tested in
conduct disordered youth with SUD assessing outcomes on smoking and other substance use. Smoking
(and other substance) prevention efforts for high-risk
children also need further research. Early behavioral
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
dysregulation, hyperactivity, impulsivity, inattention,
and aggressivity have all been implicated as etiological
factors in the development of substance abuse (Martin
et al., 1994). Early intervention for these characteristics
through parent training has been suggested to be preventative of CD (Kazdin, 1997), and to reduce the risk
for SUD (Clark et al., 1997). Moreover, childhood and
adolescent smoking should alert clinicians of the likelihood of other co-occurring psychiatric disorders, especially disruptive behavioral behaviors and MDD.
4.5. Limitations of the study
The findings reported here must be weighed against
the limitations of the study. First, we report cross-sectional data and are thus unable to comment or assess
longitudinal or etiological questions regarding relationships of the identified comorbid disorders. Nonetheless,
this is the first study to our knowledge to report the
relationship of cigarette smoking to other comorbid
psychiatric disorders and gender differences in a large
sample of conduct-disordered adolescents with SUD.
Second, we rely exclusively on adolescent self-report of
symptoms on structured diagnostic interviews. Third,
we report on an extreme sample of adolescents with
multiple comorbidities, which may limit the generalizability of our findings. A strength of assessing such an
extreme sample is that it may help to illuminate the
relationships of cigarette smoking to other comorbidity
and substance use in a group of adolescents most likely
to have the behaviors. Other studies assessing less extreme samples often have limited sample sizes of the
youths of interest, and thus have limited power in
explaining the relationships of these multiple comorbidities. Moreover, past studies have often excluded children with multiple comorbid disorders, which may limit
the generalizability of their findings to children referred
for mental health treatment who are most often comorbid (Jensen et al., 1997).
4.6. Summary
In conclusion, our findings that MDD and ADHD
contribute to severity of nicotine dependence in delinquent adolescents and that the combination of these
disorders and early onset of smoking contribute significantly to the severity of other substance dependence in
such youth, and emphasize the necessity for coordinated assessment and treatment of smoking cessation
along with treatment of other psychiatric comorbidity.
Otherwise, treatment success with such adolescents may
be limited. Future research is needed to assess whether
early intervention in smoking prevention or cessation
and other psychiatric disorders comorbid with smoking
will prevent or reduce later development of drug abuse
and further behavior problems. Finally, it is important
203
to develop and research new pharmacotherapies that
have the potential for treating multiple aspects of the
‘general deviance syndrome’ including nicotine and
other substance dependence as well as conduct disorder
and other associated comorbidity.
Acknowledgements
This research was supported by grants DA 000293,
DA 06941, and DA 09842 from the National Institute
on Drug Abuse.
References
Abramowicz, M., (Ed.), 1989. Bupropion for Depression. Medical
Letter on Drugs Therapeutics. Issue 804, pp. 97 – 98.
American Cancer Society, 1997. Cancer Facts and Figures.
American Psychiatric Association, 1987. Diagnostic and Statistical
Manual of Mental Disorders, 3rd ed., Revised (DSM-III-R).
American Psychiatric Association, Washington, DC.
American Psychiatric Association 1994. Diagnostic and Statistical
Manual of Mental Disorders, 4th ed., (DSM-IV). American Psychiatric Association, Washington, DC.
Barkley, R.A., 1990. Attention-Deficit Hyperactivity Disorder. A
Handbook for Diagnosis and Treatment. Guilford, New York.
Biederman, J., Wilens, T., Mick, E., Faraone, S.V., Weber, W.,
Curtis, S., Thornell, A., Pfister, K., Jetton, J., Soriano, J., 1997. Is
ADHD a risk factor for psychoactive substance use disorders?
Findings from a four year prospective follow-up study. J. Am.
Acad. Child Adolesc. Psychiatr. 36, 21 – 29.
Birmaher, B., Ryan, N.D., Williamson, D.E., Brent, D.A., Kaufman,
J., Dahl, R.E., Perel, J., Nelson, B., 1996. Childhood and adolescent depression: a review of the past 10 years. Part I. J. Am.
Acad. Child Adolesc. Psychiatr. 35, 11.
Brent, D.A., Holder, D., Kolko, D., et al., 1997. A clinical psychotherapy trial for adolescent depression comparing cognitive,
family, and supportive therapy. Arch. Gen. Psychiatr. 54, 877–
885.
Breslau, N., Andreski, P., Kilbey, M., 1993. Nicotine dependence and
major depression: new evidence from a prospective investigation.
Arch. Gen. Psychiatr. 50, 31 – 35.
Breslau, N., Kilbey, M., Andreski, P., 1994. DSM-III-R Nicotine
dependence in young adults: prevalence, correlates, and associated
psychiatric and disorders. Addiction 89 (6), 743 – 754.
Brown, R.A., Lewinsohn, P.M., Seeley, J.R., Wagner, E.F., 1996.
Cigarette smoking, major depression, and other psychiatric disorders among adolescents. J. Am. Acad. Child Adolesc. Psychiatr.
35, 1602 – 1610.
Casat, C.D., Pleasants, D.Z., Vanwy, C.K., Fleet, J., 1987. A doubleblind trial of bupropion in children with attention deficit disorder.
Psychopharm. Bull. 23, 120 – 122.
Choi, W.S., Patten, C.A., Gillin, J.C., Kaplan, R.M., Pierce, J.P.,
1997. Cigarette smoking predicts development of depressive symptoms among US adolescents. Ann. Behav. Med. Winter 19 (1),
42 – 50.
Clark, D.B., Pollock, N., Bukstein, O., Mezzich, A.C., Bromberg, J.,
Donovan, J.E., 1997. Gender and co-morbid psychopathology in
adolescents with alcohol dependence. J. Am. Acad. Child Adolesc. Psychiatr. 36, 1195 – 1203.
Clay, T.H., Gualtieri, C.T., Evans, R.W., Guilliow, C.M., 1988.
Clinical and neuropsychological effects of the novel antidepressant bupropion. Psychopharm. Bull. 24, 143 – 148.
204
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
Conners, C.K., Levin, E.D., Sparrow, E., Hinton, S.C., Erhardt, D.,
Meck, W.H., Rose, J.E., 1996. Nicotine and attention in adult
attention deficit hyperactivity disorder (ADHD). Psychopharm.
Bull. 32, 67 – 73.
Cottler, L., Robins, L., Helzer, J., Becker, J., 1989. The reliability of
the CIDI-SAM. Br. J. Addict. 84, 801–804.
Covey, L.S., Glassman, A.H., Stetner, F., Becker, J., 1993. Effects of
history of alcoholism or major depression on smoking cessation.
Am. J. Psychiatr. 150 (10), 1545–1547.
Covey, L.S., Glassman, A.H., Stetner, F., 1997. Major depression
following smoking cessation. Am. J. Psychiatr. 54 (2), 263 – 265.
Duncan, T.E., Tildesley, E., Duncan, S.C., Hops, H., 1995. The
consistency of family and peer influences on the development of
substance use in adolescence. Addiction 90, 1647–1660.
Fergusson, D.M., Lynskey, M.T., Horwood, L.J., 1996. Comorbidity
between depressive disorders and nicotine dependence in a cohort
of 16-year-olds. Arch. Gen. Psychiatr. 53 (11), 1043–1047.
Fisher, P.W., Shaffer, D., Piacentini, J.C., Lapkin, J., Kafantaris, V.,
Leonard, H., Herzog, D., 1993. Sensitivity of the Diagnostic
Interview Schedule for Children, 2nd ed. (DISC 2.1) for specific
diagnoses of children and adolescents. J. Am. Acad. Child Adolesc. Psychiatr. 32, 666–673.
Glassman, A.H., Helzer, J.E., Covey, L.S., et al., 1990. Smoking,
smoking cessation, and major depression. J. Am. Med. Assoc. 264
(12), 1546 – 1549.
Greenbaum, P.E., Prange, M.E., Friedman, R.M., Silver, S.E., 1991.
Substance abuse prevalence and comorbidity with other psychiatric disorders among adolescents with severe emotional disturbances. J. Am. Acad. Child Adolesc. Psychiatr. 30, 575–583.
Hollingshead, A.B., Redlich, R.C., 1958. Social Class and Mental
Illness: A Community Study. Wiley, New York.
Hurt, R.D., Sachs, D.P.L., Glover, E.D., Offord, K.P., Johnston,
J.A., Dale, L.C., Khayrallah, M.A., Schroeder, D.R., Glover,
P.N., Sullivan, C.R., Croghan, I.T., Sullivan, P.M., 1997. A
comparison of sustained-release bopropion and placebo for smoking cessation. N. Engl. J. Med. 337, 1195–1202.
Jensen, P.S., Marten, D., Cantwell, D.P., 1997. Comorbidity in
ADHD: implications for research, practice, and DSM-V. J. Am.
Acad. Child Adolesc. Psychiatr. 36, 1065–1079.
Jessor, R., Jessor, S.L., 1977. Problem Behavior and Psychosocial
Development: A Longitudinal Study of Youth. Academic Press,
New York.
Kandel, D., Yamaguchi, K., 1993. From beer to crack: developmental patterns of drug involvement. Am. J. Public Health 83, 851 –
855.
Kandel, D., Yamaguchi, I., Chen, K., 1992. Stages of progression in
drug involvement from adolescence to adulthood: further evidence for the gateway theory. J. Stud. Alcohol 53, 447–457.
Kazdin, A.E., 1997. Parent managament training: evidence, outcomes, issues. J. Am. Acad. Child Adolesc. Psychiatr. 36 (10),
1349 – 1356.
Kendler, K.S., Neale, M.C., MacLean, C.J., Heath, A.C., Eaves, L.J.,
Kessler, R.C., 1993. Smoking and major depression. A causal
analysis. Arch. Gen. Psychiatr. 50 (1), 36–43.
Levin, E.D., Conners, C.K., Sparrow, E., Hinton, S.C., Erhardt, D.,
Meck, W.H., Rose, J.E., March, J., 1996. Nicotine effects on
adults with attention-deficit/hyperactivity disorder. Psychopharmacology 123 (1), 55–63.
Martin, C.S., Earlywine, M., Blackson, T.C., Vanyukob, M.M.,
Moss, H.B., Tarter, R.E., 1994. Aggressivity, inattention, hyperactivity, and impulsivity in boys at high and low risk for substance abuse. J. Ab. Child Psychol. 22 (2), 174–203.
McLellan, A.T., Luborsky, L., Woody, G.D., O’Brien, C.P., 1983.
An improved and agnostic evaluation instrument for substance
use patients: the Addiction Severity Index. J. Nev. Ment. Dis. 168,
26– 33.
Meyers, K., 1991. Comprehensive Addiction Severity Index —Adolescents. Philadelphia Canter for Studies on Addiction, University of
Pennsylvania VA Medical Center, Philadelphia, PA.
Milberger, S., Biederman, J., Faraone, S.V., Chen, L., Jones, J., 1997.
ADHD is associated with early initiation of cigarette smoking in
children and adolescents. J. Am. Acad. Child Adolesc. Psychiatr.
36, 3744.
Moffitt, T.E., 1993. Adolescence-limited and life-course-persistent
antisocial behavior, a developmental taxonomy. Psycho. Rev. 100,
674 – 701.
Myers, M.G., Stewart, D.G., Brown, S.A., 1998. Progression from
conduct and disorder to antisocial personality disorder following
treatmant for adolescent substance abuse. Am. J. Psychiatr. 155,
479 – 485.
National Center for Health Statistics. Health, United States, 1996.
Public Health Service, Hyattsville, MD, USA.
Newcomb, M.D., 1995. Identifying high-risk youth: Prevalance and
patterns of adolescent drug abuse. In: Rahdert, E., Czechowicz,
D. (Eds.), Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions (NIDA Research Monograph 156). US
Dept of Health and Human Services, Rockville, MD, pp. 7–38.
Offord, D.R., Boyle, M.H., Szatmari, P., Rae-Grant, N.I., Links,
P.S., Cadman, D.T., Byles, J.A., Crawford, J.W., Blum, C.,
Thomas, H., Woodward, C.A., 1987. Ontario Child Health Study.
II. Six-month prevalence of disorder and rates of savice utilization. Arch. Gen. Psychiatr. 44, 832 – 836.
Pederson, L.L., Koval, J.J., O’Connor, K., 1997. Are factors related
to smoking in grade-6 students? Addict. Behav. 22 (2), 169–181.
Plizka, S., McCracken, J., Mass, J., 1996. Catecholamines in attention-deficit disorder: current perspectives. J. Am. Acad. Child
Adolesc. Psychiatr. 35, 264 – 272.
Pomerleau, O.F., Downey, K.K., Stelson, F.W., Pomerleau, C.S.,
1995. Cigarette smoking in adult patients diagnosed with attention deficit hyperactivity disorder. J. Subst. Abuse 7 (3), 373–378.
Riggs, P.D., Baker, S., Mikulich, S.K., Young, S.E., Crowley, T.J.,
1995. Depression in substance-dependent delinquants. J. Am.
Acad. Child Adolesc. Psychiatr. 34, 764 – 771.
Riggs, P.D., Leon, S., Mlkulich, S., Pottle, L., 1998. An open trial of
Bupropion for ADHD in conduct-disordered adoloscents with
substance use disorders. J. Am. Acad. Child Adolesc. Psychiatr.
(in press).
Robins, L.N., Wing, J., Wittchen, H.U., Helzer, J.E., Babor, T.F.,
Burke, J., Farmer, A., Jablenski, A., Pickens, R., Regier, D.A.,
Sartorius, N., Towle, L.H., 1988. The Composite International
Diagnostic Interview: an epidemiological instrument suitable for
use in conjunction with different diagnostic systems and in different cultures. Arch. Gen. Psychiatr. 45, 1069 – 1077.
Salin-Pascua, R.J., Drucker-Colin, R., 1998. A novel effect of
nicotine on mood and sleep in major depression. Neuroreport 5 9
(1), 57 – 60.
Shea, V.K., Wang, C.M., 1985. Bupropion (Wellbutrin) inhibits the
firing rate of noradrenagic but not serotonergic neurons. Soc.
Neurosci. Abstr. 11, 185.
Spencer, T., Biederman, J., Wilens, T., Harding, M., O’Donnell, D.,
Griffin, S., 1996. Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J. Am. Acad. Child Adolesc.
Psychiatr. 35, 409 – 432.
SPSS, 1990. SPSS Reference Guide. SPSS, Chicago, IL.
Szatmari, P., Boyle, M., Offord, D.R., 1989. ADDH and CD: degree
of diagnostic overlap and differences among correlates. J. Am.
Acad. Child Adolesc. Psychiatr. 28, 865 – 872.
Thompson, L.L., Riggs, P.D., Mikulick, S.K., Crowley, T.J., 1996.
Contnbution of ADHD symptoms to substance problems and
delinquency in conduct disordered adolescents. J. Abnorm. Psychol. 24, 325 – 347.
Tonnesen, P., Fagerstrom, K.O., 1994. Nicotine replacement. In:
Richmond, R., (Ed.), Interventions for Smokers: An International
Perspective. Williams & Wilkins, Baltimore, MD, USA.
P.D. Riggs et al. / Drug and Alcohol Dependence 54 (1999) 195–205
Wang, M.Q., Fitzhugh, E.C., Turna, L., Fu, Q., Westerfield, R.C.,
1996. Association of depressive symptoms and school adolescents’
smoking: a cross-lagged analysis. Psychol. Rep. 79 (1), 127 – 130.
Weinberg, N.Z., Rahdert, E., Colliver, J.D., et al., 1998. Adolescent
substance abuse: a review of the past 10 years. J. Am. Acad. Child
Adolesc. Psychiatr. 37 (3), 252–261.
Whitmore, E.A., Mikulich, S.K., Thompson, L.L., Riggs, P.D.,
Aarons, G.A., Crowley, T.J., 1997. Influences on adolescent substance dependence: conduct disorder, depression, attention deficit
hyperactivity disorder, and gender. Drug Alcohol Depend. 47,
87– 97.
Wilens, T.E., Biederman, J., Spencer, T.J., 1996. Attention-deficit
hyperactivity disorder and the psychoactive substance use disorders. Child Adolesc. Psychiatr. Clin. North Am. 5 (1), 73 – 91.
.
205
Windle, M., 1990. A longitudinal study of antisocial behaviors in
early adolescence as predictors of late adolescent substance use:
gender and ethnic group differences. J. Abnorm. Psychol. 99,
86 – 91.
Wolfe, K.D., Weller, E.B., Weller, R.A., Fristad, M.A., Mac, D.,
1993. Treating children with attention-deficit disorda: a doubleblind bupropion trial. Am. Acad. Child Adolesc. Psychiatr. 40th
Annual Meeting, San Antonio, TX, USA.
Young, S.E., Mikulich, S.K., Goodwin, M.B., Hardy, J., Martin,
C.L., Zoccolillo, M.S., Crowley, T.J., 1995. Treated delinquent
boys substance use: onset, pattern, relationship to conduct and
mood disorders. Drug Alcohol Depend. 37, 149 – 162.
Zoccolillo, M., 1992. Co-occurrence of conduct disorder and its adult
outcomes with depressive and anxiety disorders: a review. J. Am.
Acad. Child Adolesc. Psychiatr. 31, 547 – 556.