University of Oulu

Mustonen, A, Rodriguez, A, Scott, JG, et al. Attention deficit hyperactivity and oppositional defiant disorder symptoms in adolescence and risk of substance use disorders—A general population-based birth cohort study. Acta Psychiatr Scand. 2023; 148(3): 277-287. doi:10.1111/acps.13588

Attention deficit hyperactivity and oppositional defiant disorder symptoms in adolescence and risk of substance use disorders : a general population-based birth cohort study

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Author: Mustonen, Antti1,2,3; Rodriguez, Alina4,5; Scott, James G.6,7;
Organizations: 1Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
2Department of Psychiatry, Seinäjoki Central Hospital, Seinäjoki, Finland
3Research Unit of Population Health, University of Oulu, Oulu, Finland
4Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
5Centre for Psychiatry and Mental Health, Queen Mary University, London, UK
6Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
7Child and Youth Mental Health, Children's Health Queensland, South Brisbane, Queensland, Australia
8Research Center for Child Psychiatry, INVEST Research Flagship, University of Turku, Turku, Finland
9The Finnish Institute for Health and Welfare, Helsinki, Finland
10Research Unit of Clinical Medicine, Psychiatry, University of Oulu, Oulu, Finland
11Clinic of Child Psychiatry, Oulu University Hospital, Oulu, Finland
12Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
13Department of Psychiatry, Oulu University Hospital, Oulu, Finland
14Department of Psychiatry, University of Turku, Turku, Finland
15Addiction Psychiatry Unit, Department of Psychiatry, Turku University Hospital, Turku, Finland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 1.2 MB)
Persistent link:
Language: English
Published: John Wiley & Sons, 2023
Publish Date: 2023-10-20


Background: Externalizing symptoms are associated with risk of future substance use disorder (SUD). Few longitudinal studies exist using general population-based samples which assess the spectrum of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms.

Aims/Objectives: We aimed to study the associations between adolescent ADHD symptoms and subsequent SUD and additionally examine whether the risk of SUD is influenced by comorbid oppositional defiant disorder (ODD) symptoms.

Methods: The Northern Finland Birth Cohort 1986 was linked to nationwide health care register data for incident SUD diagnoses until age 33 years (n = 6278, 49.5% male). ADHD/ODD-case status at age 16 years was defined using parent-rated ADHD indicated by Strengths and Weaknesses of ADHD symptoms and Normal Behaviors (SWAN) questionnaire with 95% percentile cut-off. To assess the impact of ODD comorbidity on SUD risk, participants were categorized into four groups based on their ADHD/ODD case status. Cox-regression analysis with hazard ratios (HRs) and 95% confidence intervals (CIs) were used to study associations between adolescent ADHD/ODD case statuses and subsequent SUD.

Results: In all, 552 participants (8.8%) presented with ADHD case status at the age of 16 years, and 154/6278 (2.5%) were diagnosed with SUD during the follow-up. ADHD case status was associated with SUD during the follow-up (HR = 3.84, 95% CI 2.69–5.50). After adjustments for sex, family structure, and parental psychiatric disorder and early substance use the association with ADHD case status and SUD remained statistically significant (HR = 2.60, 95% CI 1.70–3.98). The risk of SUD remained elevated in individuals with ADHD case status irrespective of ODD symptoms.

Conclusions: ADHD in adolescence was associated with incident SUD in those with and without symptoms of ODD. The association of ADHD and SUD persisted even after adjustment for a wide range of potential confounds. This emphasizes the need to identify preventative strategies for adolescents with ADHD so as to improve health outcomes.

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Series: Acta psychiatrica Scandinavica
ISSN: 0001-690X
ISSN-E: 1600-0447
ISSN-L: 0001-690X
Volume: 148
Issue: 3
Pages: 277 - 287
DOI: 10.1111/acps.13588
Type of Publication: A1 Journal article – refereed
Field of Science: 3124 Neurology and psychiatry
Funding: NFBC1986 has received funding from EU QLG1-CT-2000-01643 (EUROBLCS) Grant no. E51560, NorFA Grant no. 731, 20056, 30167, USA/NIH 2000G DF682 Grant no. 50945. For this study, Antti Mustonen has received funding from Juho Vainio Foundation, Emil Aaltonen Foundation, The Hospital District of South Ostrobothnia, and The Finnish Foundation for Alcohol Studies. Anu-Helmi Halt and Tuula Hurtig have received funding from Terttu foundation. Solja Niemelä has received funding from Juho Vainio foundation, Sohlberg foundation. James G. Scott is supported by a National Health and Medical Research Council Practitioner Fellowship (APP1105807). Jouko Miettunen has received funding from Juho Vainio Foundation and from the Yrjö Jahnsson Foundation. Miika Vuori reports no potential conflicts of interest.
Dataset Reference: NFBC data are available from the University of Oulu, Infrastructure for Population Studies. Permission to use the data can be applied for research purposes via electronic material request portal. In the use of data, we follow the EU general data protection regulation (679/2016) and Finnish Data Protection Act. The use of personal data is based on cohort participant's written informed consent at his/her latest follow-up study, which may cause limitations to its use. Please, contact NFBC project center (NFBCprojectcenter(at) and visit the cohort website for more information.
Copyright information: © 2023 The Authors. Acta Psychiatrica Scandinavica published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.