Kurt Cobain was wrong – the treatment of Attention Deficit Hyperactivity Disorder with Methylphenidate does not predispose to substance misuse indeed precisely the opposite is true.  Adults with Attention Deficit Hyperactivity Disorder have difficulties tending to tasks and activities and inhibiting their impulses. They have a poor ability to sustain attention over long periods, and are unable to concentrate on short, focussed work. They act without thinking, often resulting in reckless and impetuous behaviour.  Indeed, impulsiveness may be an important defining characteristic of Attention Deficit Hyperactivity Disorder in adulthood.  Although they do not necessarily present with the overactive behaviour frequently seen in children they feel restless.  As a result an individual may act without reflection or consideration for the consequences of action.  They may be disorganised, forgetful, and have planning deficits and poor time management skills.  Impetuous novelty-seeking behaviour may result in criminal acts, substance misuse and dependence according to Susan Young a psychologist who focuses on adult Attention Deficit Hyperactivity Disorder.  About 4.4% of adults in the community have adult Attention Deficit Hyperactivity Disorder.  Unfortunately there is an error in DSM-IV diagnosis for Attention Deficit Hyperactivity Disorder. Particularly with adults the age seven cut off is unsatisfactory and it is likely in future that onset in primary school or before the age of 12 will be accepted rather than onset before the age of seven.  In making the diagnosis multiple informants are very helpful or information from parents of a person with adult Attention Deficit Hyperactivity Disorder or school records to improve diagnosis.  It is more common in males than females.  Clearly there is a great deal of comorbidity particularly in the area with Antisocial Personality Disorder, substance misuse, and depression.  They have often poor occupational histories and considerable breakdown in the long term in interpersonal relationships, marriages etc. They often feel socially isolated and misunderstood.  This is unfortunate since there is relatively good treatment available.  Nevertheless they can be successful particularly in the artistic areas.  John Osbourne, Clark Gable, Jesse James, George Carman, and Kenneth Tynan had adult Attention Deficit Hyperactivity Disorder.

Kurt Cobain had Attention Deficit Hyperactivity Disorder, and was prescribed Methylphenidate when he was at school. Unfortunately he only took it for three months.  The impression was given later that this was a factor in his developing substance abuse. Indeed precisely the opposite is the truth.  Persons who are treated for Attention Deficit Hyperactivity Disorder on a continuous basis with Methylphenidate are less likely to abuse substances as they get older. The abuse of drugs like cannabis or cocaine is often a feature of self-medication for Attention Deficit Hyperactivity Disorder.  The increased use of cigarettes by persons with Attention Deficit Hyperactivity Disorder may also be done for the same reason.  There is no doubt that persons with Attention Deficit Hyperactivity Disorder have an earlier onset of cigarette smoking and a greater use of it. There is no evidence for long term risks for substance use disorders in persons prescribed Methylphenidate. Indeed there is a reduced likelihood of substance misuse if Attention Deficit Hyperactivity Disorder is properly treated with stimulants.  This doesn’t mean that there aren’t some risks from stimulants i.e. through diversion. A new medication for Attention Deficit Hyperactivity Disorder Atomoxetine has been shown to have no greater abuse liability than Desipramine an antidepressant or placebo. Unfortunately Attention Deficit Hyperactivity Disorder is a serious condition which requires early intervention and the misinformation about it is preventing some children from getting the treatment that they need.

Children with Attention Deficit Hyperactivity Disorder are at risk of increasing complications as they get older.  They start in childhood with Attention Deficit Hyperactivity Disorder alone and then can develop disruptive behaviour disorders, oppositional disorders, challenging behaviour, and later from about 14 years onwards they experience often school exclusion, substance abuse, mood disorder, conduct disorder, and finally antisocial personality disorder and often get involved with the law at the same time.  Of course this trajectory only occurs in those with severe Attention Deficit Hyperactivity Disorder and severe complications.  Comorbid Oppositional Defiant Disorder occurs in over 40%, Conduct Disorder in 20 to 56%, delinquent and antisocial activities in 18 to 30%. Many continue their problems into adulthood and they are more likely to enter the workforce at unskilled or semi skilled level. They are twice as likely to be dismissed from their employment, tend to have many more jobs than the average, and to show much lower work performance than the average.

In examining motor vehicle driving risks persons with Adult Attention Deficit Hyperactivity Disorder are 60% more likely to have a crash with injuries as compared to 17% of the general population. As well as having much more accidents they tend to have worse accidents.  They have four times higher risk of having sexually transmitted diseases because of their earlier onset of sexual activity and their increased number of sexual partners.  In addition they are less likely to employ contraception and spend less time with each partner than the average population.  Girls with Attention Deficit Hyperactivity Disorder are over 9 times more likely to have a teen pregnancy than those without Attention Deficit Hyperactivity Disorder.  The judicial costs of having Attention Deficit Hyperactivity Disorder are vastly increased as compared to people without Attention Deficit Hyperactivity Disorder. In America it has been estimated that the total criminal costs for persons with Attention Deficit Hyperactivity Disorder and Conduct Disorder combined are 37,830 dollars.

Unfortunately Adult Attention Deficit Hyperactivity Disorder is largely missed as a diagnosis.  It appears to me that the  next most missed diagnosis in adults is Asperger’s syndrome which nowadays tends to misdiagnosed as Mild Bipolar disorder.  It tended in the past (and this still occurs in the present) to be misdiagnosed as Personality disorder or Schizophrenia.  This meant they didn’t get the treatment they needed and got inappropriate treatment.  A typical example is the novelist who was nominated for a Nobel Prize Janet Frame who was diagnosed with Schizophrenia outside Europe.  She was put on a list for lobotomy in 1952.  She was told by the Maudsley Hospital later that she did not have Schizophrenia.  She died in 2004.  In actual fact she had Asperger’s syndrome.  There may be thousands in a similar situation throughout the world with misdiagnosis of psychiatric disorder.  Hopefully the Irish College of Psychiatrists, Irish Psychiatric Association and those responsible for C.M.E. will take up this issue.

Going back to Kurt Cobain he would have a much greater chance of having survived if he persisted taking his Methylphenidate on a regular basis and had intensive multimodal treatment for his Attention Deficit Hyperactivity Disorder and associated problems.  He showed the majority of comorbidities that one can get with Attention Deficit Hyperactivity Disorder.  It was not surprising that he completed suicide.

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