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Experimental and Clinical Psychopharmacology © 2014 American Psychological Association

2014, Vol. 22, No. 2, 110 –121 1064-1297/14/$12.00 DOI: 10.1037/a0035656

Heavy Alcohol Use in Early Adulthood as a Function of Childhood

ADHD: Developmentally Specific Mediation by Social Impairment
and Delinquency

Brooke S. G. Molina and Christine A. P. Walther JeeWon Cheong

University of Pittsburgh University of Alabama, Birmingham

Sarah L. Pedersen Elizabeth M. Gnagy and William E. Pelham, Jr.

University of Pittsburgh Florida International University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Frequent heavy drinking in early adulthood, particularly prior to age 21, is associated with multiple health
and legal consequences including continued problems with drinking later into adulthood. Children with
attention-deficit/hyperactivity disorder (ADHD) are at risk of alcohol use disorder in adulthood, but little
is known about their frequency of underage drinking as young adults or about mediational pathways that
might contribute to this risky outcome. The current study used data from the Pittsburgh ADHD
Longitudinal Study to test social impairment and delinquency pathways from childhood ADHD to heavy
drinking in early adulthood for individuals with (n ⫽ 148) and without (n ⫽ 117) childhood ADHD.
Although ADHD did not predict heavy drinking, indirect mediating effects in opposing directions were
found. A delinquency pathway from childhood ADHD to increased heavy drinking included adolescent
and subsequently adult delinquent behavior. A social impairment pathway from childhood ADHD to
decreased heavy drinking included adolescent, but not adult, social impairment. These findings help
explain the heterogeneity of results for alcohol use among individuals with ADHD and suggest that
common ADHD-related impairments may operate differently from each other and distinctly across
developmental periods.

Keywords: attention deficit disorder, alcohol, mediation, developmental, social behavior

Alcohol use typically begins in adolescence and increases in Wood, 2001; B. O. Muthén & Muthén, 2000). Excessive use of
frequency until it reaches its peak prevalence in the United alcohol, including the consumption of five or more drinks
States between ages 18 and 25 (Jackson, Sher, Gotham, & within 2 hr (four or more for women), is widespread among
young adults including underage drinkers (less than 21 years of
age). Findings from the 2010 National Survey on Drug Use and
Health (Substance Abuse and Mental Health Services Admin-
This article was published Online First March 10, 2014. istration, 2012) indicated that 37.3% of 20-year-olds reported
Brooke S. G. Molina, Departments of Psychiatry and Psychology, Uni- binge drinking in the past 30 days, and 13.7% reported past-
versity of Pittsburgh; Christine A. P. Walther, Department of Psychology, month “heavy drinking” (binge drinking on at least 5 days of
University of Pittsburgh; JeeWon Cheong, Department of Health Behavior, the past 30). Although excessive underage drinking is more
University of Alabama, Birmingham; Sarah L. Pedersen, Department of
frequent among college students (Substance Abuse and Mental
Psychiatry, University of Pittsburgh; Elizabeth M. Gnagy, Department of
Psychology, Florida International University; William E. Pelham, Jr., De-
Health Services Administration, 2003), it also reaches its peak
partments of Psychology and Psychiatry, Florida International University. during this age range for the general population, and it is
Grants AA011873 and AA00202 from the National Institute on Alcohol associated with multiple negative consequences such as injury
Abuse and Alcoholism and Grant DA12414 from the National Institute on and participation in other risk behaviors (Hingson, Zha, &
Drug Abuse, awarded to Brooke Molina and William Pelham, funded the Weitzman, 2009; Substance Abuse and Mental Health Services
Pittsburgh ADHD Longitudinal Study, which was the data source for this Administration, 2003, 2006). Excessive alcohol use is also
project. Additional funding was provided by Grants AA12342, AA00202, associated with increased risk of alcohol use disorder (Knight et
MH50467, MH12010, ESO5015, DA016631, MH065899, KAI-118-S1, al., 2002; Merline, O’Malley, Schulenberg, Bachman, & John-
DA85553, MH077676, MH069614, MH62946, MH065899, MH53554, ston, 2004). Consequently, identification of vulnerable sub-
MH069434, IES LO3000665A, IESR324B060045, and NS39087. Portions
groups of the population has been an important research agenda
of this study were presented at the 2010 Annual Meeting of the Research
Society on Alcoholism, San Antonio, TX.
in the effort to understand alcoholism risk and to develop
Correspondence concerning this article should be addressed to Brooke targeted interventions.
S. G. Molina, Department of Psychiatry, University of Pittsburgh School of Children with attention-deficit/hyperactivity disorder (ADHD)
Medicine, 3811 O’Hara Street, Pittsburgh, PA 15213. E-mail: molinab@ have been found, in meta-analytic reviews (Charach, Yeung, Cli-
upmc.edu mans, & Lillie, 2011; Lee, Humphreys, Flory, Liu, & Glass, 2011),


to have increased risk of alcohol disorders (abuse or dependence) cessive drinking may reflect common genetic influences (Edwards
in adulthood. The magnitude of the risk is modest, with an aggre- & Kendler, 2012; Slutske et al., 1998) as well as socialized beliefs,
gated odds ratio of 1.74 across 11 studies of children with ADHD attitudes, and behaviors favorable to both types of outcomes
followed longitudinally into adulthood (Lee et al., 2011). Prospec- (Chassin et al., in press; Tarter et al., 2011). Dispositional tenden-
tive longitudinal studies have supported this association in clinical cies related to ADHD, such as impulsivity, are also established risk
and epidemiologic samples (Elkins, McGue, & Iacono, 2007; factors for conduct problems and alcohol or other substance use in
Knop et al., 2009; Sihvola et al., 2011; Wilens et al., 2011), adolescents and young adults (Caspi, Moffitt, Newman, & Silva,
although exceptions exist (e.g., Fischer, Barkley, Smallish, & 1996; Martel et al., 2009; Tarter et al., 2012). Similar to findings
Fletcher, 2002; Klein et al., 2012; Lambert & Hartsough, 1998). from nonreferred samples (Brook, Brook, Zhang, & Koppel,
Studies of the link between ADHD and problem drinking have 2010), we recently found support for a “delinquency pathway”
increased in recent years because of the overlap between the core from childhood ADHD to late adolescent alcohol use frequency.
symptoms of the disorder and the personality and temperament Childhood ADHD increased risk of adolescent delinquency, which
traits implicated in alcoholism etiology (Chassin, Colder, Hus- in turn was associated with more frequent drinking at age 17
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

song, & Sher, in press; Molina & Pelham, 2014; Sher, 1991; (Molina et al., 2012). These findings suggest the important possi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Tarter, Kirisci, Feske, & Vanyukov, 2007; Tarter, Kirisci, Ha- bility that, for children with ADHD, underage drinking in adult-
beych, Reynolds, & Vanyukov, 2004; Zucker, 2006). However, hood is part of the etiologic chain of events that characterizes
despite this strong conceptual link, longitudinal studies of child- antisocial alcoholism and includes a poor prognosis (Zucker, Don-
hood ADHD have tended to emphasize alcohol disorders instead ovan, Masten, Mattson, & Moss, 2008). If so, then a pathway from
of alcohol consumption indices, such as heavy drinking frequency childhood ADHD to heavy drinking in adulthood should include
that is known to predict later alcohol disorders (O’Neill, Parra, & an association with delinquent behaviors in adulthood and in
Sher, 2001). This increased risk of continued use and later prob- adolescence, with a mediational pathway that includes both. We
lems is especially relevant for young adults who, like many chil- tested this possibility in the current study.
dren with ADHD (Biederman et al., 2008; Kuriyan et al., 2013;
Mannuzza, Klein, Bessler, Malloy, & Hynes, 1997), do not attend
Social Impairment Pathways
college (Merline et al., 2004).
In one of the few studies to examine heavy drinking frequency It is well established that children with ADHD have social
as an outcome of childhood ADHD, we previously reported high difficulties beginning at a young age (McQuade & Hoza, 2008;
rates of binge drinking for young adults in the Pittsburgh ADHD Pelham & Bender, 1982) that are also present in adolescence and
Longitudinal Study (PALS) regardless of their ADHD history adulthood. For example, longitudinal studies of children with
(Molina, Pelham, Gnagy, Thompson, & Marshal, 2007). With an ADHD report fewer friends and more peer rejection in adolescence
average sample-wide frequency of binge drinking 34 times in the (Bagwell, Molina, Pelham, & Hoza, 2001), fewer friends in adult-
past year (approximately 2 of every 3 weeks), we failed to find hood (Barkley, Fischer, Smallish, & Fletcher, 2006; Belendiuk,
ADHD group differences in this outcome. However, binge- 2013; Weiss & Hechtman, 1993), and more parent-rated social
drinking rates were significantly more frequent for the ADHD problems in adulthood (Barkley et al., 2006). One study reported
versus nonADHD 15- to 17-year-olds. Many studies have shown that boys with ADHD and parent-rated social disability have
long-term prognostic differences between adolescents who do and significantly higher rates of later alcohol use disorders than boys
do not begin to drink heavily at a young age, suggesting increased with ADHD alone and comparison children without ADHD
risk of alcohol use disorder for this population in addition to other (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997),
negative outcomes (e.g., Chassin, Pitts, & Prost, 2002; McCarty et although social disability included relationship difficulties with
al., 2004). Thus, these findings from the initial follow-up interview parents and siblings as well as peers.
of the PALS suggest that despite the typicality of heavy drinking Given the high prevalence of peer problems for individuals with
by all adults in their early 20s, there may be meaningful differ- ADHD, more research is needed on the relation between this
ences in the ontogeny of heavy drinking between adults with and specific aspect of impairment and alcohol use. This need is par-
without ADHD histories, and these differences may be clinically ticularly important given the prominence of peer social influence
and prognostically meaningful. In the current study, we followed and selection processes in discussions of alcohol use in both
the PALS adolescents to the oldest underage drinking endpoint adolescence (Curran, Stice, & Chassin, 1997; Hussong, 2002) and
(age 20) to examine their rates of heavy drinking in early adult- in early adulthood (Wood, Read, Mitchell, & Brand, 2004).
hood and to investigate potential mediating pathways that could We recently found support for a “social deviance” pathway to
lead to prognostic differences regarding long-term consequences adolescent alcohol use for children with ADHD (Molina et al.,
of heavy drinking. 2012). Specifically, adolescents with childhood ADHD had more
problems in relationships with same-aged peers, as rated by par-
ents, which were then associated with higher levels of delinquent
Delinquency Pathway
behavior and, subsequently, higher levels of adolescent alcohol
Alcoholism researchers have, for many years, recognized the use. At the same time, social impairment appeared to “protect”
important contribution made by “deviance proneness” to the de- against drinking in a different mediating pathway in which child-
velopment of alcohol and other substance use disorders in adoles- hood ADHD predicted more social impairment, which in turn
cence (Donovan, Jessor, & Costa, 1999; Jessor & Jessor, 1977) predicted less drinking. We offered the speculation that these
and in adulthood (Sher, 1991). Tendencies toward delinquency, opposing pathways may reflect the heterogeneity of social impair-
sometimes diagnosed categorically as conduct disorder, and ex- ment in ADHD (McQuade & Hoza, 2008). For example, social

isolation, withdrawal, and/or social anxiety (Mikami, Ransone, & sylvania, from 1987 to 1996. Of the 516, 493 were recontacted an
Calhoun, 2011) might decrease drinking in adolescence when average of 8.35 years later (SD ⫽ 2.79) to participate in annual
alcohol use primarily occurs in social contexts (Pedersen, LaBrie, interviews for the PALS. Of those contacted, 364 (70.5%) enrolled
& Lac, 2008). However, childhood ADHD also predicts adolescent in the follow-up study. At the first follow-up interview, partici-
friendships characterized by less conventional activity involve- pants with ADHD histories ranged in age from 11 to 28 years, with
ment (Bagwell et al., 2001) and greater use and tolerance of 99% falling between 11 and 25 years of age. They were admitted
alcohol and other drugs (Marshal, Molina, & Pelham, 2003), and to the follow-up study on a rolling basis between the years 1999 –
these factors contribute more strongly to substance use in the 2003 and completed their first follow-up interview immediately
presence of comorbid behavior problems (Marshal & Molina, upon enrollment.
2006). It is unclear whether these same associations would be All adolescents and young adults with childhood ADHD par-
found in adulthood given the widely accepted use of alcohol in the ticipated in the Summer Treatment Program for children with
early 20s and the associated increased opportunities for drinking ADHD, an 8-week intervention that included behavioral modifi-
(Hussong, Jones, Stein, Baucom, & Boeding, 2011). To our cation, parent training, and psychoactive medication trials when
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

knowledge, there are no studies of children with ADHD that have indicated (Pelham, Fabiano, Gnagy, Greiner, & Hoza, 2005). Di-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

specifically examined peer social impairment longitudinally and in agnostic information for the participants with ADHD histories was
concert with delinquency. collected at initial referral to the clinic in childhood (baseline)
using parent and teacher DSM–III–R and DSM–IV symptom rat-
The Current Study ings scales (disruptive behavior disorders [DBD]; Pelham, Gnagy,
Greenslade, & Milich, 1992) and a semistructured diagnostic in-
In the current study, we tested delinquency and social impair-
terview administered to parents by a doctoral-level clinician. The
ment pathways to underage heavy drinking in early adulthood.
interview consisted of the DSM–III–R or DSM–IV descriptors for
Because of the longitudinal design of the PALS, we were able to
ADHD, oppositional defiant disorder (ODD), and conduct disorder
test these pathways prospectively from childhood ADHD through
(CD) with supplemental probe questions regarding situational and
adolescence into early adulthood (age 20). By doing so, we incor-
severity factors as well as functional impairment. It also included
porated tests of stability in these mediating variables to determine
queries about other comorbidities to determine whether additional
whether social impairment and delinquency influences in adult-
hood extended from their earlier presentations in adolescence. assessment was needed. Following DSM guidelines, diagnoses of
Moreover, our analyses were carried out in the structural equation ADHD, ODD (47%), and CD (36%) were made if a sufficient
modeling framework that included several important features: (a) number of symptoms and clinically significant impairment was
Mediational paths involving social impairment were examined endorsed (considering information from both parents and teachers)
simultaneously with delinquency, which allowed tests of their to result in diagnosis. Two doctoral-level clinicians independently
relative and unique effects; (b) prior alcohol use was controlled to reviewed all ratings and interviews to confirm DSM diagnoses;
test whether these mediational pathways contributed to heavy when disagreement occurred, a third clinician reviewed the file and
drinking in early adulthood over and beyond the contribution of the majority decision was used. Exclusion criteria for participants
drinking in the teen years; and (c) postsecondary school atten- with ADHD histories were assessed in childhood (baseline) and
dance, known to be lower in the ADHD than in the non-ADHD included a full-scale IQ ⬍80 and a history of seizures, neurological
group in this sample (Kuriyan et al., 2013) and in others (e.g., problems, pervasive developmental disorder, schizophrenia,
Barkley et al., 2006; Mannuzza et al., 1997), and known to be and/or other psychotic or organic mental disorders.
associated with increased heavy drinking in early adulthood (Sub- Participants in the follow-up study were compared with the
stance Abuse and Mental Health Services Administration, 2003), eligible individuals who did not enroll in the follow-up study on
was controlled to examine influences on drinking above and be- demographic and diagnostic variables collected at baseline. Only
yond this important contextual factor. The current study represents one of 14 comparisons was statistically significant (p ⬍ .05):
the first attempt to test these pathways longitudinally, to ascertain PALS participants had a slightly lower average CD symptom
their contributions to heavy drinking in early adulthood, in a rating at baseline as indicated by a composite of parent and teacher
prospectively followed sample of children with and without ratings (participants M ⫽ 0.43, nonparticipants M ⫽ 0.53).
ADHD. Non-ADHD group. Participants without ADHD (n ⫽ 240)
were recruited for the PALS from the greater Pittsburgh commu-
Method nity between 1999 and 2001. These individuals were recruited
from several sources including pediatric practices in Allegheny
County (40.8%), advertisements in local newspapers (27.5%),
Participants local universities and colleges (20.8%), and other methods
ADHD group. Participants with childhood ADHD were re- (10.9%), such as Pittsburgh Public Schools and word of mouth.
cruited from a pool of 516 study-eligible participants diagnosed Non-ADHD participant recruitment lagged 3 months behind the
with Diagnostic and Statistical Manual of Mental Disorders (3rd ADHD group enrollment to facilitate efforts to obtain demo-
ed., rev.; DSM–III–R; American Psychiatric Association, 1987) or graphic similarity (discussed below). A telephone screening inter-
Diagnostic and Statistical Manual of Mental Disorders (4th ed.; view was administered to parents of potential non-ADHD partic-
DSM–IV; American Psychiatric Association, 1994) ADHD in ipants to gather basic demographic characteristics, history of
childhood and treated at the Attention Deficit Disorder Clinic at diagnosis or treatment for ADHD and other behavior problems,
the Western Psychiatric Institute and Clinic in Pittsburgh, Penn- presence of exclusionary criteria as previously listed for the

ADHD group, and a checklist of ADHD symptoms. Young adults cation level. A non-ADHD participant was deemed study-eligible
(aged 18⫹) also provided self-report of ADHD symptoms. if his or her enrollment increased the non-ADHD group’s demo-
ADHD symptoms were counted as present if reported by either graphic similarity to the participants diagnosed with ADHD. At the
the parent or the young adult. Non-ADHD individuals meeting end of the recruitment process, the two groups were equivalent on
DSM–III–R criteria for ADHD, either currently or historically, the four demographic variables noted above.
were immediately excluded from study consideration. Based on Subsample for the current study. Data were selected from
parent report with the DBD, none of the non-ADHD group par- the first 13 annual interviews of the PALS for any participants who
ticipants had conduct disorder in childhood. were between 14 and 20 years old at any of the interviews. Thus,
If a potential non-ADHD participant passed the initial phone this subsample of the PALS, selected on the basis of age, primarily
screen, senior research staff members met to determine whether he consists of the younger PALS participants followed longitudinally
or she was demographically appropriate for the study. Each po- to age 20. This sampling resulted in 265 participants (117 non-
tential non-ADHD participant was examined on four demographic ADHD, 148 ADHD participants; see Table 1). There were no
characteristics: (1) age, (2) gender, (3) race, and (4) parent edu- statistically significant differences between the ADHD and non-
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Table 1
Descriptive Statistics by Attention-Deficit/Hyperactivity Disorder (ADHD) Groups

Variable (n ⫽ 117) (n ⫽ 148)

Gender, male, n (%)
Race/ethnicity, n (%) 108 (92.3) 136 (91.9)
Caucasian 96 (82.1) 116 (78.4)
Other 21 (17.9) 30 (20.3)
Socioeconomic advantage, n (%)
Low 2 (1.7) 9 (6.1)
Medium 28 (23.9) 56 (37.8)
High 87 (74.4) 83 (56.1)
Parental psychopathology, n (%)
0 62 (53.0) 29 (19.6)
1 29 (24.8) 41 (27.7)
2 15 (12.8) 33 (22.3)
3⫹ 11 (9.4) 45 (30.4)
Years living at home at ages 18–20, n (%)
0 11 (9.4) 8 (5.4)
1 26 (22.2) 37 (25.0)
2 33 (28.2) 40 (27.0)
3 47 (40.2) 63 (42.6)
Years enrolled in school at ages 18–20, n (%)
0 2 (1.7) 17 (11.5)
1 9 (7.7) 37 (25.0)
2 26 (22.2) 44 (29.7)
3 80 (68.4) 50 (33.8)

Mean (SD) adolescent social impairment 0.18 (0.60) 2.23 (1.68)
Mean (SD) age 20 social impairment 0.14 (0.52) 2.20 (1.88)
Mean (SD) adolescent delinquency 0.03 (0.04) 0.07 (0.08)
Mean (SD) age 20 delinquency 0.04 (0.06) 0.05 (0.07)

Mean (SD) frequency of alcohol use in the past 12 months at age 17 1.68 (1.91) 1.69 (2.42)
Percentage reporting weekly drinking at age 17 4.30 9.50
Mean (SD) frequency of heavy alcohol use at age 20 3.37 (2.54) 2.48 (2.60)
Percentage reporting weekly heavy drinking at age 20 21.40 14.30
Note. For socioeconomic advantage, low ⫽ single parent with high school education or less education,
medium ⫽ single parent with more than high school education or married parent with high school or less
education, high ⫽ married parent with more than high school education. For parent psychopathology, sum score
of absence (0) or presence (1) of mother’s and father’s alcohol use disorder, antisocial personality disorder, or
depression based on parent report on the Structured Clinical Interview for the DSM–IV Axis I and Axis II
disorders and Short Michigan Alcoholism Screening Test (First, Gibbon, Spitzer, Williams, & Benjamin, 1997,
1998; Selzer, Vinokur, & van Rooijen, 1975). For social impairment, 0 ⫽ no problem and 6 ⫽ extreme problem.
For delinquency, score ⫽ proportion of delinquency items endorsed. For frequency of alcohol use at age 17 and
heavy alcohol use at age 20, 0 ⫽ not at all, 1 ⫽ 1–3 times, 2 ⫽ 4 –7 times, 3 ⫽ 8 –11 times, 4 ⫽ once a month,
. . . 11 ⫽ several times a day.

ADHD participants on gender, ␹2(1) ⫽ 0.02, ns; racial/ethnic with same-aged people. Parents rated “How your son’s or daugh-
minority, ␹2(1) ⫽ 0.28, ns; frequency of alcohol use in the past ter’s problems affect his or her relationships with other people his
year at age 17, t(243) ⫽ ⫺0.04, ns; or time spent living at home or her age.” Response options ranged from 0 (no problem, defi-
during young adulthood, t(263) ⫽ ⫺0.63, ns. However, highest nitely does not need treatment, counseling, or extra help) to 6
parental education was lower, ␹2(2) ⫽ 10.40, p ⬍ .01, parental (extreme problem, definitely needs treatment, counseling, or extra
psychopathology was higher, t(263) ⫽ ⫺6.46, p ⬍ .001, and help). As published in Molina et al. (2012), average social impair-
proportion of years in postsecondary education was lower (for the ment in adolescence ranged from 0.22 to 5.13. Social impairment
young adults), t(263) ⫽ 6.45, p ⬍ .001, in the ADHD than in the at age 20 was modeled as a manifest variable, with scores ranging
non-ADHD group. Younger teens were excluded from the analy- from 0.00 to 6.00 for the full sample.
ses because of their smaller numbers and low rates of drinking Delinquent behavior. Delinquency data were collected annu-
(Molina et al., 2007). As in the study by Molina and colleagues ally in the PALS with the Self-Reported Delinquency question-
(2012), variables were modeled by age rather than by year of naire (SRD; Elliott, Huizinga, & Ageton, 1985). The SRD pro-
annual interview as recommended when age varies considerably vides a continuous measure of delinquency that is a more
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

within the sample in a given year or “wave” (Bollen & Curran, comprehensive assessment of conduct problems than is a CD
This document is copyrighted by the American Psychological Association or one of its allied publishers.

2006). symptom checklist or diagnosis. The SRD was administered to

adolescents, young adults, and their parents and inquired about
past-year occurrence of 37 delinquent acts. After the age of 18,
items regarding status offenses (e.g., school truancy) were no
Informed consent was obtained and all participants were assured longer included. An item regarding public drunkenness was also
confidentiality of all disclosed material except in cases of impend- removed because of overlap with drinking behavior outcomes. The
ing danger or harm to self or others. Interviews with participants full SRD was not administered to adolescents under the age of 18
and parents were conducted in the ADD program offices by at the first annual follow-up; for these participants, items were
postbaccalaureate research staff. PALS questionnaires were com- supplemented from any positive reports on the CD module of the
pleted privately by participants and their parents via paper and Diagnostic Interview Schedule for Children for DSM–IV (Shaffer,
pencil, Web-based versions, or secure Internet connection. Teach- Fisher, Lucas, Dulcan, & Schwab-Stone, 2000), parent and self-
ers and guidance counselors completed measures by mail. When report; and DBD, parent, teacher, and self-report. A proportion
distance prevented office visits, mail and telephone were used, score was calculated for each participant at each wave of assess-
with home visits as needed. Privacy was reinforced with a U.S. ment to reflect the proportion of independent delinquent acts
Department of Health and Human Services Certificate of Confi- endorsed as occurring in the past year (range ⫽ 0.00 to 0.78). The
dentiality. variable was multiplied by 10 to render its scale similar to other
variables for ease of model estimation. Delinquency at age 20 was
modeled as a manifest variable, with scores ranging from 0.00 to
0.47 for the full sample.
Heavy drinking. A structured paper-and-pencil substance use Covariates. Seven covariates were tested for inclusion in the
questionnaire (SUQ; Molina et al., 2007), administered annually in analyses. These included frequency of alcohol use at age 17,
the PALS, was used to assess alcohol use. The SUQ is an adap- gender, race/ethnicity, socioeconomic advantage, parental psycho-
tation of existing measures, including the Health Behavior Ques- pathology, and two variables about education and living arrange-
tionnaire (Jessor, Donovan, & Costa, 1989) and the National ments between ages 18 and 20. Postsecondary education between
Household Survey of Drug Abuse interview (National Institute on these ages was calculated as the proportion of years that the young
Drug Abuse, 1992). Pertinent to the current study are the two SUQ adult reported being enrolled in any form of postsecondary edu-
items assessing frequency of binge drinking in the past 12 months cation on a questionnaire assessing educational experiences since
(“In the past 12 months, how often did you drink five or more the last interview (Kuriyan et al., 2013); living arrangement was
drinks when you were drinking?”) and frequency of drunkenness the proportion of these years that the young adult reported living at
in the past 12 months (“In the past 12 months, how often have you home when completing an annual demographics questionnaire.
gotten drunk or very, very high on alcohol?”), with an average Socioeconomic advantage, parent psychopathology (for construc-
correlation between these two items of .92, p ⬍ .001. Participant tion of these variables see Table 1; also Molina et al., 2012), and
responses ranged from 0 (not at all) to 11 (several times a day). gender were tested in initial models, but they were subsequently
Responses to these two items were averaged at age 20. Heavy excluded because of their lack of statistically significant effects.
drinking of either type occurred at least once/week for 19% (50/
265) of the sample at age 20.
Analytic Overview
Social functioning. Parents annually provided ratings of the
target individual’s impairment in multiple domains of functioning We first tested the association between childhood ADHD (no ⫽
using the Impairment Rating Scale (Fabiano et al., 2006). The 0, yes ⫽ 1) and heavy drinking at age 20. Multiple regression was
Impairment Rating Scale can be completed by multiple informants used to test whether childhood ADHD contributed to age 20 heavy
from natural settings and has acceptable psychometric properties drinking frequency after inclusion of the covariates described
for children, adolescents, and young adults (Fabiano et al., 2006; above.
Sibley, Pelham, Molina, Gnagy, Waschbusch, et al., 2012; Sibley, Our primary hypotheses regarding social impairment and delin-
Pelham, Molina, Gnagy, Waxmonsky, et al., 2012). For the current quency pathways to early adult drinking were tested in a structural
analyses, we used the item assessing impairment in relationships equation model using Mplus 7.0 (L. Muthén & Muthén, 2012).

Mediational pathways between childhood ADHD and heavy alco- ipated opposite directions of the relations by social impairment and
hol use at age 20 through delinquency in adolescence and at age 20 delinquency).
and social impairment in adolescence and at age 20 were examined Model fit was determined using conventional fit statistics (chi-
in the model. This allowed a test of whether childhood ADHD was square, root mean square error of approximation [RMSEA], and
associated with heavy alcohol use at age 20 through continued comparative fitness index [CFI]). Maximum likelihood estimation
delinquency and social impairment from adolescence to young with robust standard errors estimation was used to take into ac-
adulthood. A path from adolescent social impairment to delin- count the nonnormality of the heavy alcohol use variable.
quency at age 20 was also estimated to examine the potential
contribution of social impairment on later delinquency above and Results
beyond prior delinquency. As in Molina et al. (2012), adolescent
delinquency and social impairment were modeled as intercept-only
latent factors to estimate the stable overall level of each construct
Preliminary Results
from the repeated measures between ages 14 and 17. Delinquency Consistent with our previous report for the PALS participants
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

and social impairment at age 20 were modeled as manifest vari- who were already adults at their first annual interview (Molina et
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ables to understand the co-occurrence of these factors at the peak al., 2007), the regression results indicated no statistically signifi-
of underage drinking. cant relation between childhood ADHD and age 20 heavy drink-
Including both adolescent and adult measures of these variables ing, ␤ ⫽ ⫺.05, p ⫽ .44.
also allowed for estimating age-specific unique contributions on Among the covariates, more frequent age 17 drinking, ␤ ⫽ .55,
alcohol use outcome (e.g., unique contribution of adolescent social p ⬍ .001, less living at home, ␤ ⫽ ⫺.11, p ⫽ .04, and more
impairment over and beyond the concurrent impairment at age 20). postsecondary education, ␤ ⫽ .18, p ⫽ .002, predicted more
All covariates were included in the initial model and incrementally frequent heavy drinking at age 20. Predictions from the remaining
removed based on lack of statistically significant effects on age 20 covariates failed to attain statistical significance. The overall
heavy drinking. Significance tests for mediated effects were con- model R2 was .40.
ducted using the delta method implemented in Mplus, in which
mediated effects are obtained by the product of the path coeffi-
Mediation by Social Impairment and Delinquency
cients between the variables in the mediational pathways and the
statistical significance is tested under the normality assumption of The results of the mediation model are shown in Figure 1. The
mediated effects. Following recent recommendations (e.g., Mac model fit the data adequately, ␹2(21) ⫽ 58.71, p ⬍ .001; RMSEA ⫽
Kinnon, Lockwood, Hoffman, West, & Sheets, 2002; Rucker, .06; CFI ⫽ .92. As previously reported in Molina et al. (2012),
Preacher, Tormala, & Petty, 2011) and a growing body of research, childhood ADHD significantly predicted adolescent social impair-
our decision to test mediation pathways was not contingent on ment, ␤ ⫽ .57, p ⬍ .001, and adolescent delinquency, ␤ ⫽ .26,
demonstration of a statistically significant relation between child- p ⬍ .001, and these indicators of adolescent functioning were
hood ADHD and age 20 alcohol use (especially because of antic- significantly correlated, r ⫽ .24, p ⬍ .001, after controlling for

Impairment .44*** -.14*
14-17 Impairment
.57*** 20 -.03

Childhood Heavy
ADHD .24*** .16*
Drinking 20

.26*** -.02
Delinquency 20
14-17 .21* .10

χ2 = 58.71, df = 21, p < .001

RMSEA = .06, CFI = .92
Coefficients are standardized.
p < .10, *p < .05, **p < .01, *** p < .001

Figure 1. Social impairment and delinquency as mediators of childhood attention-deficit/hyperactivity disorder

(ADHD) and young adult heavy alcohol use. The reported path coefficients are standardized. Alcohol use at age
17, race/ethnicity, proportion of time living at home from ages 18 to 20, and proportion of time enrolled in school
from ages 18 to 20 were controlled for in the model.

childhood ADHD. Childhood ADHD also significantly predicted Our replicated finding that childhood ADHD does not predict
social impairment at age 20, ␤ ⫽ .24, p ⬍ .001, over and above heavy drinking frequency in early adulthood appears to be at
adolescent social impairment, but not delinquency at age 20, odds with some prior findings of increased alcohol use in
␤ ⫽ ⫺.02, p ⫽ .77, after controlling for adolescent delinquency. adolescence by children with ADHD (Barkley, Fischer, Edel-
Adolescent social impairment predicted age 20 social impairment, brock, & Smallish, 1990; Molina & Pelham, 2003; Molina et
␤ ⫽ .44, p ⬍ .001, and less frequent age 20 heavy alcohol use, al., 2007, 2013) or an earlier age of first use (Elkins et al., 2007;
␤ ⫽ ⫺.14, p ⫽ .03. Adolescent delinquency predicted age 20 Milberger, Biederman, Faraone, Wilens, & Chu, 1997; Molina
delinquency, ␤ ⫽ .21, p ⫽ .03, but not age 20 heavy alcohol use, et al., 2013). These earlier signs of increased drinking are
␤ ⫽ .10, p ⫽ .29. Age 20 delinquency and social impairment were well-established risk factors for excessive and problematic
significantly correlated, r ⫽ .16, p ⫽ .02, after controlling for drinking in adulthood (Chassin et al., 2002; McCarty et al.,
childhood ADHD and adolescent delinquency and social impair- 2004). Thus, it is somewhat surprising that we have twice failed
ment. Finally, age 20 delinquency was associated with age 20 to identify ADHD group differences in heavy drinking in early
heavy alcohol use, ␤ ⫽ .27, p ⬍ .001, but age 20 social impairment adulthood. We suspect that these developmentally specific find-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

was not associated with age 20 heavy alcohol use, ␤ ⫽ ⫺.03, p ⫽ ings, which parallel to some extent the overall modest ADHD-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

.67. Forty-two percent of the variance in heavy drinking was related risk of alcohol use disorder described in the literature
explained. (Lee et al., 2011), reflect important heterogeneity in the ADHD
Two statistically significant mediational pathways resulted. In clinical presentation, associated features, and course over time
one, childhood ADHD predicted more social impairment in ado- that translate to risk and resilience in this population.
lescence, which in turn predicted less frequent heavy alcohol use Our findings confirmed the importance of deviance prone-
at age 20, ␤ ⫽ ⫺.08, p ⫽ .04, 95% CI [⫺.16, ⫺.01]. In the other, ness (Donovan et al., 1999; Sher, 1991) for ADHD-related
childhood ADHD predicted more delinquency in adolescence, drinking vulnerability by using a developmental model that
which in turn predicted more delinquency at age 20. Age 20 considered the presence of delinquent behavior through adoles-
delinquency was then associated with more frequent heavy alcohol cence and concurrently in adulthood. Rather than controlling
use at age 20. This indirect effect was also statistically significant, for CD diagnosis, as analyzed in many studies, our approach
␤ ⫽ .02, p ⫽ .04, 95% CI [.001, .03]. modeled the dimensional and adolescent/adult form of this
Among the covariates, alcohol use at age 17 positively predicted variable to more powerfully test its mediating role (e.g., Brook
heavy drinking at age 20, ␤ ⫽ .43, p ⬍ .001, over and above the et al., 2010). Although co-occurring conduct problems/CD are
other variables in the model. Caucasian participants reported more widely established as important for the development of alcohol
frequent heavy alcohol use at age 20 than participants of other use vulnerability in ADHD (Edwards & Kendler, 2012; Flory &
racial/ethnic backgrounds, ␤ ⫽ .11, p ⫽ .03. Participants who Lynam, 2003; Molina & Pelham, 2003; Molina et al., 2007;
reported living at home a greater proportion of ages 18 to 20 Tuithof, ten Have, van den Brink, Vollebergh, & Graaf, 2012),
reported less frequent heavy drinking at age 20, ␤ ⫽ ⫺.13, p ⫽ prior studies have often failed to consider the developmental
.01. Finally, a higher proportion of years in school between ages 18 unfolding of these problems in the ADHD population by con-
and 20 predicted more frequent heavy drinking at age 20, ␤ ⫽ .13, trolling for concurrent CD rather than studying its contribution
p ⬍ .01. developmentally. The former approach also risks overcontrol-
ling for variance common to the two disorders (e.g., impulsiv-
ity) that contributes to alcoholism vulnerability (Derefinko &
Discussion Pelham, in press). Along these lines, we previously found
We tested social impairment, social deviance, and delinquency inconsistent prediction of alcohol outcomes from childhood CD
pathways to heavy drinking in early adulthood in a longitudinally in the current sample (Molina et al., 2007), presumably due to
followed sample of children with and without ADHD. We did not the tendency for delinquent behaviors to increase with age
find ADHD group differences in frequency of heavy drinking in (Barnes, Welte, & Hoffman, 2002; Sibley et al., 2011). Others
early adulthood and thus replicated our prior findings with the have reported a similar cascade of unfolding risks from disin-
older subset of the PALS participants (Molina et al., 2007). How- hibited temperament within a sample at high risk by virtue of
ever, indirect and opposing pathways to heavy drinking from parental alcoholism and antisociality (Martel et al., 2009). In
childhood ADHD were supported. One pathway, largely expected common among these types of high-risk samples are undercon-
from the existing literature (e.g., Brook et al., 2010; Knop et al., trolled temperament profiles in childhood that, in interaction
2009; Molina et al., 2012), indicated progression to heavy drinking with other psychosocial and environmental factors, lead to
following from adolescent and, subsequently, young adult delin- deviant behaviors that include drinking (Chassin et al., in press;
quent behavior. A second pathway suggested a suppression effect Sher, 1991). Our findings indicate that this pathway is still
(Mackinnon, Cheong, & Pirlott, 2012; Rucker et al., 2011) such applicable in early adulthood for a subset of deviance-prone
that childhood ADHD led to adolescent social impairment, which children with ADHD, even when heavy drinking becomes
led to decreased heavy drinking. Age 20 social impairment and highly normative (Substance Abuse and Mental Health Services
heavy drinking were unrelated, suggesting some diminution of the Administration, 2012) and may only be developmentally lim-
social impairment protective effect in adulthood. These findings ited for some (perhaps those without ADHD histories; Sher,
provide new information regarding potentially important yet op- 1991; Zucker, 2006). We cannot rule out the likely possibility
posing impairment-related pathways to heavy drinking in early of bidirectional associations between delinquency and heavy
adulthood for children with ADHD. drinking at age 20 (e.g., Barnes et al., 2002), but the inclusion

of adolescent delinquency in the mediational pathway is strong drinking in noncollege adults (Merline et al., 2004), future research
evidence that it partially contributes prospectively. would benefit from examining academic trajectories that extend
Interpersonal difficulties are widespread among people affected from childhood through adolescence into adulthood. Such analyses
by ADHD (McQuade & Hoza, 2008), and our findings with regard may uncover potential benefits of targeting academic performance
to alcohol suggest that accounting for them, in tandem with delin- throughout the high-risk periods of alcohol entry for individuals
quency pathways, may help explain the heterogeneity of the with ADHD. Our findings may also be affected by other unmea-
ADHD-related alcoholism risk. We found suppression of heavy sured mediators and moderators such as aspects of parental in-
drinking risk from social impairment in adolescence: Children volvement that are known to exert protracted effects on drinking
with ADHD were significantly more likely to be rated by their even into adulthood (Guo, Hawkins, Hill, & Abbott, 2001;
mothers as having relationship problems with other same-aged Raudino, Fergusson, & Horwood, 2013).
people, and this social difficulty predicted less frequent heavy Although the majority of children with ADHD continue to
drinking at age 20 above and beyond age 17 drinking frequency. experience statistically deviant (nonnormative) levels of symptom-
Thus, these findings extend our report of the same result in atology into adulthood (Barkley, Fischer, Smallish, & Fletcher,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

adolescence (Molina et al., 2012) prospectively to early adulthood 2002; Sibley et al., 2012b), heterogeneity exists (Barkley, Murphy,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

when drinking contexts have changed. Importantly, this protective & Fischer, 2008; Sibley et al., 2012b), and several studies have
effect disappeared when delinquency was dropped from the model shown that symptom persistence contributes to more alcohol use
in a post hoc analysis, which speaks directly to the heterogeneity (Barkley et al., 2008; Chang, Lichtenstein, & Larsson, 2012;
of social functioning in ADHD. Specific aspects of interpersonal Molina & Pelham, 2003; Molina et al., 2012). For pragmatic
tendencies related to delinquency may increase and others (e.g., purposes, our model focused on two key domains of impairment
social isolation, withdrawal, social anxiety) may decrease heavy for ADHD, but our inclusion of adults for whom ADHD symptoms
drinking risk. Models of ADHD risk may be aided by separating had dissipated may have partially diluted the ADHD– drinking
these tendencies into those that result in greater, versus lesser, association (although many of these children were probably cap-
affiliation with peers who drink. This is especially the case given tured in the delinquency pathway). We also did not separately
the largely socially mediated context of alcohol consumption in model the two dimensions of ADHD, inattention and impulsivity-
early adulthood (Pedersen et al., 2008; Wood et al., 2004). It is hyperactivity, because our interest was in testing pathways from
additionally quite interesting that, despite the significant stability childhood ADHD to underage heavy drinking rather than explain-
of social impairment from adolescence to adulthood, adult social ing variability within the ADHD group. Future research should
impairment was not correlated with heavy drinking frequency. extend the growing body of literature investigating this distinction
Other studies have shown that heavy drinking in early adulthood is within ADHD that, measured as subtypes of ADHD, is highly
largely predicted by adolescent and not concurrent risk factors unstable over time (Willcutt et al., 2012) but that might be effec-
(Sher & Rutledge, 2007). However, we offer an additional inter- tively studied longitudinally with repeated measures (Molina &
pretation based on our findings that heavy drinking was signifi- Pelham, 2014). This approach would also incorporate questions of
cantly associated with postsecondary school attendance and living persistence/desistance. We did not include medication treatment
away from home. These factors, known from other samples to be commonly used for children with ADHD. In prior analyses, we
strongly associated with heavy drinking in early adulthood (Sub- found no association between stimulant medication (by far the
stance Abuse and Mental Health Services Administration, 2003), most common psychoactive drug used) and substance use (Pelham,
may simply be more important. Alternatively, our measurement of 2008). A recent meta-analysis (Humphreys, Eng, & Lee, 2013) and
social impairment, despite its apparent stability and predictive comprehensive tests of the association with a large multisite sam-
utility, may need to draw from additional reporters in adulthood. It ple (Molina et al., 2013) also failed to detect associations. Finally,
is based on a single parent-reported item that may fail to assess our sample was predominantly male and we were therefore unable
nuances of social functioning important for heavy drinking, such to test whether our findings were equally applicable to females.
as number of heavy drinking peers and time spent together and In summary, our findings provide, with prospectively gath-
quality or reciprocity of these relationships. ered data for children with ADHD, evidence of two opposing
Our model was constrained to include only social functioning pathways to heavy drinking frequency in early adulthood. Ev-
and delinquency because we were specifically interested in the idence of a delinquency pathway suggests the potential impor-
longitudinal effects of these mediators that are so commonly tance of forestalling entry into adolescent peer groups that
associated with ADHD. We previously found support for an “ac- socialize around delinquent behavior and alcohol use. Refining
ademic deviance” pathway to adolescent drinking in which lower the measurement of social functioning to identify specific in-
grade point averages in the ADHD group were related to delin- terpersonal tendencies that promote affiliation with drinking
quency and subsequently alcohol use (Molina et al., 2012). De- peers, known to be elevated for adolescents with ADHD histo-
velopmental substance use theorists have long suggested that fail- ries (Marshal et al., 2003), may clarify these associations.
ure to engage in activities that promote future goal attainment, Integration of evidence-based treatments for ADHD (Pelham &
such as academic success, create vulnerability (Brook, Brook, Fabiano, 2008) and adolescent substance abuse (Waldron &
Gordon, Whiteman, & Cohen, 1990; Jessor & Jessor, 1977). As Turner, 2008) may hold promise in this regard. More detailed
expected, the non-ADHD group was more likely to attend post- measurement of social functioning, to include collateral ratings
secondary education, as we previously demonstrated for the older by partners and adult friends, and refinement of the various
PALS participants (Kuriyan et al., 2013), indicating that lower constructs inherent in social functioning may clarify targets of
academic achievement continues into early adulthood. Given find- treatment in adulthood. Finally, future model testing will ben-
ings that alcohol problems are more likely to follow from heavy efit from consideration of the wide range of additional psycho-

social and environmental variables that emerge as potentially Charach, A., Yeung, E., Climans, T., & Lillie, E. (2011). Childhood
important to consider when literatures on the etiology of ADHD attention- deficit/hyperactivity disorder and future substance use disor-
and substance abuse are juxtaposed (Molina & Pelham, 2014). ders: Comparative meta-analyses. Journal of the American Academy of
Child & Adolescent Psychiatry, 50, 9 –21. doi:10.1016/j.jaac.2010.09
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