Among 1,424 adolescents at age 13, the association between internalizing symptoms (anxiety/depression) and cannabis use was significant only in girls with high ADHD hyperactivity-impulsivity symptoms.
Child and adolescent psychiatrists; school psychologists; researchers studying sex differences in substance use risk.
Internalizing predicted cannabis use only in females with high ADHD-HI symptoms
What the researchers found
A significant three-way interaction between internalizing symptoms, ADHD hyperactivity-impulsivity, and sex was found for cigarette use (BF=48.40) and supported for cannabis use (BF=3.54-9.08). Internalizing symptoms predicted cannabis use only among females with high ADHD-HI symptoms (β=0.14-0.21).
Why it matters
The inconsistent relationship between anxiety/depression and substance use in adolescents has puzzled researchers. This study reveals that ADHD hyperactivity-impulsivity is a key moderator, particularly in girls, helping explain who is actually at risk.
The numbers in context
1,424 adolescents, 53% female. Cigarette use three-way interaction: BF=48.40 (very strong evidence). Cannabis use: self-report ADHD BF=3.54, father-report BF=9.08 (substantial evidence). Effect among females with high ADHD-HI: cigarette β=0.15, cannabis β=0.14-0.21.
How the study worked
Cross-sectional analysis of 1,424 adolescents (53% female) at age 13 from the Quebec Longitudinal Study of Child Development. Alcohol, cigarette, and cannabis use along with internalizing and ADHD hyperactivity-impulsivity symptoms were assessed. Used multi-informant ADHD ratings (self, teacher, father).
What this study cannot tell us
Cross-sectional design at a single age point cannot establish temporal ordering. ADHD-HI symptoms were not clinical diagnoses. The cannabis finding did not reach conventional statistical significance but was supported by Bayesian evidence.
How to read the evidence
Moderate: large population-based cohort with multi-informant assessment, though cross-sectional and cannabis interaction did not reach conventional significance.
When this study was published
Published in 2022.
The bigger picture
ADHD is often underdiagnosed in girls, partly because hyperactivity-impulsivity presents differently in females. This study suggests that the combination of internalizing distress and hyperactive-impulsive traits in girls creates a specific risk profile for substance use that deserves targeted intervention.
Questions still open
- Would treating ADHD in girls with internalizing symptoms reduce their cannabis use risk? Does this three-way interaction persist into later adolescence? Why is this pattern specific to girls?
Common questions
Are girls with ADHD at higher risk for cannabis use?
Why does this only affect girls?
Read the original research
The moderating role of sex and self-, teacher-, and father-reported ADHD hyperactivity-impulsivity symptoms, on the association between early adolescent internalizing symptoms and substance use.
Addictive behaviors, 135, 107437
Citation
Pocuca, Nina; Parent, Sophie; Côté, Sylvana; Boivin, Michel; Tremblay, Richard E; Séguin, Jean R; Castellanos-Ryan, Natalie. (2022). The moderating role of sex and self-, teacher-, and father-reported ADHD hyperactivity-impulsivity symptoms, on the association between early adolescent internalizing symptoms and substance use.. Addictive behaviors, 135, 107437. https://doi.org/10.1016/j.addbeh.2022.107437
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