Issues involving ADHD and Substance Abuse
Attention deficit hyperactivity disorder (ADHD) is actually a heterogeneous set of disorders that are typically first noticed and diagnosed in children; however, new diagnostic criteria put forth by the American Psychiatric Association in 2013 allows for a diagnosis of ADHD in adults age 17 and over without a specific documented history of the symptoms in childhood.
This article will briefly discuss the symptoms of ADHD, the various types of ADHD, how ADHD is related to substance abuse, and how treatment for individuals diagnosed with both ADHD and substance abuse is often approached.
ADHD is a clinical neurodevelopmental disorder that is most often identified in children or adolescents. The formal diagnosis of ADHD for children requires them to display six or more of nine problems associated with attentional difficulties and/or six or more of nine symptoms with hyperactivity and impulsivity.
Adults or individuals over 17 years of age who are given the diagnosis of ADHD (without being previously diagnosed with the disorder) need to display five or more of nine symptoms of inattention and five or more of nine symptoms of impulsivity or hyperactivity.
- Symptoms of inattention include behaviors like the following:
- Signs of impulsivity or hyperactivity include:
- Very often overlooks important details in schoolwork or during other activities
- Being very fidgety
- Often displays difficulty in sustaining one’s attention over time
- Does not seem to be able to remain in place when required to do so
- Difficulty listening and paying attention
- Unable to maintain control in situations where one is supposed to
- Begins tasks but quickly loses focus and frequently does not finish them
- Unable to engage in leisure activities quietly
- Demonstrates major difficulties with organizing activities and tasks
- Often moving
- Avoids tasks that require prolonged mental effort
- May often talk excessively
- Very often loses things that are necessary
- Impulsively exclaims answers to questions before the person is finished asking them
- Very easily distracted by thoughts or stimuli
- Very often has difficulty waiting
- Very forgetful regarding chores or tasks
- Very often interrupts or intrudes on others
- The symptoms must occur in two different settings (e.g., at school and at home for children).
As one can see from the abbreviated list of the type of symptoms that are noted in people diagnosed with ADHD, these are behaviors that many people occasionally experience or at least occasionally engage in. In children, many of these behaviors are to be expected given their level of development. The difference between a behavioral symptom of a mental health disorder and normal behavior represents a difference in both quantitative and qualitative aspects of the behavior.
This is why a professional assessment is crucial to determining if a child or adult has a formal disorder of attention such as ADHD.
ADHD Is a Heterogeneous Disorder
When it is explained that ADHD is a heterogeneous disorder, this means that the disorder often presents quite differently in individuals who are given an ADHD diagnosis. Just saying that someone has ADHD does not communicate a whole lot about the person’s actual symptom presentation and any resulting difficulties that may be present.
In order to understand each case on an independent level, more information is needed. As a result, the American Psychiatric Association has further separated the disorder into three different presentations of ADHD that represent different manifestations of the disorder. These include:
- ADHD (predominantly inattentive presentation): In this presentation, the individual presents primarily with symptoms of inattention (the first group of symptoms listed above) and does not present with impulsivity or hyperactivity. This presentation is mistakenly referred to in lay circles as ADD (attention deficit disorder). In clinical diagnostic terms, the formal diagnosis of ADD does not exist, but instead individuals who have issues with attention that are clinically dysfunctional are diagnosed with this variant of ADHD.
- ADHD (predominantly a hyperactive/impulsive presentation): In this presentation, the person displays primarily symptoms of hyperactivity and impulsivity, and does not display significant symptoms of inattention.
- ADHD (combined presentation): This is the presentation that most people visualize when they think of ADHD. Clinically, significant issues with attention, hyperactivity, and impulsivity are present in this presentation.
Clinicians can also formally ascertain whether or not the presentation of the disorder is mild, moderate, or severe. In order to be diagnosed with ADHD, the symptoms cannot be better explained by another mental health disorder, the use of medication or drugs, or some other medical condition, such as a head injury or other condition.
There are also other diagnostic categories that allow for a tentative diagnosis of ADHD when someone does not meet the specific diagnostic criteria for the disorder, but is still presenting with some of the symptoms of the disorder and experiencing difficulty as a result of those symptoms.
ADHD and Substance Abuse
There several things to understand regarding substance use disorders and other mental health disorders. First, individuals with a diagnosis of a psychological disorder as a group have higher rates of substance use disorders than found in the general population. Individuals with complicated mental health histories, such as having one or more comorbid (co-occurring) mental health disorders have even higher rates of substance use disorders. There is an extensive body of research that looks at how ADHD and other types of mental health disorders are related.
Children diagnosed with ADHD are often diagnosed with learning disorders, oppositional defiant disorder, and conduct disorders. Individuals diagnosed with ADHD also have high rates of comorbid anxiety disorders and depression. Substance use disorders occur in adults who are diagnosed with ADHD at a higher rate than they are in the general population; however, according to the American Psychiatric Association, the proportion of adults diagnosed with ADHD who also have a substance use disorder is relatively small. Research has indicated that the risk of substance abuse co-occurring with ADHD increases as an individual is diagnosed with another mental health disorder, such as a conduct disorder, a personality disorder, or an obsessive-compulsive disorder.
In summary, the research shows that:
- As a group, individuals diagnosed with psychological disorders have higher rates of comorbid substance use disorders than the general population.
- Adults diagnosed with ADHD have higher rates of substance use disorders than the general population; however, the total proportion of adults diagnosed with ADHD who have substance use disorders is relatively small.
- ADHD is often comorbid with a number of different psychological disorders.
- Individuals diagnosed with more than one psychological disorder are at even greater risk of developing substance use disorders.
Having a diagnosis of ADHD and a conduct disorder or personality disorder, such as antisocial personality disorder, appears to place one at a much higher risk for the development of a substance abuse issue or substance use disorder.
Of course, individuals with comorbid ADHD and some other psychological disorder are potentially at a higher risk for the development of any type of substance use disorder. Since using alcohol and marijuana would produce effects that would counteract hyperactivity and inattention in people with ADHD, this may be at least partially why individuals with ADHD commonly abuse these drugs. Nicotine may produce calming effects as well, but the mechanism that makes nicotine a susceptible drug of abuse for individuals with ADHD is not fully understood.
Treatment for ADHD
Treatment for ADHD in children typically involves some form of medication management combined with a behavioral management program. Common medications used in the treatment of ADHD include stimulant medications like Ritalin and Adderall: The manner in which these medications work seems contradictory – using a stimulant to treat hyperactivity. However, it is hypothesized that the issue with children diagnosed with ADHD is that their systems run more slowly than normal, and that hyperactivity and inattention (needing to quickly focus one’s attention back and forth) are results of the person trying to compensate. When given the stimulant medication, the person no longer needs to compensate and is able to pay attention and settle down.
Stimulant medications may cause a number of side effects. Three nonstimulant medications – Strattera, Guanfacine, and Kapvay – are approved for treating ADHD. All of these work on different neurotransmitter systems in the brain.
Other medications, such as antidepressants, can be used to treat symptoms associated with ADHD, but typically are not first line treatments for ADHD.
There is no indication that being on medication such as Ritalin for the treatment of ADHD increases the risk that an individual will develop a substance abuse issue.
Behavioral modification for ADHD involves reinforcing limits to behavior, strictly enforcing rules and regulations, setting up a contingency system of rewards and punishments for appropriate and inappropriate behavior, and so forth.
Treatment for comorbid ADHD and substance abuse will depend on the specific issues involved; however, treatment for substance abuse should occur alongside treatment for ADHD.
Controversy surrounding ADHD
Finally, it is important to briefly mention some issues that have stirred some controversy regarding this diagnosis. First, the American Psychiatric Association clearly states that ADHD occurs in most cultures in about 5 percent of children and 2.5 percent of adults; however, it is clear that in the United States, diagnostic rates of ADHD in schools are significantly higher and appear to range anywhere between 9 and 15 percent, with males diagnosed significantly more often than females. These findings have questioned the legitimacy of the process of diagnosing ADHD.
Secondly, child psychiatrist Leon Eisenberg who was important in the conceptualization of many developmental disorders, including ADHD, reportedly admitted shortly before his death that ADHD was a fictitious disease. This story received quite a bit of press. There have been a number of other articles and books written by psychologists, psychiatrists, and others claiming that ADHD is not a valid psychiatric or psychological disorder. Dr. Eisenberg’s statements were more related to his opinion that the notion of ADHD as a primarily genetic disorder was overstated and to the haphazard approach of pediatric diagnoses of this disorder as opposed to the actual legitimacy of the disorder itself.
These two above issues are excellent examples of the difficulty in diagnosing a psychological disorder in a child by use of behavioral criteria. There are no hard line medical markers for most psychological disorders in the same way that there are biological markers for diseases like cancer, heart disease, and so forth. Thus, when someone is being assessed for psychological disorders, it is important to have experienced mental health professionals looking at the evidence for the disorder as opposed to a haphazard approach to diagnoses.
When a child is being assessed for ADHD, the child should receive a full medical workup that can identify other issues that might explain the behavior. In addition, a full psychological/psychiatric evaluation should be included in order to better understand why the child is behaving in a manner that raises concern. Adults diagnosed with ADHD should have some evidence that is documented regarding the presence of symptoms that interfered with their functioning before they were 12 years old. Failure to adhere to strict diagnostic protocols regarding disorders like ADHD results in a high number of false-positive diagnoses.