Substance Use Disorder and Attention Deficit/Hyperactivity Disorder
There has been a consistent amount of attention paid by clinicians and cultural pundits to children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) for several decades now, and rightly so as the numbers of children diagnosed with this condition have been increasing for years (CDC, 2016), making this is a situation that begs to be understood further. But further light needs to be shed on ADHD and its connection to Substance Use Disorder (SUD) as a co-occurring disorder. This is becoming more of a problem due to a couple of different factors, including adults being more commonly diagnosed with ADHD, and with often the first attempt at treatment being stimulant medication that can be addictive. Taking the steps to understand this diagnosis and the issues surrounding it will benefit the people who have it, and their loved ones as well.
An Important Note
Some of the fastest acting and most effective treatments for ADHD include medications that are stimulants, typically Ritalin, Concerta, or Adderall. Being a stimulant, a psychoactive substance that, “increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respiration. (NIDA, 2016). Used correctly, and with the help of a doctor, stimulants can and do make a tremendous difference in the lives of people with ADHD. This article is not meant to steer people away from that treatment method, but to alert people to the possibility of misuse.
According to the CDC (2016), approximately 11% of children between the ages of 4 and 17 have been diagnosed with ADHD, with an estimated 4-5% of adults being diagnosed with it as well. While the medication of choice to treat ADHD can be an addictive substance, research does NOT show a higher chance for a child or adolescent who is legitimately prescribed it to treat ADHD to become addicted to it and abuse it than the average adolescent (CHADD, n.d., CDC, 2016). This is a very positive sign, as medication is often the treatment of choice for people with ADHD. However, these individuals are at higher risk to abuse other substances, including alcohol and opioids, which is theorized to be a way of self-medicating the inattentiveness and hyperactivity, and slowing the mind down to a manageable level (CHADD, n.d., CDC, 2016). Or in other words, be warier of using other substances to manage the symptoms of ADHD, rather than the medication used to actually treat it.
What is it?
ADHD is a persistent pattern of inability to focus or pay attention, inability to remain still in situations requiring it, for example a school classroom, or a combination of both. Prior to the DSM-5, ADD and ADHD were two separate diagnoses, but since the DSM-5, they have been combined into one diagnosis, with three different specific subtypes all under the heading, Attention Deficit/Hyperactivity Disorder. Initially ADHD was a diagnosis solely for children and adolescents, but as more research has been done, it appears that up to one third of cases diagnosed in childhood remain throughout adulthood (CDC, 2016). Each subtype of ADHD, inattentive, hyperactive, and combination, have different symptomology and diagnostic criteria, and a preponderance of symptoms must be present for the diagnosis to be officially made. aConsidering the complexity of diagnosis, and the attention that diagnosing ADHD in children receives in this culture, the complete DSM-5 list of symptoms and criteria for making this diagnosis is being presented. The following is a complete list of the diagnostic criteria from the DSM-5 along with certain conditions that also must be met for an actual diagnosis of ADHD to be made (APA, 2013):
Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
- Often has trouble holding attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
- Often has trouble organizing tasks and activities.
- Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
- Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted
- Is often forgetful in daily activities.
Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
- Often fidgets with or taps hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
- Often unable to play or take part in leisure activities quietly.
- Is often “on the go” acting as if “driven by a motor”.
- Often talks excessively.
- Often blurts out an answer before a question has been completed.
- Often has trouble waiting his/her turn.
- Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
- Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
- Several symptoms are present in two or more settings, (e.g., at home, school or work; with friends or relatives; in other activities).
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
- The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a
- Personality Disorder).
Here, the more symptoms present the more complex the case is. Also, it is important to note that for a true diagnosis, this must be something that occurs across several areas of the individual’s life, and not just at school, or at home; if it only occurs in one arena, then that might be an indication that there is something specifically challenging about that area alone. For children and adolescents this is a persistent thing; although there may be times where it does not interfere as much, it will be there consistently. Adults often will age out of these symptoms, but again roughly one third of adults will maintain this diagnosis if they have been diagnosed in childhood.
SUD is presented in the DSM 5 on a continuum of mild to severe, depending on how many symptoms are present. The more symptoms, the more serious the disorder is, and the more risk the person is at in life overall. These are (APA, 2013):
- Taking the substances in larger amounts and for longer than intended.
- Wanting to cut down or quit but not being able to do it.
- Spending a lot of time obtaining the substances.
- Craving or a strong desire to use substances.
- Repeatedly unable to carry out major obligations at work, school, or home due to substance use.
- Continued use despite persistent or recurring social or interpersonal problems caused or made worse by substance use.
- Stopping or reducing important social, occupational, or recreational activities due to substance use.
- Recurrent use of substances in physically hazardous situations.
- Consistent use of substances despite acknowledgment of persistent or recurrent physical or psychological difficulties from using the substance.
- Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount.
- Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal.
So, we can see the impact of SUD on a person’s life by the symptomology here, and the problems that arise from continued, and increasing, use. Or to put it more concisely, the more a person cuts off parts of their life for substance use, the worse the problem really is.
Clearly ADHD is an issue in many lives, and SUD complicates that, and magnifies those struggles. There are treatment options available for one or both of these conditions, and the sooner that they are addressed, the sooner suffering can end. This is especially true in the case of children and adolescents; the sooner any issues are addressed, the less likely there will be lifelong impact or problems.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Center for Disease Control. (2016). Attention Deficit/Hyperactivity Disorder Data & Statistics. Retrieved from https://www.cdc.gov/ncbddd/adhd/data.html.
Children and Adults with Attention Deficit Disorder CHADD.org. (n.d.). Substance Abuse and ADHD. Retrieved from http://www.chadd.org/Understanding-ADHD/For-Parents-Caregivers/Coexisting-Conditions-in-Children/Substance-Abuse-and-ADHD.aspx.
National Institute on Drug Abuse. (2016). What Are Stimulants? Retrieved from https://www.drugabuse.gov/publications/research-reports/prescription-drugs/stimulants/what-are-stimulants.