Children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) often face ongoing challenges that extend into adulthood, significantly affecting their academic, professional, and social lives. Compounding these difficulties is the heightened risk for individuals with ADHD to develop alcoholism and other drug addictions, particularly when there’s a family history of either condition. In cases where ADHD coexists with behavioral or mood disorders, Alcohol and Other Drug (AOD) abuse can emerge earlier, sometimes as early as mid-adolescence. While the precise nature of the connection between ADHD and AOD use disorder remains unclear, it’s believed that co-occurring disorders may play a mediating role. Furthermore, ADHD-related AOD abuse might initially arise as a coping mechanism to alleviate the emotional distress associated with persistent failure, feelings of inadequacy, and conflicts with family and peers. Effective therapeutic interventions must address both addiction and mental health aspects, including the judicious use of psychiatric medications.
Keywords: Aod Diagnosis, ADHD, hyperactive behavior, child, AODD (alcohol and other drug use disorder), comorbidity, drug therapy, disease course, AODD recovery, self administration of drugs, biochemical mechanism, adulthood, AOD prevention, psychosocial treatment method, literature review
Since the early 20th century, terms like “hyperactive” have been used to describe a diverse group of children who are restless, inattentive, and struggle with learning. Many of these children are now diagnosed with attention deficit/hyperactivity disorder (ADHD). Children with ADHD may exhibit behaviors such as running around without purpose, fidgeting and squirming while seated, and talking excessively. They are frequently characterized as irritable, impatient, and impulsive. Additional symptoms can include difficulty concentrating, forgetfulness, daydreaming, and being easily distracted. This disorder often persists into adulthood, leading to substantial impairments in academic, occupational, and social functioning.
The presence of ADHD is a significant risk factor for the development of alcoholism and other disorders related to alcohol and other drug (AOD) use.1 Furthermore, AOD use disorders (AODDs) tend to appear earlier and progress more rapidly in individuals with ADHD. Alcoholics with ADHD are also less likely to remain in treatment programs for alcoholism or achieve moderation or abstinence (Tarter and Edwards 1988). Identifying specific risk factors for AODD in individuals with ADHD is crucial for developing more targeted prevention and treatment programs for both disorders at earlier stages. Accurate aod diagnosis in this population is therefore paramount for timely intervention.
This article delves into the co-occurrence (comorbidity) of ADHD and AODD, exploring potential underlying mechanisms of their association. It also discusses ADHD treatment, focusing on medications that can alleviate ADHD symptoms and potentially influence the subsequent development of AODD. Understanding the nuances of aod diagnosis in individuals with ADHD is key to effective management.
Attention Deficit/Hyperactivity Disorder: Diagnostic Overview
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) (American Psychiatric Association [APA] 1994) provides the established criteria for diagnosing ADHD. According to DSM–IV, ADHD symptoms are categorized into “inattention” and “hyperactivity-impulsivity.” The majority of patients (approximately 75 percent) present with a combination of both inattention and hyperactivity-impulsivity symptoms. A smaller proportion of ADHD patients exhibit primarily inattentive symptoms (15 to 20 percent), while an even smaller group (5 to 10 percent) mainly display hyperactivity-impulsivity without significant inattention (for a review, see Biederman 1998). A thorough aod diagnosis process must consider these varying presentations of ADHD.
DSM–IV criteria also serve to differentiate ADHD from other disorders or normal variations in temperament. For instance, symptoms must be pervasive, occurring across multiple settings (e.g., home and work or school), and persistent, not merely a transient reaction to stress. Crucially, these symptoms must cause significant impairment in social, academic, or occupational functioning (APA 1994).2 When considering aod diagnosis, it is important to distinguish ADHD symptoms from those potentially arising from substance use or withdrawal.
ADHD affects a significant portion of the population, with prevalence rates estimated at 6 to 9 percent among children and adolescents and up to 5 percent in adults (Biederman 1998). Research indicates that childhood ADHD persists into adolescence in roughly 75 percent of cases and into adulthood in about 50 percent (Biederman 1998). While the disorder may spontaneously remit in adolescence for some, attention-related challenges, in particular, can persist into adulthood. This persistence underscores the importance of ongoing monitoring and consideration of potential comorbid conditions like AODD, necessitating careful aod diagnosis throughout the lifespan.
The Comorbidity of ADHD and AOD Use Disorder
ADHD and AODD frequently co-occur in the same individual, either concurrently or sequentially, at a rate higher than expected by chance (Wilens et al. 1996). ADHD symptoms typically manifest years before the onset of AODD, often as early as infancy (APA 1994). Therefore, early detection of ADHD may provide a window of opportunity for preventative measures to mitigate the risk of future AODD, highlighting the significance of early aod diagnosis considerations.
Studies have identified comorbid ADHD in 25 to 30 percent of adolescents with AODD in specific populations. However, these studies often focused on repeat criminal offenders and patients in residential treatment for psychiatric and addictive disorders (Wilens et al. 1996). This specificity raises questions about the generalizability of these findings to the broader population. Among adults with AODD, ADHD rates range from 15 to 25 percent (Wilens et al. 1996).3 Conversely, approximately 50 percent of adults with ADHD experience AOD abuse or dependence (Wilens et al. 1996). Data suggests that the lifetime risk of developing AODD for an adult with ADHD is twice that of adults without ADHD (52 percent versus 27 percent, respectively) (Biederman et al. 1995). These statistics emphasize the crucial need for clinicians to be vigilant about aod diagnosis in individuals with ADHD.
Family studies further support the link between co-occurring ADHD and AODD. Elevated rates of alcoholism are consistently observed in parents of children with ADHD (Wilens et al. 1996). Conversely, children and adolescents of alcoholics, compared to children of nonalcoholics, exhibit shorter attention spans, higher levels of impulsivity, aggressiveness, and hyperactivity, as well as increased rates of ADHD (Wilens et al. 1996). This familial clustering suggests a genetic component to both disorders. However, aod diagnosis in children from families with a history of substance use requires careful consideration of both genetic and environmental factors.
Interpreting family studies is complex due to the potential influence of prenatal AOD exposure. For example, offspring of mothers dependent on alcohol and cocaine are at increased risk for psychiatric disorders, including ADHD (Wilens et al. 1996). Family genetic data in these studies are often insufficient to fully disentangle the contributions of prenatal AOD exposure, parental psychopathology, and the interplay of genetic and environmental factors, such as poverty and inadequate prenatal care. Therefore, a comprehensive aod diagnosis should consider these multifaceted influences.
Disease Course and Remission in Comorbid ADHD and AODD
AODD tends to emerge at an earlier age in adults with ADHD compared to those without ADHD (average age 19 versus 22) (Wilens et al. 1997). Furthermore, adults with AODD exhibit more severe AOD use problems when ADHD is also present (Carroll and Rounsaville 1993). The presence of ADHD appears to accelerate the progression from AOD abuse to dependence (Wilens et al. 1998) and increases the risk of developing a drug use disorder in individuals already abusing alcohol (Biederman et al. in press). This accelerated and intensified course underscores the urgency of early aod diagnosis and intervention in individuals with ADHD.
ADHD also impacts the rate of recovery from AODD. One study found that adults with ADHD took more than twice as long to recover from comorbid AODD compared to those without ADHD (144 versus 60 months, respectively). Additionally, AODD lasted over 3 years longer in individuals with ADHD (Wilens et al. 1998). These findings highlight the significant challenges in AODD recovery for individuals with comorbid ADHD and emphasize the need for tailored treatment approaches informed by accurate aod diagnosis.
Potential Mechanisms Linking ADHD and AODD
The underlying mechanisms connecting ADHD and AODD are still not fully understood, but likely involve intricate interactions between biological and psychological factors. Two significant contributing factors for risk assessment and treatment strategy are comorbidity with other psychiatric disorders and the use of AODs for self-medication of psychological distress. A thorough aod diagnosis must consider these potential underlying mechanisms to develop effective treatment plans.
Comorbid Psychiatric Disorders and AOD Risk
Certain psychiatric conditions frequently co-occur in youth with combined ADHD and AODD (Wilens et al. 1996). These include bipolar disorder and conduct disorder. Juvenile bipolar disorder is characterized by irritability and mood instability. Conduct disorder involves a persistent pattern of aggressive behavior, criminality, or violation of social norms (APA 1994). While childhood ADHD itself is associated with an increased risk of developing AODD in adolescence, independent of other comorbid psychiatric conditions, the presence of conduct disorder or bipolar disorder further elevates this risk, leading to an even younger onset of AODD (age 16 or younger), again, independent of ADHD (Wilens et al. 1997; Biederman et al. 1997). Although anxiety and depressive disorders may co-occur with ADHD, they do not appear to add further risk for AODD development during adolescence in ADHD youth (Biederman et al. 1997). The presence of these comorbid conditions significantly impacts aod diagnosis and treatment planning.
Self-Medication Hypothesis
Evidence suggests that AOD use, in some instances, represents an attempt to self-medicate psychiatric symptoms and the associated subjective distress (Khantzian 1997). The academic struggles and behavioral problems linked to ADHD can lead to conflicts with adults and peers, chronic failure, and demoralization. It is plausible that some individuals with ADHD may develop AODD as a response to the emotional consequences of social, occupational, and emotional impairment, coupled with a poor self-image. Consistent with this self-medication theory, adolescents with ADHD report using AODs to adjust their mood rather than primarily to experience a “high” (Biederman et al. 1995; Wilens et al. 1996). Understanding this self-medication aspect is crucial for accurate aod diagnosis and developing empathetic and effective treatment strategies.
Treatment Considerations for Comorbid ADHD and AODD
Treatment for patients with both ADHD and AODD should be grounded in a comprehensive evaluation encompassing psychiatric, social, cognitive, educational, and family factors, alongside a detailed history of the patient’s AOD use and prior treatment experiences. Clinicians must rule out medical and neurological conditions that may mimic ADHD symptoms (e.g., restlessness and emotional lability in hyperthyroidism) or result from AOD use (e.g., agitation during withdrawal) (Riggs 1998). Differential aod diagnosis is essential to ensure appropriate intervention.
The treatment of ADHD and AODD must be addressed concurrently; however, active addiction necessitates immediate attention (Riggs 1998). Depending on the severity and duration of AODD, residential treatment may be required. Psychosocial therapies designed for co-occurring ADHD and AODD can be combined with patient and family education, participation in self-help groups (e.g., Alcoholics Anonymous), and appropriate medications (pharmacotherapy) (Riggs 1998). An integrated approach, informed by accurate aod diagnosis, is crucial for successful outcomes.
Pharmacotherapy in Comorbid Conditions
Medications play a significant role in the long-term management of ADHD. However, the impact of such treatment on the subsequent development of AODD remains unclear and may depend on the severity of the underlying ADHD. Preliminary studies suggest that certain medications can alleviate ADHD symptoms in adolescents and adults while simultaneously reducing co-occurring AOD use or cravings (Levin et al. 1997; Riggs 1998). Careful consideration of medication options is a vital component of treatment following aod diagnosis.
Psychostimulants are the most frequently prescribed medications for ADHD. This class of drugs enhances concentration, wakefulness, and alertness. Common psychostimulants used for ADHD include amphetamine (Dexedrine®), methylphenidate (Ritalin®), and pemoline (Cylert®) (Riggs 1998). Children with ADHD treated with these medications often show improved attention in class and better academic and social performance.
However, psychostimulants themselves carry a potential for abuse. Among the three mentioned, pemoline has the lowest abuse potential, followed by methylphenidate and amphetamine (Riggs 1998; Drug Enforcement Administration [DEA] 1995). When used as prescribed for ADHD, psychostimulants do not appear to increase the risk of subsequent stimulant misuse or abuse of other addictive drugs (Hechtman 1985). In fact, one study indicated that untreated ADHD patients and those with poorer responses to psychostimulants exhibited more illicit AOD use compared to successfully treated patients (Loney et al. 1981). Nevertheless, patients with ADHD and their families should be educated about the risks of diverting psychostimulants to individuals for whom they are not prescribed (DEA 1995). When considering pharmacotherapy, aod diagnosis must be carefully considered to mitigate potential risks.
Other medications used to treat ADHD include various antidepressants (e.g., bupropion [Wellbutrin®], imipramine [Tofranil® and others], and venlafaxine [Effexor®]) and certain antihypertensive medications (e.g., clonidine [Catapres®]) (Spencer et al. 1996). The choice of medication depends partly on potential adverse interactions with AODs the patient may be using. Throughout pharmacotherapy, clinicians should regularly monitor treatment adherence, conduct random urine drug screens to detect AOD use, and coordinate care with other involved parties. These monitoring practices are crucial in the context of aod diagnosis and treatment.
Conclusions and Future Directions
Research strongly supports a link between ADHD and AODD, with ADHD symptoms typically preceding the onset of AOD abuse by many years. AODDs that begin in adolescence tend to have a more severe course than those starting in adulthood. Therefore, prevention and early intervention strategies should target children with ADHD before AOD use problems develop and become chronic (Wilens et al. 1997). Further longitudinal studies are needed to better understand the causal factors linking these disorders and to identify youth at heightened risk for ADHD–AODD comorbidity. This research can lead to more effective treatments, including pharmacotherapies, for both disorders (Biederman 1998). Improving the precision and timeliness of aod diagnosis in individuals with ADHD is a critical step towards better prevention and treatment outcomes.
Footnotes
1AOD disorders in this context include both addiction (dependence) and abuse.
2The term “ADHD” as used in this article encompasses previous definitions of the disorder.
3For comparison, between 10 and 30 percent of adults in the United States experience alcohol use disorders (Kessler et al. 1997).
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