ADHD is the acronym for attention deficit hyperactivity disorder, a disorder that is most commonly associated with children and adolescents but can be diagnosed in adults in some cases. The diagnosis of ADHD in an adult can only occur if there is a documented history that the adult had the symptoms of ADHD when they were a child.
The ADHD diagnosis represents the full spectrum of attention deficit diagnoses. Some sources and lay individuals still refer to a diagnosis of ADD (attention deficit disorder); however, this is not a formal diagnosis used by the American Psychiatric Association (APA). Instead, individuals who present primarily with deficits of attention and little or no hyperactivity or impulsivity are given a specialized diagnosis of ADHD that reflects one of the three subtypes of the disorder. Only a trained mental health professional can diagnose ADHD in anyone.
Because the cognitive function that we often referred to as “attention” is quite variable in the same individual from situation to situation, many individuals may believe that they have difficulties that reflect a disorder of attention, when they are actually expressing behaviors that are within functional limits. Anyone who believes that they may have a formal mental health disorder or neurological condition that interferes with their attention-related abilities should consult with a licensed mental health professional.
The Symptom Profile of ADHD
Diagnosis of the majority of mental health disorders listed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), the most current release of APA’s diagnostic criteria, is complicated because there are no formal medical tests, such as laboratory tests, brain scans, blood tests, etc., that can definitively diagnose the vast majority of these disorders. Instead, the diagnostic criteria for disorders like ADHD are based on a number of symptoms and signs in the individual’s behavior.
For a diagnosis of ADHD, the child must express significant signs and symptoms of the diagnosis in at least two different settings (e.g., at school and at home). In order to be formally diagnosed with ADHD, they must meet criteria for at least six of nine problems that are associated with attentional dysfunction and/or at least six of nine symptoms that are associated with impulsivity and hyperactivity. Individuals over the age of 17 who are receiving a first-time diagnosis of ADHD need to display five or more of the nine symptoms associated with dysfunctional attention and/or five or more of the nine symptoms associated with impulsivity and hyperactivity in addition to a documented history of having some of these issues when they were young children (before the age of 12).
Symptoms of attentional dysfunction that may be observed follow:
- The person often displays problems sustaining attention.
- The person may often overlook important details in their work or in other important activities.
- The person often expresses difficulty listening to someone, and this cannot be related to a problem with hearing.
- The person often begins tasks but quickly loses interest or focus on the task and often does not finish tasks that were started.
- The person often loses things that are important or necessary to them.
- The person is very forgetful, particularly when it comes to doing work or chores.
- The person demonstrates repetitive and major difficulties with organization.
- The person often avoids tasks that require them to engage in sustained mental effort.
- The person is easily distracted by either external stimuli in the environment or by internal stimuli, such as their thoughts.
Signs and symptoms of hyperactivity and/or impulsivity consist of:
- Frequent and extreme difficulty in controlling behaviors when one is required to do so
- Being fidgety
- Inability to become involved in leisure activities in a quiet manner
- Inability to remain in one spot when they are required to do so
- Excessive talking
- Blurting out responses or answers to questions before the person asking them is able to finish the question or request
- Difficulty waiting one’s turn
- Interrupting or intruding on others
- Inability to slow down
The behavioral manifestations of ADHD are actually relatively common issues that many people have from time to time. The symptoms must be very frequent, rigid, and persistent in order for an individual to actually get a diagnosis of ADHD. Because the symptoms associated with ADHD reflect extreme manifestations of common behaviors, only trained individuals can assess someone to determine if they have this disorder.
The Main Subtypes of ADHD
ADHD is a disorder that can be expressed in three different manifestations. According to professional texts, such as Kaplan and Sadock’s Synopsis of Psychiatry, ADHD is one of a number of mental health disorders that are heterogeneous, meaning that it can display itself in a number of different and surprisingly contrasting ways.
The three subtypes of ADHD are:
- Predominantly inattentive presentation: In this presentation of the disorder, the person meets the criteria for the inattentive symptoms but does not meet the full criteria for the hyperactive/impulsive symptoms. This is the manifestation of ADHD that people are referencing when they speak of ADD.
- Predominantly hyperactive/impulsive presentation: In this presentation of the disorder, the individual does not meet the diagnostic criteria for the inattentive symptoms, but does meet the diagnostic criteria for the hyperactive impulsive symptoms.
- Combined presentation: This presentation is consistent with what most individuals think of when they think of ADHD. The person meets the diagnostic criteria for both the inattentive symptoms and the hyperactive/impulsive symptoms. This is also the presentation with the most negative prognosis if it is not treated effectively.
In order for an individual to be formally diagnosed with ADHD, their symptoms cannot be better explained by some other mental health condition (e.g., a disorder like schizophrenia, depression, bipolar disorder, etc.), some other medical condition (e.g., as a result of a head injury or endocrine disorder, such as a thyroid problem), or by the use of drugs. In addition, the person’s behaviors must result in significant areas of dysfunction and/or distress in daily functioning.
How Common Is ADHD?
APA states that ADHD occurs in most cultures in about 5 percent of children and about 2.5 percent of adults. It is more commonly diagnosed in males than females. The diagnosis is given twice as often to male children compared to female children, and slightly more than 1.5 times as often in male adults than females adults; however, females are more likely to be diagnosed with the primarily inattentive subtype of ADHD than males.
In recent years, there have been a number of questions regarding this particular diagnosis, particularly the notion that the diagnosis is given too often. This controversy began when the Centers for Disease Control and Prevention reported in 2011 that ADHD was formally diagnosed in 11 percent of children in the United States between the ages of 4 and 17, more than twice the stated prevalence by APA. In addition, a number of other sources indicate that nearly one-fifth of high school males are told that they have ADHD, and formal diagnoses of ADHD increased significantly between 2003 and 2011. A number of other sources have suggested that the diagnosis is a sham diagnosis, and it represents an attempt to medicalize relatively normal behaviors in children and adults.
The issue most likely stems from poor diagnostic practices used by physicians, other healthcare professionals, and individuals who are not in the healthcare field or specifically trained in psychiatric disorders attempting to give unruly children a formal diagnosis that will result in medication. In addition, the changes in the latest edition of the DSM indicate that there will be an increasing trend of adult ADHD diagnoses as previous editions did not allow for the diagnosis to be made in adults as easily. Data from some European countries where the diagnosis is not made as readily as in the US support the notion that the prevalence of ADHD is most likely far lower than 11 percent and may even be lower than 5 percent in children. These issues highlight the need for the diagnosis to only be made by licensed, mental health professionals who have specific training and experience in these disorders.
ADHD and Substance Use Disorders
The presence of any mental health disorder is associated with a greater probability of the presence of a substance abuse issue than in individuals without these diagnoses. In addition, a substance abuse issue is a risk factor for having some other mental health disorder. Many individuals who have mental health issues often have more than one formal diagnosis, and individuals diagnosed with ADHD are no different.
When an individual is diagnosed with two or more different disorders at the same time, the term often used to describe this condition is comorbid disorders. Individuals who have comorbid disorders that consist of a mental health disorder and a substance use disorder are often referred to as having co-occurring conditions or a dual diagnosis.
Children who are diagnosed with ADHD are at increased risk to also be diagnosed with several different developmental disorders that include:
- Conduct disorder
- A learning disability or learning disorder
- Oppositional defiant disorder
Other diagnoses that can occur in both children and adults with ADHD include:
- Some type of anxiety-related disorder, such as a phobia, panic disorder, or social anxiety disorder
The prevalence of a substance use disorder in an individual diagnosed with ADHD is greater than the prevalence for substance use disorders in the general population, but also not as significant as the prevalence of substance use disorders in individuals with other types of mental health disorders. The relationship is rather complicated.
- First, any diagnosis of a mental health disorder is associated with a greater probability of also having a substance abuse issue than in individuals who do not have these diagnoses.
- ADHD is often comorbid with a number of other mental health disorders.
- Adults and adolescents who have a diagnosis of ADHD have higher rates of co-occurring substance use disorders than the general population; however, APA reports that the total proportion of adults who have ADHD and a co-occurring substance use disorder is actually relatively small compared to those who have some other mental health disorder and a co-occurring substance use disorder.
- A great number of individuals who have ADHD and a co-occurring substance use disorder often have some other mental health diagnosis, such as a conduct disorder, personality disorder, anxiety disorder, etc.
Thus, it appears that individuals who have ADHD and some other comorbid mental health disorder are at a significant risk to develop issues with substance abuse compared to individuals who are just diagnosed with ADHD and no other mental health disorder.
The most common drugs abused by individuals with ADHD include:
- Cannabis products
Alcohol and cannabis products have sedating and calming effects that may assist an individual with severe issues with attention or impulsivity. Nicotine may actually have calming effects on some individuals with ADHD.
It should be noted that individuals with ADHD can abuse any drug besides the drugs mentioned above, which are most commonly abused by this group. Some individuals may abuse prescription medications, illicit narcotic drugs (e.g., heroin), stimulants, and hallucinogenic drugs. Individuals who consistently abuse more than one drug at a time have very complicated presentations and can be difficult to treat.
Treatment for ADHD most often consists of medications combined with a behavioral management program. This is particularly true for the treatment of children diagnosed with ADHD. Common medications that are used to treat ADHD are outlined below.
- A number of stimulant medications that include Adderall, Ritalin, and Concerta are used to treat ADHD. It is hypothesized that these medications regulate the central nervous system of a person with ADHD, such that the system functions normally, allowing the individual to focus. It is suggested that the central nervous system of individuals with ADHD actually operates at a suppressed level compared to normal functioning, and their difficulty with attention and hyperactivity reflects issues associated with this deficit. Stimulant medications normalize the central nervous system to allow these children to direct their attention and behavior in a positive manner.
- Several non-stimulant medications, such as Strattera, Kapvay, and Guanfacine, are also approved for the treatment of ADHD. These medications were developed due to a number of side effect profiles associated with the use of stimulant medications in children. Different non-stimulant medications have different mechanisms of action.
- A number of other medications may be used in the treatment of issues associated with people diagnosed with ADHD, such as depression, anxiety, etc.
Despite being presented in the media as a risk factor for the development of substance abuse and often the focus of many uninformed laypeople, the research indicates that individuals who are maintained on stimulant medications for the treatment of ADHD are not at a significant risk to develop a substance use disorder or substance abuse issue.
The other component used in the treatment of ADHD is behavioral modification, which is based on behavioral therapy or even Cognitive Behavioral Therapy. A number of techniques have been developed to address issues associated with ADHD, including Contingency Management systems (rewarding children and adolescents with ADHD for performing behaviors that are positive), cognitive techniques to assist these individuals in thinking through their actions, stress management techniques to deal with other complications, etc.
Individuals who are diagnosed with ADHD and a substance use disorder are most often either teens or adults, not children. All comorbid mental health issues should be addressed concurrently. Attempting to treat one disorder, such as attempting to treat ADHD and ignoring any other comorbid disorders such as depression and/or substance abuse, is not an effective approach.
Treatment programs designed to focus on the specific issues associated with people who have dual diagnoses are typically referred to as integrated treatment programs. These programs are often delivered by a multidisciplinary team of physicians, therapists, and other treatment providers who work together to address all of the individual’s issues in a total treatment package. The specific types of treatments and therapies that are used will depend on the specific individual.
These types of integrated treatment protocols often have overall blueprints that are implemented for specific combinations of comorbid disorders, and then, fine-tuned adjustments are made to suit the individual case. Of course, standard protocols for certain drugs of abuse, such as the need for a physician-assisted withdrawal management program, inpatient treatment, social support group, etc., would also be utilized when appropriate.
Because individuals who are diagnosed with ADHD at an early age do not “grow out” of the disorder, many of these individuals need some form of intervention throughout their lives. In addition, substance use disorder treatment is considered to be a long-term process, and individuals need to remain active in some form of intervention for many years.