ADHD and substance-use disorder (SUD) are often observed concurrently in adolescents, but current guidelines do not group those with both of these conditions into a distinct subgroup of individuals with ADHD. Individuals being treated for ADHD in psychiatric settings are not routinely screened for SUD and screening for ADHD is not routine in SUD treatment settings. Therefore, patients with comorbid ADHD and SUD often remain undiagnosed and thus undertreated. Research on comorbid ADHD and SUD is limited, therefore, there is insufficient evidence on which to base treatment recommendations or guidelines. The goal of this study was to develop an International Consensus Statement on screening, diagnosis and treatment of adolescents with concurrent ADHD and SUD.
A modified Delphi analysis was performed involving a multidisciplinary group of 55 experts from 17 countries. Experts were asked to rate a series of statements on:
- The effect of ADHD treatment of children on the development of SUD in adolescence and early adulthood.
- The possibilities for screening, diagnosis and treatment of adolescents with ADHD and SUD.
Three rounds of rating and adapting 37 statements were conducted.
A total of 52 (95.0%) experts in the consensus group participated in the first round and 55 (100.0%) experts participated in the second and third rounds of rating and commenting. The experts did not reach a consensus on 10 of the 36 statements proposed in the first round. These statements were adapted and re-sent to the experts along with three statements for which consensus had been reached but were rephrased based on comments from the experts, and an additional statement that had been proposed by the experts in the first round of review. In the second round, a consensus was reached on 11 of the 14 statements. The remaining three statements were further revised and sent for a third round of rating and commenting. Consensus was reached on 36 of the 37 statements representing six domains: general (n = 4), risk of developing SUD (n = 3), screening and diagnosis (n = 7), psychosocial treatment (n = 5), pharmacological treatment (n = 11) and complementary treatments (n = 7).
Expert recommendations included:
- Routine screening for ADHD in adolescents in substance abuse treatment and for SUD in adolescents with ADHD in mental health care settings.
- Long-acting stimulants for first-line treatment of ADHD in adolescents with concurrent ADHD and SUD.
- Pharmacotherapy should be used in combination with psychosocial treatment.
- A consensus on whether full abstinence should be required before initiation of pharmacotherapy could not be reached. In addition, some experts disagreed with the use of stimulants in those with ADHD and SUD regardless of abstinence, and others did not support the use of bupropion in these individuals.
Limitations of the study included possible bias in selecting the experts as most participants had a special interest in ADHD and SUD. Furthermore, paediatricians and patient representatives were not included in the expert panel. Finally, the consensus statement was not officially approved by scientific, professional or patient organisations.
In summary, this International Consensus Statement can be used by clinicians and individuals with ADHD and SUD to make shared decisions on optimal treatment selection. However, this statement is not a substitute for an evidence-based guideline; additional studies are needed to further explore optimal management approaches for the subgroup of individuals with concurrent ADHD and SUD.
Özgen H, Spijkerman R, Noack M, et al. International Consensus Statement for the screening, diagnosis, and treatment of adolescents with concurrent attention-deficit/hyperactivity disorder and substance use disorder. Eur Addict Res 2020; 26: 223-232.