Substance-use disorder is a common comorbidity with ADHD and there are many mechanisms that may explain substance misuse in individuals with ADHD, such as behavioural disinhibition, comorbidity, self-medication and sensitisation (Dalsgaard et al, 2014; Sizoo et al, 2010; Steinhausen & Bisgaard, 2014). The authors of this article provided a set of practical guidelines on how to deliver early interventions to individuals with ADHD and comorbid substance-use disorder.
As there may be high rates of substance misuse amongst individuals with ADHD, healthcare professionals could routinely enquire about alcohol and drug use. During the clinical ADHD diagnosis process, a risk assessment for drug and alcohol use may be performed where it is deemed necessary. Caution is advised when assessing an individual with a substance-use disorder for ADHD, as there is a possibility they may report non-credible symptoms and performance. The outcome of the assessment process is the identification of a set of treatment goals, which should be the result of a collaborative effort between the individual with ADHD and the clinician. When conducting an assessment for ADHD in individuals with a substance-use disorder, the clinician is recommended to determine the individual’s expectations of diagnosis and treatment.
Following assessment, psychoeducation may be an important part of the treatment process, as it could help the individual with ADHD and comorbid substance-use disorder gain insight, knowledge and understanding which could empower them to make more informed decisions. The individual with ADHD and comorbid substance-use disorder is recommended to be guided through the process of psychoeducation so that they may acknowledge the negative effects of substance use.
The individual with ADHD and comorbid substance-use disorder should first acknowledge that they are dissatisfied with aspects of their life and have belief that alternatives are achievable. The clinician may encourage the individual to understand that this is a process of change. To this end, a set of highly structured goals and steps could be outlined to aid the individual in understanding the process. A dissonance chart could be utilised to aid the individual in realising the discrepancies and/or differential between their current circumstances and goals for the future. Furthermore, a decisional balance matrix, which sets out the pros and cons of the individual’s current situation, could be employed. This matrix may aid the individual with ADHD and comorbid substance-use disorder to recognise that the benefits of reducing and stopping the substance can outweigh its continual usage.
Cognitive behavioural therapy techniques may also be utilised to develop the skills of an individual with comorbid ADHD and substance-use disorder to reduce temptation on a long-term basis and maintain abstinence (Bellack & DiClemente, 1999). These techniques can include: activity scheduling; addressing dysfunctional beliefs and negative thinking; addressing physical cravings and urges; building confidence; building empowerment and self-efficacy; gaining positive social networks; relapse prevention; and reward techniques and self-reinforcement.
In the opinion of the authors the management techniques that are highlighted in this article may assist clinicians in supporting adolescents and adults with ADHD and comorbid substance-use disorder to address their issues and behaviours. Furthermore, the authors recommended that an integrated multidisciplinary approach to treatment for ADHD and comorbid substance abuse could be adopted. However, the authors acknowledge that in some instances, this may not be feasible or desirable.
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Steinhausen H-C, Bisgaard C. Substance use disorders in association with attention-deficit/hyperactivity disorder, co-morbid mental disorders, and medication in a nationwide sample. Eur Neuropsychopharmacol 2014; 24: 232-241.
Young S, Woodhouse E. Assessment and treatment of substance use in adults with ADHD: a psychological approach. J Neural Transm (Vienna) 2020; Epub ahead of print.