The final part of a three-part series on the impacts of undiagnosed/treated adult ADHD.Guest article by CHADDFor people with ADHD across the lifespan, the co-occurrence of other disorders is generally the rule rather than the exception. Experts estimate that at least 60-80 percent of children, adolescents, and adults with ADHD have at least one other condition. Conduct disorders, oppositional defiant disorder, learning disorders, and anxiety and mood disorders are the most common comorbid disorders in childhood and adolescence. In adults, personality disorders are also highly prevalent. Likewise, there is a significant association between ADHD and substance use disorders, constituting one of the most common forms of dual diagnosis, a term used for the co-occurrence of an addictive disorder and at least one other mental disorder.
ADHD is associated with increased risk of substance use initiation as well as of developing a substance use disorder (SUD). Children and adolescents with ADHD are significantly more likely to try alcohol, tobacco, and a range of substances during their lifetime compared with their non-ADHD counterparts. Indeed, a study by Steve Lee and colleagues (2011) reports that individuals with ADHD are: ● twice as likely to have ever smoked cigarettes and nearly three times more likely to become addicted to nicotine, ● almost twice more likely to develop an alcohol or a cocaine use disorder ● approximately 1.5 times more likely to meet criteria for cannabis use disorder ● more than 2.5 times more likely to develop any form substance use disorder ● more vulnerable to develop a gambling disorder. Experts estimate that approximately 15 percent of adolescents and young adults with ADHD have a concurrent substance use disorder. A large meta-analysis revealed that almost one in every four patients seeking treatment for a substance use disorder also have ADHD (van Emmerik-van Oortmerssen, 2012). In the vast majority of these cases, ADHD remained undiagnosed and consequently untreated. Clinical evidence and findings from multiple studies show that the bidirectional overlap between these disorders is not random. Several explanations have been posed for their link. The link between ADHD and substance use disorders The mechanisms underlying the increased risk of substance use and SUDs among individuals with ADHD have not been fully established. The increased risk is most likely due to a combination of several vulnerability factors, including: ● shared neurobiological mechanisms ● the difficulties in psychosocial functioning or certain traits and characteristics that are common to both disorders ● the comorbidity with other psychiatric disorders ● the underlying neuropsychological deficits, or what has been termed as the self-medication hypothesis. Several neuroimaging studies show that individuals with ADHD display motivation and reward deficits characterized by a failure to delay gratification and preference for small immediate rewards over larger delayed rewards, mediated by altered dopamine transmission in certain brain areas. These deficits have been proposed as an underlying mechanism for impulsive behaviours associated with ADHD and the increased vulnerability to substance abuse. Researchers also hypothesize that ADHD and addictive disorders could share common familial risk factors due to shared genetic risks between the two conditions. In addition, several studies indicate a threefold-increased risk of ADHD in children of women who smoked cigarettes or used alcohol or other drugs during pregnancy. Initiation of substance use in adolescence commonly takes place within social and peer contexts. Therefore, some studies indicate that the psychosocial problems and poor academic functioning frequently seen in ADHD may contribute to the development of an SUD. Alternatively, the increased vulnerability to addictive disorders in people with ADHD may also be related with some of the core symptoms of this neurodevelopmental disorder, such as impulsivity, which is also a significant feature of substance abuse. Likewise, some personality traits and symptoms that are generally genetically determined and are frequently associated with both ADHD and addictive disorders– such as novelty seeking, sensation seeking, harm avoidance, low self-esteem, and altered executive functions– may also increase the link to developing a dual diagnosis. Another key factor in understanding their increased vulnerability to substance use and abuse is the high comorbidity with other psychiatric disorders in children, adolescents and adults with ADHD, including depressive and anxiety disorders, bipolar disorder, or conduct disorders. Of particular relevance is the coexistence of a conduct disorder. Among individuals with ADHD, conduct disorder not only increases the risk of developing a substance use disorder, it is also associated with an earlier onset of substance use, a greater severity of the addictive disorder, and an overall worse outcome of both disorders. Researchers suggest that some individuals with ADHD use substances in order to attenuate or alleviate some of their symptoms or dysfunctions in an attempt to “self-medicate.” Indeed, for some people with ADHD, cocaine has a paradoxical effect of increasing attention span and decreasing motor restlessness. Some adolescents and adults with ADHD, particularly those with more prominent hyperactivity and impulsivity symptoms, experience a decrease in psychomotor activation with marijuana use. For others, however, marijuana use can mimic the symptoms of ADHD and has been associated with worsening in sustained attention, deficits in problem-solving, or difficulties in organization that may persist even after several weeks of abstinence. Treatment for ADHD and comorbid substance use disorders Treatment of ADHD with or without a concurrent substance use disorder requires a multidisciplinary approach that integrates therapy and medications. Psychotherapy is always recommended, often in conjunction with any medication. Psychoeducation, motivational interviewing, and cognitive behavioural therapy are among the most useful intervention strategies for ADHD and concurrent SUD. An adequate treatment plan needs to consider the trajectory and severity of both disorders, the number of substances used, the presence of withdrawal symptoms, the stability of ADHD symptoms during prolonged periods of abstinence, and the occurrence of other comorbid psychiatric disorders. Several studies have assessed the efficacy of stimulant and non-stimulant medications in individuals with ADHD and SUDs. The majority of these studies have shown that the different ADHD medications are equally effective and well tolerated, generally in combination with psychological interventions. The effects of ADHD medications on craving or abstinence is more limited. Nonetheless, none of the studies has shown a detrimental effect of stimulant or non-stimulant medications on substance use outcomes. Clinical practice reveals that treatment of ADHD may help individuals to remain and benefit from treatment for the addictive disorder. The good tolerability and safety profile of psychostimulants or atomoxetine (Strattera) in dually diagnosed individuals and the scarcity of significant interactions indicate these medications can be easily associated with pharmacotherapies commonly used in the treatment of specific substance abuse or dependence (Martínez-Raga et al, 2013). Medication treatment for ADHD is often deferred until the individual reaches a protracted period of abstinence from the addictive substance. However, there is limited empirical evidence supporting such practice, and clinical guidelines recommend deciding treatment order based on the severity of ADHD and the comorbid disorder. A recent study evaluating the effects of stimulant medication in individuals with co-occurring ADHD and cocaine dependence (Levin et al, 2018) reported that abstinence is most likely preceded by improvement in ADHD, which tends to occur early with medication treatment. This suggests that treatment of ADHD should not be postponed. Medication concerns Several concerns often arise on the use of medications for ADHD and their relationship with drug abuse. Many parents fear that prescription of psychostimulants during childhood may increase the susceptibility to subsequent drug use in adolescence or adulthood. As mentioned earlier, the fact is that untreated ADHD is a significant risk factor for substance abuse in adolescence and adulthood. Solid basic and clinical research shows there is no evidence that stimulants increase substance use or the risk of addiction. It remains to be established if they protect against the risk of later developing an addictive disorder, however. Another frequent concern relates to the potential risk of abuse or misuse of psychostimulants prescribed for ADHD. This is one of the arguments against prescribing these medications in individuals at risk or who have a concurrent SUD. However, the majority of cases of medication abuse or misuse are related to short-acting stimulants, whilst there is little evidence of abuse or misuse with long-acting formulations, more so with nonstimulants. In any case, careful assessment of potential abuse of ADHD medication is warranted. Although psychostimulants are considered first-line treatments for adults with ADHD, a common concern is whether they can be safely and efficaciously used in those with both ADHD and a substance use disorder. In these dually diagnosed adults, long half-life or slow-release formulations are preferable, as they maximize treatment adherence and minimize the risk of abuse due to their pharmacological characteristics. A growing body of research and clinical practice indicate that long-acting stimulants are as effective on symptoms of ADHD and well-tolerated in individuals with and without a concurrent SUD. Often considered a second-line option for adults with ADHD, atomoxetine (Strattera) may be considered a first-line treatment alternative for adults with SUD– especially those for whom treatment with stimulants previously failed and those with a history of prescription stimulant abuse. José Martínez-Raga, MD, PhD, heads the psychiatry department at the University Hospital Doctor Peset, one of the major teaching hospitals in Valencia, Spain. He is also a lecturer at the University of Valencia Medical School. Dr. Martínez-Raga received his medical degree from the University of Valencia Medical School and completed an MSc Degree in Drug Addiction. Later, he completed a PhD, having conducted a study as a research fellow in Psychiatry at McLean Hospital and Harvard Medical School. He completed his specialist psychiatric training at the Bethlem and Maudsley Royal Hospital School in London. Then, he returned to Spain and worked as a psychiatrist within the Spanish National Health Service. Until 2012, he was the coordinator of an outpatient addiction behaviours unit. Dr. Martínez-Raga has coauthored over 100 peer-reviewed scientific journal articles, as well as over 40 book chapters and 12 books and monographs. He has been invited to present at national and international psychiatry and addiction conferences and meetings. Currently, he is vice president of the Sociedad Española de Patología Dual (Spanish Society of Dual Disorders or SEPD). Read the original article here. Tara Carman-French, Director/ADHD CoachI spent the bulk of my adult life as an undiagnosed individual struggling with ADHD. Unfortunately, I didn’t realize that there was anything different about me, I just thought I was never enough.
Post-secondary education is where it really caught up with me. I couldn’t focus on lectures. I struggled to complete homework. Being on my own and having to look after laundry, cleaning, shopping, cooking, and keeping on budget along with my homework just felt impossible. I had a ton of self-doubt regarding if I should even be in school. I felt far to dumb to be there. Everyone seemed to have their stuff together and I was struggling to keep up with the simplest of things. The school did notice that there was something wrong. They suggested I take a learning strategies course. It helped a little. I know now that it wasn’t aimed at people who have ADHD, so their organization, prioritization, and time management strategies never worked for me because I wasn’t struggling in the ways they thought I was. Proper identification is very important. Eventually, I dropped out. It took me far more years than I wish to disclose here to obtain my degree. Initially, my work life ended up successful. I spent 15 years working in theatre across Canada. Being in a fast paced, creative, flexible environment really helped me to shine. Although, I struggled to fit in and always felt like an outcast. Looking back, I realize that I was immature compared to my peers. I imagine they saw me as incredibly awkward and very inappropriate at times. I couldn’t see any of this in the moment, but I felt it and my self-esteem suffered. So did my decision making. I flitted through many relationships, both long and short term throughout my life. I couldn’t maintain a good relationship with anyone, particularly as a life partner. I really wasn’t a good partner to myself, let alone trying to support or stand beside anyone else. My saving grace was that I was able to establish and maintain very long-term friendships. Today, I was reminded by one of my good friends that we have known each other for 30 years! When I first started working with Artemis, I wasn’t sure that this was my thing. It was incredibly different than theatre and didn’t hold much interest for me. Until I was assessed, and it opened my eyes to what I had been struggling with all along. Finally, there wasn’t something wrong with me. My brain was built differently. It became my mission to help others see themselves and their struggles in a better light. My interpersonal relationships also improved after diagnosis and treatment. I have a close family relationship with my husband, children, and extended family, and we are compassionate about all of our unique struggles. Sure, we still have difficult times and don’t always see eye to eye, but we are solid, overall. I had some grief over what could have been had I been recognized early. My path would have been so much easier. The thing is, I wouldn’t change anything at this point. I am who I am because of my struggles, and I am happy with me. How can we help make you happy with you? A Part two of a three-part series on the impacts of undiagnosed/treated Adult ADHD.Guest article by CHADDThe symptoms of ADHD can create challenges for adults in the workplace, just as they do for children in school. Some adults with ADHD have very successful careers. Others may struggle with a variety of challenges, including poor communication skills, distractibility, procrastination and difficulty managing complex projects. Seeking assistance from a career counsellor, psychologist, social worker or other health care worker with career counselling training can be helpful in understanding and coping with ADHD on the job. Each individual with ADHD has a different set of challenges. Therefore, it is important to consider your unique picture, as you go about designing strategies, accommodations and modifications for the workplace. Below are suggestions for coping with many of the symptoms or impairments associated with ADHD.
1. Distractibility. Problems with external distractibility (noises and movement in the surrounding environment) and internal distractibility (daydreams) can be the biggest challenge for adults with ADHD. The following strategies may help:
2. Impulsivity. Adults with ADHD may struggle with impulsivity and temper outbursts in the workplace. Try the following strategies:
3. Hyperactivity. Adults with the hyperactive presentation of ADHD often do better in jobs that allow a great deal of movement, such as sales, but if you have a sedentary job, the following strategies may help:
4. Poor Memory. Failing to remember deadlines and other responsibilities can antagonize coworkers, especially when working on a team. To improve memory, try the suggestions below:
5. Boredom-blockouts. Because of their strong need for stimulation, some adults with ADHD become easily bored at work, especially with detailed paperwork and routine tasks. To prevent boredom, try the following tips:
6. Time management difficulties. Managing time can be a big challenge for adults with ADHD. Here are some guidelines for improving time management skills:
7. Procrastination. Putting things off not only prevents the completion of tasks but also creates problems for others on the team. Here are some strategies for success:
8. Difficulty managing long-term projects. Managing complex or long-term projects may be the hardest organizational challenge for adults with ADHD. Managing projects requires a range of skills, including time management, organizing materials, tracking progress, and communicating accomplishments. Try the following guidelines:
9. Paperwork/details. The inability to find important papers, turn in reports and time sheets, and maintain a filing system can create the impression of carelessness. If paperwork is a significant part of the job, try these tips:
l0. Interpersonal/social skill issues. Individuals with ADHD may unintentionally offend co-workers by interrupting frequently, talking too much, being too blunt, or not listening well. If social skills are a challenge, try the following strategies:
Making a Career Change Sometimes, no matter how hard they try, adults with ADHD find that their initial career choice does not play to their strengths, and it is necessary to make a change. The following categories reflect aspects of an individual that impact effective functioning on the job. Collect data about each of these categories as it applies to you. This data will permit you to see yourself as a unique, complete person and to evaluate better the careers that match your characteristics. 1. Interests (professional & leisure). Since individuals with ADHD work better in fields that interest them, it is important that they identify their interests. After the interests have been identified, a consultation with a trained career counsellor, who can provide a list of occupations or jobs that correspond to their interests, should be considered. The list of occupations that correspond to the individual's interests will provide the basis for the steps that follow. 2. Skills (mental, interpersonal, and physical). Identifying skills and accomplishments can reveal marketable skills that can be used in various work settings. Generally, skills fall into three categories: skills working with data, people, or things. People do best when their skills correspond to the job requirements. Skills can be assessed through standardized tests or through checklists that trigger knowledge of success in past accomplishments. For example, you might ask yourself the following questions:
In addition, using a skill word list provided by a career counsellor or published in a career book may be helpful in identifying skills that may not have been considered important or considered at all. 3. Personality. What type of personality are you? Personality preferences can be measured by standardized testing or by checklists that force you to choose between two situations. Knowing personality strengths can help improve work habits, increase career options, and achieve a more successful path to a career future. 4. Values (work and leisure). People value different things. It is generally agreed that people work harder and with more focus when the task at hand is in line with their values. Leisure values are also important because a personal passion can often turn into a career. Career counsellors and other professionals who work with career issues or checklists in career books can help isolate these values. 5. Aptitudes (verbal, numerical, abstract reasoning, clerical speed and accuracy, mechanical, spatial, spelling, and language). An aptitude is defined as the ability to acquire proficiency in a specific area. It often seems that these are innate, but this is not necessarily true. Aptitudes can also be learned. While a skill is a current ability, an aptitude is the potential to acquire a skill based on natural talents or training. Aptitudes can be formally assessed by a professional or by using informal checklists. When you understand what your strengths are, you can compare them to the requirements of any given job. The Dictionary of Occupational Titles and The Occupational Outlook Handbook are two sources for such information. Doing these comprehensive assessments ensures that you have a clear knowledge of the essential tasks of a job for which you are applying and how your strengths match up with the requirements of the job. 6. Energy patterns (Is there a pattern that's reliable?). All jobs require differing amounts of energy. Are you a sprinter or a plodder alonger? While those are not real terms, they define the types of people who can either go through each day with the same amount of energy output or sprint through a job, depleting their energies and thus feeling "spent." Some people have a pattern to their energy output, while others do not. To figure out if there is a pattern to your energy output, keep an energy log for 1 or 2 months. Rate yourself on a scale from 1 (very low energy level) to 10 (very high energy level) three times per day -- at the beginning, middle, and end of the day. Record these ratings in a log book or day planner. Periodically review the log to see whether there is any pattern in energy level across the day, week, and month. If a pattern is not noticeable, then it will not be difficult to sustain energy at most jobs. However, if a fairly reliable pattern exists, then it may be necessary to learn how to harness energy to do difficult tasks at times when energy is high and do more "automatic" tasks when energy is low or depleted. 7. Workplace habits (what is expected vs. how we measure up). Job success often depends on personal characteristics, such as dependability, reliability, commitment, and attitude. Consult a career-related book on the reference list for a list of the qualities that employers most often look for in employees. Decide how you measure up to these qualities, and determine whether it is necessary to improve these workplace habits. 8. A complete history of all previous jobs (useful for extracting valuable information). People learn the most from their mistakes and successes. Look back and explore such things as:
Look for patterns that might help to plan for a future career. Using the Data After collecting this data, follow these three steps to maximize the chance of success and minimize the chance of failure:
When all of this information has been collected, the following questions can be answered:
A personal reflectionTara Carman-French—Director/ADHD Coach The different ways ADHD presents in my family are just awesome.
My husband and I are about to go on vacation. The car will pick us up and take us to the airport at 3:00 p.m. It is now 12:30, and neither of us can sit still and relax. Everyone keeps telling us to just enjoy, sit, and chill out. Yeah, right. I am catching up on my article writing. You see, I finally have a calm brain. Okay, a calmer brain. I’m not at work with a million things to do, so I can have some creative time, which I love! I need something to burn up all the pent-up energy due to the excitement of going away, so I’m writing. My husband is currently vacuuming the basement. That’s my son’s job. After this morning, we have the cleanest house we have had in months. Too bad we are going away and can’t enjoy it. We talked to our oldest child today, who is finally learning to drive at 25 years old. We were told that if you learn to drive in a parking lot, you can be charged with reckless driving. Yeah, we laughed at that, too. What you need to understand is that my child’s brain craves excitement. Everything becomes a drama, and we constantly challenge the narratives that we are told. Our youngest child is struggling to finish high school. Unfortunately, this child does not live with us full-time, so we don’t have many options to help in this area. It is the last semester, but the interest in schoolwork is becoming difficult to maintain, particularly when there has been an offer of an apprenticeship in an area of intense interest. We will keep working to ensure that this one graduates successfully. Our middle child fluctuates with remembering tasks and getting up on time for work. When things are going smoothly, this child is totally on the ball! Up on time, getting things done, anticipating what needs to be done. Then, suddenly, for no clear reason, everything becomes bumpy again. It is painful to watch the struggle and self-judgement when things aren’t running so smoothly. We keep working on self-forgiveness and self-esteem. ADHD is not one size fits all. It is different for all of us. Having patience and understanding for everyone’s individual struggles is what keeps our family close and strong. A The reality behind Adult ADHD and how it affects relationships. |
Tara Carman-FrenchDirector, Certified ADHD & LD Coach Archives
February 2025
Categories
All
|