Inattention symptoms
1
Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2
Often has difficulty sustaining attention in tasks or play activities
3
Often does not seem to listen when spoken to directly
4
Often does not follow through on instructions and fails to finish schoolwork or duties in the workplace (not due to oppositional behavior or failure to understand)
5
Often has difficulty organizing tasks or activities
6
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (like schoolwork or homework)
7
Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
8
Is often easily distracted by extraneous stimuli
9
Is often forgetful in daily activities
Hyperactivity/impulsivity symptoms
1
Often fidgets with hands or feet or squirms in seat
2
Often leaves seat in classroom or in other situations in which remaining in seat is expected
3
Often runs about or climbs excessively in situations in which it is not appropriate (in adolescents and adults, may be limited to subjective feelings of restlessness)
4
Often has difficulty playing or engaging in leisure activities quietly
5
Is often “on the go” or often acts as if “driven by a motor”
6
Often talks excessively
7
Often blurts out answers before the questions have been completed
8
Often has difficulty awaiting turn
9
Often interrupts or intrudes on others (e.g., butts into conversations and games)
While the core symptoms of inattention, hyperactivity, and impulsivity are well pronounced in children, the presentation is generally more subtle in adults. Hyperactivity at an adult age for instance is not expressed in running and climbing excessively, but rather as inner restlessness, inability to relax, over talkativeness, or avoiding going to theatres, etc. This makes it more difficult to recognize the symptoms, especially since the description of symptoms in the DSM is sometimes more suitable for a childhood situation than for adults.
As mentioned before, ADHD is often accompanied by comorbid disorders. This is also true for SUD patients with ADHD: in comparison to SUD patients without ADHD they even suffer more often from additional psychiatric disorders, such as antisocial personality disorder, borderline personality disorder, depression or anxiety disorders. In fact, the majority of SUD patients with ADHD have at least one more comorbid disorder (van Emmerik-van Oortmerssen et al. 2014), which contributes to the fact that this is a subgroup of SUD patients with more severity.
Although in childhood, ADHD is more often recognized in boys, the rates of ADHD for men and women are more equal in adult populations and are equal in adult SUD populations as well.
13.5 Screening and Diagnostic Assessment of ADHD
Typically, in many SUD patients with ADHD the disorder has not been identified by health-care workers, so substance abuse treatment centres may often be the first to recognize the ADHD symptoms and perform diagnostic assessment. Screening and diagnostic assessment is however hampered by a number of important difficulties. As an example, ongoing substance use can mask ADHD symptoms, but it may also mimic ADHD symptoms that are no longer present when the effects of substance use have faded. The same holds for withdrawal symptoms such as restlessness and concentration problems. Several ADHD screening instruments exist, of which the ASRS-v1.1 has been validated in a population of SUD patients (van de Glind et al. 2013). It is important to remember that a diagnosis cannot be based on a simple screening, so in case of a positive result of the screening instrument, diagnostic assessment is indicated. This is usually postponed until after a period of several weeks of abstinence when interfering intoxication/withdrawal symptoms have been minimized. However, valuable information can also be obtained if careful attention is given to childhood ADHD symptoms and to ADHD symptoms in past periods of abstinence, even if a patient is not abstinent at the time of assessment. It is generally recommended to involve an informant, such as a parent, to collect additional information on childhood symptoms; similarly, a partner or other significant person can shed light on adulthood symptoms. Structured interviews such as the Conners’ Adult ADHD Diagnostic Interview for DSM-IV (CAADID) (Epstein et al. 2001) and DIVA (Kooij and Francken 2010) are helpful in obtaining all necessary diagnostic information in a standardized way.
ADHD symptoms need not only be differentiated from substance use disorders, but also from bipolar disorders, depressive and anxiety disorders, and borderline personality disorder, all of which share overlapping symptoms with ADHD. For example adults with ADHD often exhibit low self-esteem, low mood, affective lability and irritability, which may be confused with dysthymia, bipolar disorder, or borderline personality disorder (Kooij et al. 2010). Diagnosing ADHD is further complicated by the fact that these differential diagnoses can also be present as comorbidities.
Although ADHD is associated with deviations in neuropsychological functions when groups of ADHD patients and normal controls are compared, these deviations are relatively unspecific and neuropsychological tests are not sensitive enough as diagnostic tools on an individual level. They may, however, provide useful information about a person’s cognitive functioning that is important for treatment planning. This is apparent for example in patients with severe learning difficulties.
13.6 Treatment of ADHD in SUD Patients
An important first step in the treatment of ADHD in SUD patients is psycho-education about the disorder. For patients who have experienced ADHD-related problems from childhood on, it is a relief to learn that there is a condition explaining these problems. Often they have been told that they are lazy and they may have developed a low self-esteem because of failing tasks. Realizing that ADHD is involved in the origin of these difficulties is very valuable information for many patients. It is important to explain that ADHD is a lifelong condition, and treatment is aimed at reducing symptoms and learning how to cope with symptoms. In this paragraph, treatment options for ADHD are described, as well as their efficacy in SUD patients with ADHD.
13.6.1 Pharmacological Treatment
Stimulant medications such as methylphenidate are an effective treatment option for adults with ADHD (Mészáros et al. 2009). Methylphenidate blocks the dopamine transporters in the brain, which leads to enhanced dopamine levels and reduced ADHD symptoms. Dextroamphetamine, which is also a stimulant, exerts its effect through increased synaptic dopamine release. Although stimulant medication is effective in 70 % of adult ADHD patients (Kooij et al. 2010), the effect of stimulant medication is not as clear in SUD patients with ADHD. Most randomized controlled trials to date did not find a convincing effect of methylphenidate on ADHD symptoms or SUD problems (e.g. Levin et al. 2007; Konstenius et al. 2010). The reasons for this putative lack of effect are not yet clear, but a possible explanation could be that direct toxic effects of drugs have altered dopamine neurotransmission in such a way that methylphenidate is not able to exert its effect anymore (Crunelle et al. 2013). It has also been suggested that higher doses may be warranted in a SUD population (Levin et al. 2007). This is supported by results from a recent study showing that methylphenidate in doses up to 180 mg improved ADHD-symptoms, reduced relapse and improved retention to treatment in amphetamine dependent men recently released from prison (Konstenius et al. 2014) Thus, although the first choice pharmacological therapy for ADHD is methylphenidate, it is important to realize that this medication may not be effective in many SUD patients with ADHD. Still a treatment with methylphenidate can be considered if a patient wants to try the option. In that case, it is important that a patient first becomes abstinent of substances, so the effect of medication is not disturbed by intoxication or withdrawal from substances and that agreements are made in advance on how long the effect is monitored before deciding if there is any effect or not.
The regular treatment dose of methylphenidate is 0.5–1.0 mg/kg/day. Before starting treatment, a somatic check-up is required with specific attention for cardiac problems, epilepsy, thyroid problems, and registration of blood pressure and heart frequency, which is repeated during treatment. Methylphenidate is available as immediate-release and several forms of sustained release. Immediate release preparations have a short effect span and should be administered four to five times a day. One of the side effects of this type of stimulants is the rebound effect: ADHD symptoms worsen as the medication effect declines. The sustained-release formula is prescribed once or twice daily, which is more convenient and feasible for most patients. Rebound effects occur less frequent and less pronounced. Another advantage of this medication formula is the lower abuse liability, in contrast to the immediate release form, which can be inhaled through the nose or injected. Compared to oral administration, sniffing or injecting methylphenidate results in a faster increase of extracellular dopamine, which evokes a reinforcing ‘high’. In patients where abuse is a particular concern, it is probably wiser to prescribe the sustained release form.
Other medication options for the treatment of ADHD include atomoxetine and bupropion. Atomoxetine inhibits noradrenaline re-uptake and is considered an appropriate second-line alternative for stimulants. There is only limited information on the effects of atomoxetine in SUD patients with ADHD, but the scarce studies to date showed disappointing effects on ADHD symptoms. Only one double-blind RCT (Wilens et al. 2008) found that atomoxetine treatment was superior to placebo in improving ADHD symptoms in recently abstinent alcohol-dependent adults with ADHD. The usual dosage for atomoxetine is 80–100 mg/day, and it is prescribed once daily. Bupropion is an inhibitor of catecholamines re uptake. It has antidepressive effects but it is also used in the treatment of ADHD. However, its use has hardly been studied in double-diagnosis patients with SUD and ADHD. Bupropion is dosed 300–450 mg/day, divided over 1 or 2 doses.
13.6.2 Cognitive Behavioural Therapy and Coaching
Only recently, research has focused on Cognitive Behavioural Therapy (CBT) as treatment option for adults with ADHD. Even if medication is effective in a patient, for example by improving attention, many patients have never been able to learn basic planning and organizing skills. Moreover, the accumulation of failure experiences in the past may still have an impact on patient’s functioning. CBT addresses these issues, by training planning and organization skills on one hand, and teaching the patient to tackle automatic negative thoughts on the other hand. Several randomized trials have studied the effect of CBT in adult ADHD patients, and found a remarkable effect, which also lasted at follow-up (e.g. Safren et al. 2010). Unfortunately, CBT for ADHD has not yet been studied in SUD patients with ADHD. At the present an integrated CBT treatment, which addresses both SUD and ADHD, is being investigated in a randomized controlled design in the Netherlands (van Emmerik-van Oortmerssen et al. 2013). SUD and ADHD symptoms can exacerbate one another, for example substances are sometimes used to alleviate ADHD symptoms (e.g. of restlessness), and at the same time substance use can worsen ADHD symptoms (e.g. concentration problems or impulsivity). The authors hypothesize that treating SUD and ADHD at the same time may result in better treatment outcomes for both SUD and ADHD. The integrated treatment incorporates both protocolled addiction treatment and elements of the CBT protocol for ADHD treatment by Safren and colleagues (Safren et al. 2005). After initial stabilization of substance use, sessions on addiction treatment alternate with sessions on ADHD treatment. Basic planning skills are trained by instructing patients to use a calendar and task list, and ample attention is paid to prioritizing tasks and managing overwhelming tasks by cutting them into small parts. Reducing distractibility and coping with negative automatic thoughts are also part of the treatment protocol. Results of the study are not yet available at the moment of writing this chapter, but are expected in 2016.
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