Attention Deficit / Hyperactivity Disorder

One strategy for improving the effectiveness of chemical dependency treatment has been the identification of co-existing psychiatric disorders, commonly known as "dual diagnoses." In regard to Attention Deficit/Hyperactivity Disorder ("AD/HD"), two findings have already been well documented.

AD/HD is a complicating problem in a percentage of cocaine dependent patients. They typically report a calming, rather than a stimulating response to the drug, and will often work productively, rather than party, when they are using it. A more puzzling finding has been the increased incidence of AD/HD in the sons of alcoholics.

Recent studies at Harvard and Columbia suggest that AD/HD is a much more significant factor in chemical dependency than has been previously appreciated. They support research done in the early 1980s documenting a 14% incidence in alcoholics and a 22% incidence in heroin addicts. These earlier findings have attracted surprisingly little attention from clinicians. More recently, AD/HD is being identified with greater frequency in patients who are dependent on marijuana, although no papers have yet been published about this.

A partial explanation for this oversight may be that the existence of the adult form of AD/HD is a relatively recent discovery. Furthermore, the "inattentive" type of AD/HD is less noticeable and more difficult to diagnose than the "hyperactive" form, although it is probably more common and is the predominant form found in women. Finally, a recent Yale study suggests that people with higher IQs compensate in ways that mask the problem and make diagnosis more difficult.

Diagnosis

The diagnosis of AD/HD can be difficult enough by itself. To try to identify it in a person with chemical dependency can be quite a challenge. DSM IV can unfortunately be an obstacle to diagnosis because of its focus on children. Following its criteria strictly would only identify the most severely affected adults. Requiring that symptoms be retrospectively identified by the age of seven is questionable, because a sufficiently bright child or a highly structured and protective environment can obscure the clear emergence of symptoms until college or even as late as graduate school.

Being alert for "red flags" is a useful strategy for detecting AD/HD. Two examples are repeated relapses despite apparent acceptance of the addiction diagnosis or, on the other hand, recovery marked by persistent anxiety, agitation, or insomnia which does not respond to the usual medications. A history of daily, heavy marijuana smoking is also suggestive.

Also helpful is to become familiar with what the combination looks like. "When Too Much Is Not Enough" by Wendy Richardson is a recommended reference.

Most experts in the field agree that there is no single "test" for AD/HD. The diagnosis is best made on the basis of a clinical interview, assisted by a questionnaire such as the Brown ADD Scale, developed by Thomas Brown at Yale and published by The Psychological Corporation. It is quickly self-administered, easily scored, facilitates follow-up exploration, and unlike most other questionnaires, does not require a person to be hyperactive to qualify for the diagnosis.

Treatment

Dual diagnosis patients with chemical dependency and AD/HD generally fit the stereotype of alcohol and/or drugs being used to self-medicate an "underlying" — actually concurrent — condition. When these people get clean and sober, they frequently feel more agitated as their AD/HD symptoms intensify. Consequently, they are frequently diagnosed as anxious or bipolar and placed on mood stabilizers or tranquilizers. This may produce non-specific short-term relief, but can exacerbate their chemical dependency.

When the AD/HD is accurately diagnosed, the issue of medication arises. Stimulants such as Ritalin or the amphetamines have been the mainstay of treatment in the past. Prescribing stimulants to addicts understandably raises concern and even alarm with patients, their families and the recovery community. With rare exceptions, however, recovery is enhanced by the careful use of stimulants. Important precautions are to use formulations that are longer acting with a gradual onset of action, and are not divertible intranasally. A non-stimulant alternative, Straterra (atomoxetine), is now available and has shown such encouraging results that at Kolmac it has become our medication of choice for ADHD. Its advantages over the stimulants are that it has no abuse potential and is more convenient to prescribe. Prescriptions can be phoned in and refills are permissible.

Although medication is a mainstay of treatment for AD/HD, behavioral interventions are also important. Many people who are unaware of their diagnosis intuitively seek jobs that are compatible with their symptoms and allow for actively moving about in a highly stimulating environment. Introducing order and structure through the use of devices such as personal organizers is a way to limit a tendency to drift into disorganization and over-stimulation. While exploratory psychotherapy is not often necessary, more behaviorally oriented intervention and even behavioral "coaching" can be helpful. Support groups are available in some areas, sponsored by CHADD (Children and Adults with ADD).

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