Part 3 of a 3 part series by Constant Mouton.
“It’s always the small pieces that make up the big picture.” – Anonymous
This third part in the series Navigating the Chaos, ADHD and addiction, aims to provide a framework for assessing and diagnosing ADHD in addiction.
4 Steps to diagnosing ADHD in addiction
STEP 1: Awareness
Despite the growing evidence, this commonly co-occurring disorder is still under-diagnosed and undertreated. Changing this starts with awareness.
The first step to increasing awareness is recognising that the co-occurrence of ADHD and addiction exists. The evidence is already there. Up to 25% of people admitted to addiction recovery centres have ADHD, and 20 – 40% of adults with ADHD have a lifetime history of addiction.
Secondly, as explained in part I of this series, having a clear view on why people with ADHD are at higher risk of addiction dramatically increases awareness.
The next step is developing the ability to recognise ADHD symptoms. Part II of this series provides an overview on different presentations of ADHD throughout the lifespan. It is a complex disorder with not only different subtypes, but also differences in expression throughout a person’s life. Knowledge about what to look for is essential in recognising ADHD.
Finally, as explained in part II of this series it is not only the addiction counsellor, but also the partner, employer, health care provider and educator who should have more information about ADHD in order to recognise and promptly refer to the mental health setting for accurate diagnosis and treatment.
STEP 2: Screening
As soon as our level of awareness is aligned with reality, we should be able to recognise this comorbidity more quickly, more frequently and more effectively. Where ADHD is suspected in combination with addiction, the first step is usually to conduct a screening test.
Screening questionnaires can be used to quickly identify cases which may benefit from further assessment. This should not be confused with making a diagnosis or classifying a mental disorder, as it is certainly not the case that all positive screenings lead to an eventual diagnosis.
Useful screening tools for ADHD are:
- – ADHD Rating Scale, based on the DSM (Diagnostic and statistical Manual of the American Psychiatric Association) criteria
- – The six-item World Health Organisation Adult ADHD Self-Report Scale (ASRS) Symptom Checklist (available online and in many different languages on http://hcp.med.harvard.edu/ncs/asrs.php
- – Brown ADD Scale Diagnostic Form (BADDS)  that measures behaviour relating to executive functioning and inattention
- – Conners’ Adult ADHD Rating Scale that includes the DSM-IV criteria
- – Wender Utah Rating Scale (WURS)  that also includes symptoms of other, often comorbid disorders.
The total symptom scores of the ADHD Rating Scale and the CAARS may also be used to evaluate treatment.
STEP 3: Diagnosis
|Table 1: Conduct disorder
||Table 2: Additional problems
||Family and relationship problems
|General anxiety disorder
||Occupational problems (unemployment)
||Poor work performance
||Lower educational performance
|Post-traumatic stress disorder
||Legal problems / convictions
||Increased traffic violations
Diagnosing ADHD in addiction requires a full, systematic psychiatric assessment. Concerns that ADHD cannot be diagnosed in a patient still addicted are unfounded as it is a lifespan, retrospective diagnosis.
The diagnosis does not need to be confirmed by clinical observation in the consultation room. If the patient is still actively addicted at the time of assessment, a clear account of symptoms and functioning during a period of abstinence should be obtained.
The assessment should include:
- a biographical account of symptoms throughout the lifespan, starting at childhood up to current symptoms.
- an account of impairment across at least two life domains (school, work, home, relational, etc.)
- careful assessment of comorbidity focusing on frequently occurring conditions (see table 1).
- a full history of psychiatric and somatic treatments
- a family history of psychiatric and neurological problems (taking into account the inheritability of ADHD and addiction)
- a full addiction history (focusing on the frequently co-occurring addictions – see table 3)
- additional psychological problems (table 2).
|Table 3: Types of addiction with ADHD
|Downers / Hypnotics
||Internet gaming disorder and
||Addictive use of social media
It is said that one outgrows the criteria but not the disorder. DSM-5 criteria take developmentally appropriate norms into account. Therefore the number of criteria needed to diagnose ADHD in adults and the elderly are less than what is needed for children. For adults, the literature further suggests diagnosing ADHD in adults even when only four of the nine criteria are met. Focusing on the devastating effects on the sufferer’s life is more important than the number of symptoms met. Furthermore for adult patients, even though it can be helpful, it is clearly not necessary to obtain collateral history from family or teachers.
Please bear in mind that when assessing the disorder, the gravity of the impairment should be considered taking into account cultural differences and variations.
For the main diagnosis of ADHD, a structured interview can be held, based on for example:
- DIVA (Diagnostic Interview Adults with ADHD) for ADHD in adults; or
- Conners Adult ADHD Diagnostic Interview for DSM-IV (CAA- DID).
Addiction also needs special attention when assessing the individual with ADHD symptoms, due to the increased incidence in ADHD, as well as a bidirectional link between the two.
STEP 4: The Big Picture
With comorbidity being the rule rather than the exception in ADHD, it is important to obtain a comprehensive picture before treatment is suggested.
When formulating a descriptive diagnosis a two-step approach is advised.
Firstly the biopsychosocial model can be used to gain an overview of all the pieces of the puzzle. See table 4 for an example.
|Table 3: Types of addiction with ADHD
||Patterns of cognition
||Responses to stressors
Secondly the psychodynamic approach contextualises the different factors involved.
Taking all aspects involved into account in this diagnosis in a scheme such as the 5 Ps could be extremely helpful:
- Presenting problems (this is a list of problems the patient presents with)
- Predisposing factors (what makes the patient vulnerable?)
- Precipitating factors (what triggered the problem this time)?
- Perpetuating factors (why is the problem continuing?)
- Protective factors (what protects the patient?)
Involving the patient in the diagnostic process as well as the formulation has several advantages. The patient will have a better understanding of the interaction between different problems, and the formulation will act as a roadmap to developing a treatment strategy.
In part IV of this series more will be revealed about treatment strategies for sufferers from ADHD and addiction.
- Bolea-Alamañac B, Nutt DJ , Adamou M, et.al. (2014) Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology, Journal of psychopharmacology. 28(3): 179-203
- Kooij SJJ, Bejerot S, Blackwell A et. al. (2010) European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD, BMC Psychiatry 10:67
- Michielsen M, Semeijn E, Comijs HC, et al. (2012) Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. Br J Psychiatry. 201:298-305.
- Stahl, S. M., and Meghan M Grady. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide. 4th ed. Cambridge, UK ; New York: Cambridge University Press, 2011.
- Lee SS, Humphreys KL, Flory K, et.al. (2011) Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev. 31(3):328-41.
- Yen J-Y, Liu T-L, Wang P-W et al. (2017) Association between internet gaming disorder and adult attention deficit and hyperactivity disorder and their correlates: Impulsivity and hostility. Addictive behaviours, Vol 64:308-313.
- McGough JJ, Smalley SL, McCracken JT, et.al. (2005) Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry 162(9): 1621-7.
See below for more information on Constant Mouton and his talk at iCAAD London May 1-3 2017