Identification and treatment of individuals with attention-deficit/hyperactivity disorder and substance use disorder: An expert consensus statement

Table 6 Overview and practice recommendations

Recommendations
Identification and assessment
Due to the level of complexity, assessments should only be conducted by qualified healthcare professionals with appropriate training and expertise in assessing dual disorders. This may require foundation training in ADHD and SUD across the two services and/or assessments being made jointly by experts in different areas
It is critical to examine the temporal course of ADHD-like symptoms and SU/SUD. A focus on drug and alcohol-free periods may help with differential diagnosis
Symptoms of ADHD and SU/SUD may be masked for many reasons including overlapping of symptoms between disorders, other comorbid conditions (e.g., personality disorder, bipolar disorder, anxiety, depression), and the individual may have developed compensatory strategies
Substances may have a countereffect for individuals with ADHD. Where individuals appear to be functioning better under SU, this may indicate possible underlying ADHD
Assessors should be aware that for those in institutional settings, current presentation may be misleading due to structure and routine minimising deficits in functioning
A comprehensive assessment should include a full developmental history, mental health history and current mental state examination, medical history, educational/employment history, social history, cognitive executive functioning difficulties, family history of ADHD and SU/SUD, in addition to other psychiatric and neurological problems. Perceived sex differences in presentation should be considered which may result in missed or misdiagnosis
Rating scales are not diagnostic. If used to screen, services should not rigidly adhere to cut-offs as this is likely to lead to high proportion of false positives and negatives
Young people presenting with an initial diagnosis of ADHD should be continually monitored through development for SU/SUD, given high rates of ADHD and SU/SUD comorbidity
ADHD assessment should not be conducted when an individual is under the influence of substances at the time of the assessment and/or when in a stage of withdrawal. Ideally, ADHD clinical evaluations are best conducted during a period of sustained abstinence or following detoxification or stabilization
When conducting the assessment with young people, it is important to consider how parents/caregivers are involved commensurate with the wishes and needs of the young person
The assessment may need to address additional physical, criminogenic, and safeguarding risks associated with SU. The person should be informed of the confidentiality of information shared and circumstances in which this will be breached
There are high rates of comorbidity associated with both ADHD and SU/SUD; the assessment should look to exclude other conditions that could better explain presenting symptoms
Follow-up and continued monitoring of symptoms is advised to prevent misdiagnosis
Practitioners should be aware of the risk of diagnostic overshadowing, which may require improved training in mental health services
Whenever possible, collateral information should be obtained from independent sources. For those with SUD, this may be difficult due to poor/strained relationships; the absence of collateral information should not unduly delay or prevent assessment
Pharmacological treatment
A nihilistic attitude to pharmacological treatment is not appropriate; active users of substances should be offered ADHD medication, subject to appropriate risk assessment
Long-acting stimulant preparations are recommended as first line treatment. Generally non-stimulants should be reserved as a second line due to relative effectiveness and concerns regarding non-compliance
Short-acting stimulant preparations are advised for a very circumscribed group (e.g., in contexts where there is possibility for supervised consumption)
Abstinence of substance use is not necessary for individuals to benefit from ADHD medication, though SU should ideally be reduced/stabilized before initiating ADHD medication
For those with primary alcohol use, atomoxetine may be of specific consideration in light of research indicating effectiveness in reducing alcohol cravings
Prescribing needs to consider interactions between ADHD medication and other medications for comorbid conditions, where applicable
Practitioners should be aware of personal and family history of cardiovascular conditions. Where there are concerns regarding cardiovascular risk, a cardiologist should be consulted prior to prescribing stimulant medication
Heart rate, blood pressure and weight should be measured before initiating medications and routinely monitored during treatment; titration should be slow. Include height monitoring in CYP
Individuals with SU/SUD at time of stabilization should be considered for prioritization for assessment in ADHD services
Provision of developmentally appropriate healthcare (DAH) within services may be of benefit
Commissioning arrangements should permit prescribing beyond specialist services
In spite of lowered risk of misuse or diversion with long-acting stimulant preparations, practitioners should still be vigilant of signs including pattern of losing prescriptions, early re-ordering of prescriptions, demands for immediate release preparations or claims that long-acting prescriptions are not effective, and symptoms associated with heavier use or intoxication
Supervised consumption and interval dispensing should be considered as options to minimize risk. ADHD medication dispensing arrangements should correspond with prescribed methadone, where applicable
Psychoeducation on pharmacological treatment may help to improve adherence and engagement
Psychological treatment
Where neuropsychological testing has been conducted, the strengths and weaknesses profile should be used to inform adaptations to the treatment process
Email/text reminders from service should be used to reduce likelihood of non-attendance. Sessions may require increased frequency of sessions, with greater structure, being delivered at a slower pace in shorter duration and/or including mid-session breaks, with repetition and greater use of supplementary visual material
Individuals should be provided with a notebook which serves as a record of strategies learnt. This should be completed in the person’s own writing to facilitate ‘ownership’, responsibility, and action
Motivational interviewing (MI) is more suitable for older adolescents and adults and is particularly helpful in the initial motivational stages (precontemplation, contemplation, preparation)
Practitioners need to be aware of the individual’s current motivational stage and should monitor interest to engage in treatment throughout, adapting treatment interventions as necessary
Functional behavioral analysis should be used to help identify constructive or functional alternatives to substance use
Psychoeducation should be provided as an important part of the treatment process and should be returned to at regular intervals over the course of treatment, including key points of service and/or personal transition
Psychoeducational programs should differ for children, adolescents, and adult populations in relation to changing biopsychosocial needs and demands. They should be provided to both the young person and their family. Topics should include basic information about ADHD, the purpose and benefits of medication and non-pharmacological interventions, long-term consequences of SU (including legal consequences, misconceptions around medication increasing the likelihood of addiction, how and where to access local support
Societal connotations about SU can be disparaging; parent/carer group interventions provide a supportive environment where they can share experiences (common humanity) and assuage feelings of shame
Clear and realistic goals should be collaboratively identified and monitored using the SMART framework
Individuals should be invited to use self-reinforcement techniques (which hold personal meaning) as reminders of their goals
Reward systems should be incorporated into treatment to motivate new constructive behaviour
Cognitive behavioral therapy interventions should be adapted commensurate with cognitive and emotional functioning; there may need to be more of a focus on behavioral-oriented interventions when working with young people
Young people and adults may benefit from the R&R2ADHD program which adopts a transdiagnostic approach targeting difficulties common to both ADHD and SU/SUD
Psychological treatment should include a relapse and prevention action plan, with follow-up ‘booster’ sessions provided, as needed
Multiagency interventions
Signposting to services which provide routes into education, training, employment, can help to steer people away from a harmful trajectory and prevent relapse
Practitioners should be aware that individuals may lack support networks due to strained interpersonal relationships, requiring enhanced supportive scaffolding from healthcare and service-user services
Schools should have a drugs policy establishing clearly how schools will deal with SU, where appropriate, this may include a drugs contract. If deemed appropriate, schools should also screen and refer young people for assessment of ADHD
Educational and employment support services should be aware of potential challenges for individuals. Reasonable adjustments to education/workplace may be required to help individuals manage demands and prevent harmful trajectories
Healthcare services to make reasonable adjustments through offering combined appointments
Individuals to be sign-posted to alcoholics/drug addicts anonymous for support with treatment goals
Referral to social prescribing services may be helpful in connecting people with community groups and statutory services for practical and emotional support
Transition planning between child and adult services should commence early and be a primary focus
Services should not work in silos. Foundational awareness training in ADHD and SU/SUD (as individual and comorbid conditions) should be provided to key professionals across health and social care, education and justice services and third sector organizations

ADHD: Attention-deficit/hyperactivity disorder; SU: Substance use; SUD: Substance use disorder.