James Donaldson on Mental Health – Parents Guide to Co-occurring Substance Use and Mental Health Disorders (Pt.5)

Attention-deficit hyperactivity disorder (ADHD) is diagnosed when a person has difficulty concentrating, paying attention, sitting still, following directions and controlling impulsive behavior. Children with ADHD have a mix of inattentive and hyperactive or impulsive behaviors which make it challenging to learn at school and often create conflict at home.

About 30 percent of youth with ADHD also have oppositional defiant disorder (ODD). These young people are excessively oppositional to authority and rebellious. When a child has ODD, regular daily frustrations may build up over time, damaging the child/parent bond and reinforcing hostile patterns of behavior.

Characteristic signs and symptoms of ADHD include:

• Making careless mistakes
• Being easily distracted and appearing to not listen when spoken to directly
• Having trouble with organization and frequently losing things
• Fidgeting
• Excessive talking or interrupting, blurting out answers

What does an adolescent with ADHD look like? By the teenage years, the impact of hyperactive symptoms may have decreased for some teens, but they still have problems with attention, which interferes with succeeding in school or at work. They also may have trouble socially — they can be alienated from peers because of poor self-regulation and difficulty paying attention to the needs and desires of friends. Their self-esteem can take a hit because of these repeated difficulties — some young adults with ADHD can even be withdrawn or depressed because of this.

ADHD Treatment

ADHD treatment typically consists of medication, behavioral therapy, or a combination of the two.

Medications for ADHD include psychostimulants like methylphenidate (Ritalin) and amphetamine salts (Adderall). These medications have been shown in numerous studies to be effective in about 80 percent of youth with ADHD. These psychostimulants, which increase the accessibility of certain chemicals in the brain, help children focus and curb impulsivity and hyperactivity.

Behavior therapies do not eliminate the core symptoms of ADHD, but they can be very helpful in teaching children to manage them better. In children and pre-teens, the main focus of behavior therapy involves teaching parents and educators how to develop supportive relationships with children with ADHD or behavior disorders, how to implement effective behavioral strategies to promote positive behaviors, and how to make clear, calm and predictable decisions in giving consequences for misbehavior.  Importantly, at young ages, research clearly shows that it is more crucial that adults learn techniques to manage the behavior of a child with ADHD than it is for a child to be in individual therapy.  As children progress into adolescence, individual cognitive behavioral therapy can be helpful in engaging a young person in taking more responsibility for managing their ADHD symptoms or playing a role in problem-solving around their behavior.  As one example, if a teen has trouble finishing things and staying organized, she or he can learn techniques for completing tasks and keeping track of assignments.

ADHD & Interaction With Substance Use

Teens and young adults with ADHD are impulsive, sensation-seeking and eager to experiment. They tend to be drawn to substances available in their environment, which may involve low-hanging fruit like nicotine and marijuana. These substances are also attractive because they can temporarily help with the core symptoms of ADHD. Nicotine can increase focus in the short term, and marijuana can calm hyperactivity.

Structural and chemical brain differences associated with ADHD also make these young people more responsive to a drug’s effects and more likely to take drugs again. They can go quickly from experimentation to habit, and chronic use actually decreases their ability to pay attention long term. Chronic nicotine use can decrease cognitive functioning and attention while increasing impulsivity.

In some, but not all cases, youth may misuse ADHD medications by crushing and snorting them to get high, or they will sell their meds to classmates. For this reason, medication treatment of ADHD should be carefully monitored by a qualified clinician. In some cases, parental monitoring of administration may be required. Immediate release formulations are easier to misuse and should be prescribed with caution in such cases. There are newer formulations specifically designed to deter misuse by crushing and snorting.

Clinicians report that young people with ODD gravitate to more powerful drugs like prescription opioids (Vicodin, OxyContin) or benzodiazepine anxiety medications (Xanax, Valium) that help them numb painful feelings and escape or avoid frustrating peer and family relationships.

Any drugs, even nicotine, can interfere in evaluation and treatment for ADHD. Vaping or Juuling nicotine, for example, delivers very high amounts of the chemical to the brain. The side effects of nicotine (alertness, anxiety, insomnia, loss of appetite) are also associated with stimulant medications, which unfortunately can confuse the picture and potentially lead to poor treatment outcomes. Nicotine, by way of interacting with the enzymes that metabolize the medications in the liver, can lower the effectiveness of some medications. It’s important that mental health professionals have as many details as possible in order to provide the best treatment.