“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.
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:
The total symptom scores of the ADHD Rating Scale and the CAARS may also be used to evaluate treatment.
STEP 3: Diagnosis
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:
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:
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.
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:
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.
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