Attention-deficit hyperactivity disorder (ADHD) is one of the most prevalent and inadequately addressed mental health disorders in adults. Many adults live their entire lives without being diagnosed, instead managing their symptoms with overcompensation, relentless effort that looks like high functioning on the outside but is exhausting on the inside, or, for a significant portion of people with ADHD, turning to substances as the only means to cope.
The connection between ADHD and addiction is underrecognized, but it is there, and it takes an integrated approach to treat co-occurring ADHD and addiction effectively.
What Is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by continuous levels of distractedness, excessive energy, and impulsiveness that result in significant disruption to daily living.[1] It was commonly known as a childhood disorder; however, ADHD affects approximately 4% to 5% of the adult population, with a significant number of yet undiagnosed adults.[2] Adult presentation of ADHD differs from a child’s presentation, and the disorder is often missed.[3]
ADHD is associated with differences in the dopamine system, specifically in the pathways of the brain that regulate motivation, reward, and self-control.[4] Per the DSM-5, ADHD may occur in three different presentations:
- Predominantly Inattentive — Short attention span, excessive errors, disorganization, lost items, easy distractibility, and forgetting to complete daily tasks. This is typically seen in females and is frequently missed or diagnosed late.
- Predominantly Hyperactive-Impulsive — Fidgeting, unable to stay seated, excessive talking, interrupting others, difficulty being patient, and acting without considering consequences. This presentation was identified primarily in boys, especially in early childhood.
- Combined Presentation — The most common presentation for adult diagnosis.
Those with ADHD do not lack attention; they can hyper-focus on tasks that engage them. The issue is that ADHD is associated with executive dysfunction, which is the capacity to regulate attention, mitigate impulses, and regulate emotions in order to manage daily life.[5]
Symptoms of ADHD in Adults
Adult ADHD often looks different from childhood ADHD.[6] The hyperactivity that is obvious in children tends to become more internal in adults, showing up as restlessness, racing thoughts, and an inability to relax, rather than the physical behaviors that are easier to spot in a classroom. Adults with ADHD commonly exhibit the following symptoms:
- Chronic difficulties sustaining attention on non-stimulating tasks
- Frequent procrastination associated with difficulty beginning and completing tasks
- Poor organization and time management
- Forgetting appointments, obligations, and important facts or information
- Impulsive decision-making without much thought for consequences
- Symptoms of emotional dysregulation, including mood instability and difficulties tolerating frustration
- Restlessness or an internal sense of being “on-the-go”
- Low self-esteem due to a lifetime of underperformance relative to perceived potential
- Difficulties maintaining relationships as a result of inattentiveness, impulsiveness, and emotional intensity
ADHD and Addictive Personality: Understanding the Connection
Research has shown a strong connection between severe ADHD and addictive personality traits. This is partially due to differences in the reward, motivation, and impulse control systems regulated by dopamine and norepinephrine — both of which are also involved in addiction. ADHD and substance use disorders co-occur at a high rate because of these shared neurological mechanisms.[7]
Some of the specific reasons for the link between the two conditions include:
- Impulsivity — The hallmark impulsivity of ADHD directly increases the likelihood of using substances and becoming dependent on them. Impulsivity makes it much harder to weigh consequences, lowers the threshold for trying substances, and makes it hard to stop once someone has started.
- Reward-seeking and novelty — Severe ADHD means a person is constantly understimulated by their normal environment, causing them to seek out activities or substances that provide intense and immediate stimulation. People with ADHD may turn toward stimulants, alcohol, or other substances to satisfy these cravings.
- Self-medication — Many people with undiagnosed ADHD develop the habit of using alcohol or stimulants to calm racing thoughts or provide the focus they have struggled for years to obtain. This prolonged self-medication leads many to develop an addictive pattern.
- Emotional dysregulation — As a result of the emotional dysregulation associated with ADHD, many people turn toward substances to temporarily relieve their psychological discomfort.
People who have not received an ADHD diagnosis or treatment as a child are at higher risk of developing an addiction than those who have.[8] Many have developed maladaptive coping strategies, including substance use, to deal with their symptoms without clinical support.
When to Seek Help for ADHD and Addiction
If symptoms associated with ADHD are significantly impacting daily functioning, relationships, work, or self-esteem, a clinical evaluation is warranted regardless of whether substance use is present.
When both ADHD and substance use are involved, integrated dual diagnosis treatment is essential; treating only the addiction leaves the neurological drivers of self-medication untreated, and treating only the ADHD without addressing substance use creates medication management challenges and leaves the addiction unresolved.[9]
The evaluation process should be completed by credentialed mental health professionals and should involve ruling out other mental illnesses, determining the specific presentation of ADHD, and developing a treatment plan that addresses both addiction and co-occurring disorders.
How to Treat ADHD Without Addictive Stimulant Medications
When a person has a substance use disorder, treating their ADHD using stimulant medications poses a legitimate concern, as stimulant medications are classified as Schedule II drugs with potential for misuse. However, there are options available to manage this that do not compromise ADHD treatment:
- Non-stimulant medications — Medications like Strattera, Qelbree, and Intuniv. These FDA-approved medications do not have the potential for misuse and are usually the first-line treatment choice for people with a dual diagnosis.
- Careful stimulant management — If necessary, stimulant medications can be safely managed by the clinician in collaboration with the patient. Long-acting stimulants with lower misuse potential, structured dispensing, and careful monitoring can allow stimulant use when alternatives have not been successful.
- Cognitive Behavioral Therapy (CBT) — CBT for ADHD provides tools to address the specific executive functioning deficits that lead to both ADHD impairment and addictive behaviors, such as organization, time management, emotional regulation, and impulsivity.
- Mindfulness Training — Mindfulness training has demonstrated a positive effect on ADHD symptoms, including reduced impulsivity, improved attention, and the emotional regulation needed to manage ADHD without medication.
- Behavioral Skills Training — Provides practical strategies to help a person manage their ADHD on a daily basis through structured teaching of organization, planning, and coping skills.
