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Hayley: Hi everyone, this is Hayley and you’re listening to Straight Talk With The Doc, a podcast on addiction, mental health, and treatment. Our medical director Dr. Bhatt is here with us today as well as our content director Jeff. How are you guys doing?
Dr. Bhatt: Doing well Hayley, how are you? How are you and Jeff doing?
Jeff: I’m doing good, it’s a good day today.
Hayley: I’m doing good as well. Today we’re going to be talking about a very common disorder. The CDC estimates that over 6 million children have been diagnosed with it, and that disorder is ADHD. Now, something concerning about ADHD is that a significant percentage of people with substance use problems fit the diagnostic criteria for ADHD. I’d like to explore that connection, but Dr. Bhatt, let’s start by just talking about ADHD. What is it?
Dr. Bhatt: ADHD, as you mentioned, it’s a commonly diagnosed disorder. It’s considered a neurodevelopmental disorder, often first recognized in children. What we end up seeing is, children are often inattentive and hyperactive, it’s a normal part of growing up. But when we see that population of children who tend to be more hyperactive or more inattentive, more easily distracted beyond what would be normally seen at a certain age group, they start to call attention to themselves. So, ADHD becomes a disorder where somebody is persistently and pervasively having problems with attention, with concentration, or hyperactivity and restlessness that starts off in childhood and often extends for the remainder of their lives.
Hayley: Okay, and, can you kind of explain what’s going on in the brain? What’s different in the brain of someone with ADHD compared to someone without it?
Dr. Bhatt: With many psychiatric conditions, there’s a lot of hypothesis as to what are the causes. In this one, we look at the frontal lobe of the brain, which is the executive function. The part of the brain that controls attention, concentration, planning, impulse, and delay of gratification. A lot of that stuff is controlled by that part of our brain. In ADHD, we believe that there are certain deficits and certain neuro chemicals that regulate that area. So, when that deficit or lack of maturation is occurring, often that area of the brain where people need to have a proper level of that neuro chemicals dopamine, often results in those patients presenting like those who do with ADHD. Inattentive, lacking concentration, becoming restless and fidgety, they’re often hyperactive and this extends often most after the age of 4, 5, 6, 7, and persistent to adolescence, and goes on into adulthood.
Hayley: Can you tell me about the most commonly seen symptoms, and are these symptoms different in children and adults?
Dr. Bhatt: Let’s first look at how ADHD is classified. Attention Deficit Hyperactivity Disorder is classified in three distinct subtypes. There a predominately inattentive type, a predominately hyperactive type, or a combined type. And the way we classify those is basically if somebody has six or more symptoms of inattention where they’re easily distracted or forgetful or daydreaming and can’t complete certain tasks, and they don’t have the hyperactive symptomatology. So, they would be predominately diagnosed as inattentive type. And then the opposite is true if they have more hyperactive symptoms where they’re fidgety, can’t stand in line, they are constantly moving, or they are running all over the place when they’re sitting in a restaurant, or in an office. And if there’s a combination of these symptoms where there’s 12 symptoms of both inattentive and hyperactive component, then we call it the combined type. The hallmark of these diagnosis is that not only do you have to have these symptoms, these symptoms have to have some onset before the age of 12, and they have to be present in two or more major domains of a child’s life. So, it has to not occur exclusively in one setting. It has to occur both in school, and at home, or in the case when you’re getting older and still have ADHD symptoms, than it happens at work and at home. The impairment has to be occurring in two different areas, and it has to be not what would be expected at a certain age. We don’t want to call a 2-year-old an ADHD patient, when we know 2-year-olds are inattentive, running all over the place, and active. We want to make sure that we are capturing patients within the right chronological and cognitive age group, so they’re not being misdiagnosed. Again, the hallmark of it is this essential dopamine function is somewhat impaired, it’s either delayed in its maturation or not functioning at a level which can maintain the prefrontal cortex, where patients continue to present themselves as inattentive or hyperactive. We’ll get into treatment probably later in these questions, but the treatment includes rebalancing those neurotransmitters out.
Hayley: I wanted to break that down a little bit more, what you mentioned about this diagnosis. How can you tell the difference between just a regular child, because kids are a little hyper sometimes, they can be a little wild. How does a clinician make that call?
Dr. Bhatt: Well hopefully the clinician whose assessing someone for ADHD has a baseline fundamental knowledge of what is normative development. We are mental health care practitioners are trained and should be trained in assessing what are certain milestones in behaviors that should occur at certain periods throughout their lifespan. The key way to do this is to make sure you have that awareness, and not just taking one person’s testimony. An important part of making accurate diagnosis, especially in ADHD, is we like to take samples of information from more than just one person. So, you do the proper assessment with the patient yourself in your office, but then often you’re taking the mother, or the parents, or the fathers testimony, getting their history. And then also, being that I mentioned before that this is an illness that has to be present in two or more settings. Well then, in the case of a child, getting that information from the teacher, or while in school, to make sure the behaviors that we’re looking at are inconsistent than what we expected at a certain age. And these are things that teachers recognize very quickly and very well. Teachers are used to seeing how most fourth graders would behave in fourth grade, and so if there’s a child whose more inattentive or can’t finish their homework, or seems to be daydreaming, the teacher hopefully would be able to recognize that. The key is make sure you’re aware of what would be normal development and normal cognition, and normal behavior for a certain age, and then being able to get opinions and get analysis from multiple people in multiple domains, and then getting that information and drawing a conclusion.
Hayley: What age is ADHD usually diagnosed?
Dr. Bhatt: It’s most commonly diagnosed in childhood. We try to not diagnose it, again, too early, because it’s going to overlap with normal behaviors of immature children. Children are going to be hyperactive and inattentive, so we don’t want to do it too early. But childhood is usually when we start to see as children get into later parts of elementary school, or early parts of middle school, when they start to differentiate when normally you would see a kid start to become less restless, less fidgety, being able to stay seated longer, and when they start to separate. A lot of ADHD children will start to distinguish themselves by those exact behaviors. So, while kids who don’t have it can start to pay attention, stay seated, follow directions in the classroom, or attend to homework at home or do chores, and even just sit there and watch television. Children who have ADHD, they have difficulty doing those things, and they start to get themselves called out.
Hayley: Can it be diagnosed at any age? Can somebody who is an adult receive an ADHD diagnosis?
Dr. Bhatt: Yes, adults can be diagnosed with ADHD, but I think at that point it’s very important to take everything in context. I think there’s many patients who probably are getting diagnosed with ADHD when they don’t have ADHD, because many different disorders or circumstances can cause somebody to be inattentive for example. So, yes, the quick answer is somebody who can be accurately diagnosed at adulthood, or obviously hopefully as a child if caught early enough, but the important part is to make sure that if there’s something medically or something else going on, either substance abuse, or depression, or some sort of medical disorder, that could be causing somebody to behave a certain way, or be inattentive, or have problems focusing, distracted. We don’t miss that, and we don’t mislabel somebody. That’s really important.
Hayley: When you mentioned catching it early, does it make a difference if it’s diagnosed and treated earlier in life?
Dr. Bhatt: Yes, prognosis is better if somebody is diagnosed early, just like anything. I think with any illness we want to make sure the earlier we catch it, the earlier we can intervene. ADHD is a very treatable disorder, and I hate to even use the word disorder here, but it’s a neurodevelopmental disorder, and it is one that we have good treatments for. As long as somebody’s accurately diagnosed, and again, if we start at the beginning and somebody is called out and they do get a proper psychiatric evaluation by a child psychologist, or a pediatric behaviorist, somebody who has an expertise in ADHD, and they get the proper testing done, and ask the right questions with the right people. There are behavioral interventions that can be done, there are social interventions that can be done, there are medications that are available, and if treated properly with all those domains, they could have really good prognosis for these individuals and live healthy lives.
Jeff: ADHD is also very commonly misdiagnosed. There are a lot of other mental health conditions that often mimic ADHD, and sometimes substance abuse, it is misdiagnosed as ADHD if the person diagnosed does not have a particularly complete picture of what’s actually going on. Because many substances also mimic the effects of ADHD, especially after long term use.
Dr. Bhatt: Yeah, for sure Jeff. Talking about misdiagnosis, in kids, ADHD is prevalent and often exists with kids who have behavioral issues. A lot of times ADHD occurs with children who have oppositional defiant disorder, where they don’t like to follow directions from adults, and they are oppositional and have difficulty following rules. And that can be confused to the untrained eye if somebody who might have ADHD. Not only could it be co-occurring, but they tend to be more rebellious, and they could run, and they could become fidgety, or they could become more aggressive. And those are distinct and separate features, so even though there could be co-occurring disorders and they could be existing, with somebody with ADHD- aggression, and all that, that’s not part of the ADHD diagnosis, and neither is oppositionality. It’s important that things don’t get misdiagnosed or misattributed to the wrong illness or the wrong disorder. When you get older, if you use substances, medications that alter the way we think, focus, or concentrate, those people can end up looking for somebody to help them get back to the way they used to think, and focus, and concentrate prior to using drugs or alcohol. Often, they’re quickly just asked a handful of questions, do you have problems concentrating, focusing, do you have trouble sitting still, and if the answers are yes, they often can get an ADHD diagnosis when in fact the symptoms are produced by their substance use. It’s ironic, but it needs to be challenged and questioned, and be assessed by the proper clinician.
Hayley: What’s treatment like for ADHD and are there different treatments for children and adults?
Dr. Bhatt: Treatment should be comprehensive. A lot of times, patients with ADHD do well with proper structure. When somebody is struggling to focus and pay attention, and stay on task, or they struggle with touching objects and being fidgety, or being restless, it’s important that we create the right environment for them. The first thing I would do is make sure that if somebody’s accurately diagnosed with ADHD, we ensure that the environment that they’re in such as the school or home, it’s free of distractions. So, if they’re having to do something that they’re attending to certain tasks make sure that the TV’s not on in the background if they’re doing homework, or if they’re in the classroom setting maybe have smaller classroom sizes, or give them less work to do in a certain amount of time. That way we’re kind of meeting them where they’re at and not setting them up to fail by putting them in an environment which would be easily distracted for someone who doesn’t have ADHD and then make it more difficult for that person. Then second, there’s medications. Medications are a very good resource in treating ADHD in terms of good effectiveness. If they do work, and when they do work, we do see responses quickly. It just has to be introduced at the right time, at the right dosage, and monitored and managed properly by the proper physician, so that’s really another tool that we have. A good thing is that as children get older, we do see improvement with the hyperactive, restless, and the externalizing part. Because as kids mature, and it might be later with the ADHD child in terms of physical and cognitive development, we do see improvement there and so those behavioral and educational tools that we can apply, they might be more receptive for that later too. It should be done in a combination with different modalities of treatment.
Jeff: One thing that is really important with ADHD diagnosis in particular, a lot of the medications used to treat ADHD are very effective and useful when used properly by people who actually have ADHD. But many of them have opposite effects on people who don’t legitimately have ADHD, and they can be addictive and habit forming. An example of this would be common with someone who has bipolar disorder for example, to be misdiagnosed with ADHD, especially if the manic phase is what they come in for treatment for and they don’t talk so much about depression. And if you give someone with bipolar disorder ADHD medications, you probably will make them manic, in most cases, or many cases at least.
Dr. Bhatt: Yeah, Jeff, you bring up a good point and Hayley, I don’t know which direction you were going to go with any further questions but being that you brought it up Jeff, it’s really important to make sure that diagnosis is accurate, because there are so many things that can mimic one another. If they’re using Cocaine, and if they’re using drugs that can mimic certain types of hyperactivity and that increased energy, they can look like their somebody who is ADHD. But at the same time, as I mentioned earlier, the central deficit of those who have ADHD is often lower dopaminergic functioning in the brain, and we need dopamine to help us control our impulses, regulate our attention, concentrating, planning, and organizing. So, we treat this with Stimulant medication. And a lot of the time people when they hear that, they’re like, wait, why are we stimulating people who have ADHD when they don’t need to be stimulated? And, that’s not what we’re stimulating, we’re stimulating the deficit of dopamine in the brain. And so, what’s happening is when somebody is treated with medications that are the Stimulant class, we are increasing dopamine. And as Jeff mentioned, if they don’t have ADHD, that dopamine increase that is not starting from a deficit side, from a normal level it can be increased and then is an excessive level. Dopamine in excessive levels can mimic psychosis, agitation, and like people who have psychotic disorders or manic disorders. So absolutely, an accurate diagnosis leads to accurate treatment and really is important when it comes to treating people with ADHD.
Hayley: I kind of want to lean in another direction and talk about what I mentioned at the beginning of this, ADHD and addiction. Are people with ADHD more likely to struggle with an addiction?
Dr. Bhatt: People who suffer with various mental health conditions or physical conditions, they are at risk for developing addiction just because those who end up having difficulties in life, that in itself is a risk factor. We look at genetics as a risk factor or maybe some level of predisposition to develop something, but on top of it if you do have the presence or absence of certain mental health conditions, or physical conditions, those can act as additional risk factors when mixed with certain substances of abuse and then lend to the development of addiction. When we talk about ADHD we’re talking about people who have problems with attention and impulsivity, and inability to relay gratification because of that impulse- control issues. Plus, when you add the fact that the inherent problem with ADHD is often that there’s not enough dopamine, when you introduce drugs, there’s an interesting relationship that could develop. One, certain illicit drugs increase dopamine, and so when they increase dopamine, it can create almost a normalizing effect for certain individuals. If I suffer from ADHD and I’m hyperactive and I’m impulsive, or I can’t focus and I can’t concentrate, and I introduce a certain drug that helps me level out, that’s going to unfortunately negatively reinforce my substance use, and that adds as a risk factor for further using again and developing an addiction. So, the important part here is to recognize if you do have some sort of risk factor or predisposition or an illness that might render you more susceptible for having a negative relationship with drugs or alcohol, it’s important to catch it and treat it early. Again, with this case with ADHD if it’s treated early and managed well, the risk of developing addiction is lower, often we do see untreated ADHD though being a risk factor for addiction later on.
Hayley: Are those with ADHD more likely to use certain types of substances over others? More likely to use alcohol or more likely to abuse Stimulants?
Dr. Bhatt: It really depends on what the relationship becomes. We have seen patients who suffer with ADHD use multiple classes of drugs or alcohol and it really depends on what effect that drug gives to them. So, let’s use an example of what I see in clinical practice all the time, is marijuana is often a drug people use early. Often times I talk to my teenage patients and they’re like, “Well Doc, I started using because when I was a kid and I was in middle school, I had problems focusing and I would be in the classroom and would have problems finishing my task, and when I would get home I felt like I was all over the place, I couldn’t do my homework, I’d have problems following directions with my parents. But when I would smoke weed I felt like my mind slowed down and I could focus more on certain things.” So, right there, we saw a relationship where smoking marijuana gave the sensation that they’re feeling calmer and slower, and their minds not racing as much. Well that is a reinforcement factor for somebody with ADHD in these individual cases, because it helps them focus, and slows their brain down, and allows them to attend to tasks. On another side, we see people who due to the stimulant effect of drugs like Cocaine which increase dopamine, or amphetamines which increase dopamine. As I mentioned earlier, the inherent deficit in ADHD is that we hypothesize there is a dopamine deficit, and when we introduce drugs that increase dopamine, well that enhances their ability to focus, and it normalizes that dopamine level or increases it, so it’s almost medically treating them in a way. That’s another drug that can be reinforcing. Unfortunately though, the more people use it, sometimes there’s no exact recipe that can be- you get the euphoria and you get the high at the same time, and not only are they using it now to help normalize themselves, it’s very easy to go beyond that threshold and use these drugs to help get that euphoria, get that high, and unfortunately reinforces that addiction in another way. It’s a slippery slope, but depending on the drug and the relationship with the patient and what they end up feeling from it, that can either negatively or positively ultimately reinforce usage down the road.
Hayley: Can addiction worsen the symptoms of ADHD?
Dr. Bhatt: Definitely. If somebody is using drugs or alcohol they’re destructive to their brain and their bodies. If somebody is struggling with a mental health issue, such as ADHD, introducing drugs or alcohol effects the neurochemistry of the brain. When you have something that alters the way you think, alters the way you feel, alters the way you behave, you won’t know your true self. When somebody is already struggling with problems with attention, impulsive control, hyperactivity, focusing, ability to stay on task, this plays out in our lives not just by these words that I’m saying, but in your ability to do well in school, hold a job, stay in relationships. The amount of con dilute that occurs and it becomes very messy when people introduce drugs or alcohol, because you really don’t know what you’re treating and what you’re experiencing. It becomes very difficult when people combine drugs or alcohol with ADHD or any mental health issue because it just only works in the situation.
Hayley: And what would treatment be like for someone who has both an addiction and ADHD?
Dr. Bhatt: We always try to stabilize somebody first. If there’s a mental health or psychiatric exacerbation, that cannot be addressed with substances in the way, we would have to see them sober and remove the effects from the substances. It’s important to get somebody into treatment where both the substance use disorder and ADHD can be managed at the same time. The only way to actually see if somebody truthfully has ADHD though, is to remove those substances from their bodies. So, entering rehab, entering treatment, whatever, outpatient, inpatient, seeing them without any adulterants within their body and then assessing them. Many patients that I have at least assessed, I’m able to do a good psychiatric evaluation and ask them about retrospective symptoms. Back in the day when they were children, talk to their families, get good chronological history, so I’m able to ascertain was there ADHD, a true ADHD, or is it a secondary product to their substances of abuse. But again, these are things that need to happen by taking good histories looking back. So many patients come to treatment, and they’re unfortunately talking about “ADHD”, and maybe they had it, but the symptoms that they’re talking about now are really symptoms of their substance use. So, the important part is really clearing all of that up. Getting them in proper treatment, getting them in proper rehabilitation, getting substances to get sober, and then addressing the ADHD simultaneously, or after the fact. But my point is, is that you can’t address ADHD while substances are on board.
Hayley: Well thank you for explaining that Dr. Bhatt. If you want to read more about ADHD and addiction, you can go to addictioncenter.com. All of our other podcast episodes are also available on Addiction Center as well as Spotify and Apple Podcasts. Thank you for listening and we hope to have you next time for Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.
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