Episode 14 – ADHD And Addiction
Dr. Ashish Bhatt ❘
Many people with ADHD suffer from substance use problems. Dr. Bhatt talks about why that is and what kind of intervention can be done.
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Hayley: Hi, everyone. This is your host, Hayley, and you are listening to Straight Talk With The Doc: a podcast on all topics addiction, mental health, and recovery. Our doctor is addiction medicine specialist, Dr. Bhatt. How are you doing today?
Dr. Bhatt: I’m doing well, Hayley, how are you?
Hayley: I’m doing great, thank you for asking. Dr. Bhatt, your background makes you the perfect person to discuss today’s topic with. Before we get into it, can you tell me a little bit about your background in adolescent psychiatry?
Dr. Bhatt: I appreciate us speaking about this at this time especially because many kids around the country are going back to school and they’re going back to school at a time of COVID-19. But with many years I am a trained child and adolescent psychiatrist in addition to general adult psychiatry and addiction medicine. For me, I always felt in order to understand proper adult psychiatric and mental health conditions you have to know how we grew up. What are the normal, abnormal evolutions that a human being has from birth until we pass? I went and studied child and adolescent psychiatry and actually worked as faculty in the department of child and adolescent psychiatry at one of the top medical schools here in the country. So, I’ve a lot of experience treating a variety of behavioral health, addiction issues, from very, very young children to adolescence going around 18 to 21 year olds. It’s a very interesting time in a human being’s life. There’s so much changing at that time and a lot of vulnerability there, so this is going be a good topic.
Hayley: Yes, and those vulnerabilities are what ties into our topic today. We’ve all been impacted by the pandemic in different ways, some more than others, but we can’t forget about the children who are growing up during this time. I’m sure a person’s age during COVID is going to influence how they are affected by it, but let’s talk about how the brain changes through adolescence. Dr. Bhatt, are there certain years that are the most formative for a child mentally?
Dr. Bhatt: We have distinct stages that we’ve identified cognitively when we’re talking about brain development, physiologically and emotionally. There are distinct stages that occur. Up until about 5, I think, most of the brain is being developed at that time. It’s a huge impact that we have in terms of the environment, the nurturing, the experiences that anyone experiences up until that age. It’s very, very important that a proper solid environment exists for one to grow up until about 5 years of age, like I said that’s when the majority of the brain has already developed. But that does not stop or preclude us from having continual growth, actually the executive part of our brain in terms of the frontal lobe and the ability to rationalize and organize, plan, that’s continuing to evolve up until our early 20’s. When we ask what are those main years, I do believe depending on the insult, the injury, the time frame- up until you’re an adult, every part of your life is important and the proper environment has a tremendous influence, or lack of the proper environment can have an influence on how unhealthy or healthy somebody is going to be.
Hayley: What do you mean by the environment? Is that their home; where they’re being raised? Does that also mean what is going on in the world?
Dr. Bhatt: Everything from the parenting, the love, the support, the ability to have all of their psychological and physical needs met in terms of socialization, education, availability of health care, physical fitness, nutrition, emotional, cognitive cultivation. All of these things contribute to our health and wellness. It’s important how that impacts us as we evolve. And it impacts us at any age really, but in terms of our first exposure to certain things that are happening of course when we’re younger. That’s a very important part of our life. Environment means basically everything around us, even to the time when we first started eating to the first people we interact with, and especially in adolescence. Environment has a huge impact and we can talk about that as we go along.
Hayley: I want to talk about that. This environment that children are growing up in is an environment with COVID, just all of the issues COVID has caused not just the illnesses, but the isolation, the lockdown, all of that. In what ways can COVID be frightening for a child?
Dr. Bhatt: When it comes to the understanding of COVID, it’s really age dependent. It’s age dependent and it’s also dependent on what’s being told to us and what we are witnessing. It really depends on not only your age but who’s around you, because we resonate off of one another. If you’re growing up in a family who has emotional parents or emotional caregivers, that can add to the anxiety that a child might perceive. On the flip side, if there’s somebody who’s downplaying it or who is not taking it with any credibility, well, that can also minimize things and expose children to harm in a different way. It really depends on how the environment is portraying that part or aspect of COVID at a particular time. But taking it one step forward, is that if we lose a family member, this is ultimately destruction. If they’re not able to access food because the parents have lost their job. If they’re unable to go to their medical appointments because they’ve lost their health insurance because of a loss of job or loss of finances. It’s a huge trickle-down effect. All of those aspects to our psychological and physical health, at any point where any part of it is compromised, that perception of COVID as the causing agent of it can be more or less frightening. The biggest impacts that we’ve seen, though, are more of the social interactions, the more time spent on the screen, and the lack of structure from going to school in person. But the actual danger of the virus itself has been less appreciated amongst the children itself compared to those other psychological factors. But again, like I said in the outset, if people are dying around you or people have physically gotten sick, then the fear of the actual virus itself can, of course, be more severe.
Hayley: I do want to get into that and also the social isolation aspect of it, but first I want to talk about the economic hardships that a lot of families have faced. When I was doing some research, I saw a quote that said “households with children have experienced significantly higher rates of economic hardships throughout the pandemic.” How can those hardships affect access to necessities for children?
Dr. Bhatt: As I was saying previously, when anybody loses their job- COVID took away every aspect of our life, it affected everything and still is in many ways. Of course, we’ve adapted, but so many people lost their jobs and when they lost their jobs they lost their income, and with it often their health insurance. That provided and created such insecurity for families. When families are not just an adult and you’re caring for individuals, obviously they’re the ones that are going to suffer also. Children were the unfortunate recipients of negative fallout due to the financial hardships of their caregivers. And that did result in them missing out on many things that had to do with things from food going to doctors, receiving medications, access to routine health care, dental care. I had read somewhere that people couldn’t even get normal dental hygiene appointments. It was really, really disruptive. When you look at this collectively, when you look at all of the different aspects of our health- the psychological things that kids look forward to, which is socialization, playtimes, support from your family, parents, guidance. That’s compromised and taken away. Then on top of that, the basic survival aspects- food, shelter, nutrition, healthcare, all of that. People, especially in lower socioeconomic classes and people who lost their jobs, those compounding variables together, you’re going to see a more tragic mental health and physical health fallout from this and a lot of this is unfortunately going to be to be determined once all the data is collected on this and I hate to see what those results are going to be.
Hayley: Yeah, that’s a big part of it and also like you mentioned earlier where that fear can be made worse. Fear of the illness itself if they have people around them getting sick. I read that over 43,000 children are estimated to have lost a parent due to COVID. How can experiencing the loss of a parent at such a young age effect a child’s mental health?
Dr. Bhatt: Abandonment and secure abandonment. Secure attachments are a hallmark thing and a benchmark thing that we need to achieve for proper development, social relatedness, and growth for us as we become adults. The devastation that can occur depending on the child’s age, the child’s resiliency, the other supportive figures that they have in their lives can all be and need to be factored in on what the result can be. Losing a parent at any age is super difficult. It’s tragic and I know that as human beings we are going to lose people as we go along in the course of life. But unexpected loss- COVID-19 was not something that anybody at this time living has really ever experienced for the most part, and so children had a difficult time and are having a difficult time anticipating that. I think we as experts and health care professionals knew that there was going to be some fallout to this and we were going to have to deal with the negative mental health on adults and children that the pandemic was going to have, but what that tally is or how that really is going to play out is again yet to be determined. Losing a parent when you’re a child, again, it can really affect you in many ways as it relates to your attachment to other people and it could be perceived as an abandonment and depending on the cognitive level of that child. It can have tremendous enduring negative effects. It’s very sad, we see that often, though, especially in young children.
Hayley: Like you said, a lot of the effects are still to be seen. We’re going to see a lot more research coming about that in the future. But based on what we already know right now, are some children more likely to develop mental health issues than others?
Dr. Bhatt: Those kids that were already psychologically fragile. Probably people who might have a pre-existing depression or anxiety, or they had difficulty coping or adapting in different ways. Anybody with a pre-existing mental health condition, adding stress of the pandemic definitely can exacerbate those situations. I do believe we’re going to see so much more even though those that did not have pre-existing depression and anxiety develop it. But in addition, those that don’t have supportive role models or healthy, supportive caregivers, those children are going to be at increased risked for developing that because they’re not going to know how to react to this, and again it speaks to we mimic what we see. So, if we don’t have healthy role models before us, or people who are dying or people who are sick or people who are addicted, people who are catastrophizing, people who can’t moderate the perception of COVID accurately or politicizing this whole thing, those kids are going to be at an increased risk for negative psychological outcomes. A lot of it, again, I hate to use the general word environment, but we are a product of where we grow up and who we grow up with and what we’re exposed to. Having healthy caregivers, healthy parents to get us through this, it’s going to be more protective. Without those are the kids that are going to have an increased risk because of how we cope with things. The same two people can be exposed to a lack of certain food or lack of certain healthcare or lack of certain socialization, but if the parents are there to help those children guide them through these times and help them cope in healthy ways, those kids are going to have a better outcome.
Hayley: If a child does have mental health issues, how is that going to affect them as an adult?
Dr. Bhatt: Well, it depends if they’re getting treatment or not. Many of our childhood depressions, anxieties, traumas, other illnesses that we have, psychological illnesses that are present- we do have cognitive behavioral therapies and medications that are FDA approved to treat and are indicated for mental health issues. The problem, I see, is if that was disrupted during the course of the pandemic. Obviously, Telehealth being in place has served as a vehicle medium to still communicate and get access to it, but the irony is those that are capable of getting access to all of this stuff are those that probably had less issues, because it’s the unfortunate part and unfortunate reality that those that are struggling struggle more pervasively, more globally, and more comprehensively. It is those people who are living in areas that might be not ecologically having the resources that in itself. Don’t have parents who may have jobs that don’t have insurance, don’t have vehicles, don’t have the means to get them through the obstacles that the pandemic caused. They might already have more vulnerabilities by having the presence of more mental health issues that are more prevalent within such populations. And then when they get an insult, meaning something gets taken away, then whatever structure or support that was there is going to crumble. And that is the irony of this whole situation. There are things that, of course, we’ve done to compensate. But if those could have been replaced and those could have been modified and those needs met, those kids are going to get through this better. But it all depends if there was continuation or substitution of their therapies and modalities that kept them healthy in the first place.
Hayley: Let’s talk more about those obstacles that have been put in place by the pandemic. One of those is social isolation. Some sources say that they saw an increase in fear of going in public in children. Do you think that this is going to be irreversible for some children as they grow up?
Dr. Bhatt: Well, the beauty about kids is kids are resilient. But I don’t think we’ve seen them through this type of test before. What we do know, if the sooner we get kids back to normal behaviors and normal routines, the better and more protective the outcomes are. The longer we allow somebody to live outside of what they consider normal or that structure without compensating the creative measures that somehow recreate or at least simulate or substitute whatever was being deprived, well, that’s really how we can measure what’s going to end up happening. We have seen people substitute for this when the pandemic first started and people were staying home from school- which is the biggest thing I think with kids, the number one thing is taking away their socialization. Kids need other children. They need other people to be around. And so, we did have distance learning, virtual learning, and now many people went back to school in person when school resumed. And, for the most part, I think we have gotten to a spot where people have understood that going back to school is super important. And we’ve put provisions in place that allow that socialization to take place. That I think is very productive here. But, again, I think if you use a simple formula, if you can get kids back to their normal routine from a social perspective, a health perspective, a fitness perspective, the mindfulness perspective, you’re going to have less fallout from this. Any way that creates that normalcy, for lack of a better word, is going to be better for that child. And I think we’re trying it as a society as much as possible. The unfortunate part is the risk versus benefits. Those kids that have been stuck at home or might not have access to all of these things, well they’re the ones that are going to have far worse in this situation.
Hayley: What can parents do to try to ease some of that anxiety and stress for their children?
Dr. Bhatt: Well, definitely, it’s important to not catastrophize it ourselves. I think many parents or many people- an unfortunate part of this pandemic is it has been polarized. There’s people looking at it like it’s nothing, and there are people who are looking at it like, “Oh my god. How are we going to survive at all?” Well, life is about adjusting and adapting and reacting in a healthy way. That’s the way that we do things in order to have the best outcomes. Parents, we need to ensure that our kids are socializing. We have to use graded levels of reintegration, but most parents have started doing that and have done it either by virtual playdates or having a select group of people that they can vent or they can talk to that they know that they’re not putting themselves in risky behaviors so they can keep a few kids together that maybe aren’t at high risk of contracting COVID. At the same time, spending time with our children. I think the pandemic has allowed for many parents to maybe look at their own lives and say, “Hey, how can I give back to my kids and be more emotional with them in terms of a supportive manner?” I think there was something that we read recently that talked about that. And we did mention that families and parents have got another opportunity to be close again here and that’s good. We need to continue that positive emotional, psychological interaction with our children. But it’s really keeping them away also from that negative constant grind, that news that can be on, keeping them away from being in front of social media where certain repetitive negative stimuli can be exposed to them. It’s really trying to create that proper balancing act and getting them physical, getting them outdoors- it’s huge. It’s a huge component to keeping kids mentally well, physical activity. Obesity, unfortunately, and poor nutrition in children, it’s a problem here in the United States and in many other parts of the world. So getting our kids physical, it’s scientifically proven all of us who are capable. If we’re physically active, it releases endorphins. It allows us to feel a certain sense of wellness and health and that needs to be maintained throughout this whole time. It’s fall coming up in terms of returning back to school and we know that many school systems have put provisions in place that will allow kids to return back to a lot of the normal activities that they have lost, and especially were absent maybe during the summer time. It’s a collective effort in all of these things that we just talked about.
Hayley: That was some great advice; thank you for that. Another side of this, one of the realities of these mental health issues that are happening to kids, it can increase the chance that someone is going to try to self-medicate with drugs and alcohol. What age do children or young adults typically start experimenting with drugs and alcohol?
Dr. Bhatt: On average, you see it at 11, 12, 13, 14 years of age. You see it depending on where you are, what kind of surroundings you are in, how much parental control there may be. But when we see that initial usage, it’s often in that pre-teen-teenage years, early adolescence that the experimentation may occur. There are studies done basically annually on the prevalence of what drugs are being used by what age group. And we do often see Marijuana, cigarettes, alcohol often being the first drugs that are being abused and experimented with. That doesn’t necessarily mean that these kids are going to be chronically using this over time, but adolescence is a time where we do usually see kids experimenting with drugs. And depending on the education, the risk factors that might be around them, you may see the progression into further substance use and potential addiction. The younger you start, the worse the outcome is, unfortunately. We do see that one of the big risk factors for adult addiction is the onset of when you first started using. These younger people using is 11, 12, 13, 14, we see that ring.
Hayley: Okay, and the younger that they start using the more likely that they are to continue usage?
Dr. Bhatt: Not just continue, always, but that does increase the risk of potential other substance use and potential addiction. It doesn’t necessarily mean they’re going to continue using that specific substance. But we do see that association with onset of substance use and often the development of addiction as a whole and further experimentation with other drugs. And it is because our brain is still developing there. And actually this allows me to segue a little bit into that executing functioning and that continued evolution- the development of the brain. If we start introducing drugs or alcohol at our time where our brain receptors are still developing, the adaptation, the need, and the reward, the whole definition of addiction and how our brain will continue to adapt to either require or need it to tolerate it or crave it. Well, that risk is enhanced. You can see why the earlier somebody uses, the higher the risk Is there.
Hayley: What kind of signs should parents look out for that their child is abusing drugs or struggling with mental health issues and may need professional intervention?
Dr. Bhatt: The most overt one is when you see the behavioral changes. A lot of times it’s hard to tease out if it’s secondary to a substance of abuse sometimes from a primary mental health condition like depression. Because somebody getting irritable could get irritable coming off of smoking marijuana, or they can get irritable because they’re feeling sad or depressed or angry about something. The hallmark thing is, of course, if you see some behavioral change of pattern that starts to change you should be concerned, especially if it’s a negative pattern. If kids’ clothing starts to change, their hygiene starts to change, they start losing interest in things that they obviously were engaged in before- healthy interests. If they start to become persistently sad, articulating that they’re feeling depressed or angry, or they tell you that they cannot control their feelings. If you see grades declining, many of these are things that we see as kids grow up. But then it’s the degree and the pervasiveness that we need to watch out for, that if it’s not congruent with something that’s transient or reacting to a certain stimulus that might seem proportionate, you need to be watching out that something else is going on- drugs, alcohol, or maybe some developing mental health condition.
Hayley: Alright, Dr. Bhatt, thank you for sharing your expertise with us today. For anyone listening who wants to learn more about mental health and addiction, we have a lot of great information on addictioncenter.com as well as more podcast episodes. Thank you for listening to this episode of 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.