Attention deficit hyperactivity disorder and dual disorders. Educational needs for an underdiagnosed condition

Abstract

A wide range of comorbid psychiatric disorders overlap with attention-deficit hyperactivity disorder (ADHD) across the life span. There is a robust and complex link between ADHD and substance use disorders (SUD). The aim of this report was to review the neurobiological and other vulnerability factors explaining the comorbidity of ADHD and an addictive disorder, as well as the key aspects of the assessment and diagnosis of dually diagnosed ADHD patients. A comprehensive and systematic search of relevant databases (PubMed, Embase, and PsychINFO) was conducted to identify studies published in peer-reviewed journals until July 31, 2012, with the aim of exploring the association of ADHD and SUD with postgraduate training and residency education. Across the life span, ADHD is associated with significant impairment and comorbidity. Data from epidemiological, clinical and epidemiological studies show a very solid link between ADHD and SUD. Therefore, it is very important to carefully and systematically assess for any substance use in patients with suspected ADHD coming to initial assessment, and vice versa. While there are various valid and reliable rating and screening scales, diagnosis cannot solely rely on any of the instruments available for both SUD and ADHD in adult patients with dual pathology. The most important and effective tool in the assessment of dually diagnosed patients with ADHD and SUD is a full and comprehensive clinical and psychosocial assessment. Hence, it is essential to actively incorporate training opportunities on the assessment, diagnosis, and management of adult ADHD and dually diagnosed ADHD patients during postgraduate education residency or specialist training.

Adult ADHD and comorbid disorders: clinical implications of a dimensional approach

“…The National Comorbidity Survey reported that adults with ADHD are three times more likely to develop major depressive disorder (MDD), six times more likely to develop dysthymia, and more than four times more likely to have any mood disorder [ 37 ]. Most notably, individuals with ADHD are twice as likely to experience substance abuse or dependence [ 43 ]. These comorbidities present important clinical challenges since their co-occurrence results in greater disease burden and more severe illness courses than ADHD or mood and anxiety disorders alone [ 44 ].…”

“…Studies have concluded that emotional dysregulation is a distinctive attribute of adult ADHD psychopathology, however these symptoms may be misdiagnosed as a mood disorder [ 66 – 68 ]. Similarly, ADHD symptoms may be masked by substance use [ 43 ]. Physicians are often more familiar with mood and anxiety disorders, which may contribute to misdiagnosis and delays in treating ADHD in adults [ 69 ].…”

International Consensus Statement on Screening, Diagnosis and Treatment of Substance Use Disorder Patients with Comorbid Attention Deficit/Hyperactivity Disorder

“…The literature argues towards a targeted training on the dual-diagnosis of ADHD and SUD [20]. The expert group recommends that a physician or clinical psychologist can make the diagnosis of ADHD in SUD patients, provided he/she has received extensive training on the differential diagnosis of ADHD, has experience in addiction care, and has experience with adult ADHD populations.…”

Who says this is a modern disorder? The early history of attention deficit hyperactivity disorder

“…Whilst some of the children described by Still, as is probably the case of some the earlier descriptions included in the present report, may have suffered from a variety of neurological and psychiatric disorders, including conduct disorder, oppositional defiant disorder, learning disabilities, autism spectrum disorders, epilepsy, chorea, among many others, many of these children showed clear symptoms of ADHD and may present with these comorbid disorders, as it is commonly the case in clinical practice. Moreover, as we now fully comprehend, the existence of other comorbid disorders not only does not exclude a diagnosis of ADHD, but often makes the diagnostic process of this neurodevelopmental disorder more difficult [74] . In any case, although many of the symptoms and diagnostic criteria of inattention, hyperactivity and impulsivity are not exclusive to this neurodevelopmental disorder, the characteristic presentation of these symptoms, are typical of the disorder currently known as ADHD, as indicated not only in the solid neurobiological research on this disorder, but on the broad and diverse clinical descriptions published during the 20 th century and, as outlined in the present report, in the various medical descriptions during the 18 th and 19 th centuries.…”