by Bree Lawrence

The road to recovery for people suffering from a substance use disorder (SUD) is often long and difficult. Many factors can complicate the process; one commonly cited by practitioners is the level of motivation. A strong sense of intent and commitment to change is considered a necessary component to successful treatment and recovery. To address a person’s motivation, practitioners regularly use strategies like motivational interviewing or motivational enhancement therapy (Moos, 2007), often with great success. These strategies aim to address the hesitancy or ambivalence an individual may feel about their drug use. Low motivation can present in many ways; such as a client who’s consistently late to treatment or misses sessions entirely, doesn’t seem to engage in treatment or focus during programming, shows frustration or emotional outbursts, or frequently “quits” treatment. Motivational-based interventions have been shown to help increase engagement in SUD treatment and lower an individual’s substance use (Smedslund et al., 2011). Due to this success, motivational-based strategies have been adopted by many treatment facilities and programs (Hall et al., 2016). Often, when those seeking treatments continue to display signs of low motivation, treatment facilitators may feel they aren’t ready for treatment or don’t want to address their substance use. But what if the tell-tale signs of low motivation in some clients are actually symptoms of something else, something more rigid, that motivational-based strategies don’t properly address?

Attention Deficit Hyperactivity Disorder

Most of us are familiar with attention deficit hyperactivity disorder (ADHD) in one way or another. ADHD is a neurodevelopmental disorder that is categorized into three distinct types, each with unique and overlapping symptoms. This disorder is commonly associated with symptoms like restlessness, excessive daydreaming, trouble focusing, and hyperactivity. It is one of the most prevalent neurodevelopmental disorders, affecting between one and 13% (Attention Deficit Hyperactivity Disorder (ADHD), n.d.) of the population. While our understanding and the public perception of ADHD are improving, there are still plenty of people holding on to misconceptions about the disorder. ADHD is not a diagnosis limited to children and symptoms don’t always improve or fade as someone ages. In fact, without treatment, symptoms often get worse with time. Symptoms of ADHD also aren’t as simple as excessive energy or distractibility. In adults, ADHD symptoms often present themselves as behaviours like missing appointments, poor memory recall, or displaying intense emotional reactions or fluctuating interest. Many of these symptoms have to do with executive functioning: our ability to plan, problem-solve, organize thoughts and feelings, and regulate our emotions. Executive dysfunction is a core element of ADHD. When people struggling with both ADHD and SUD seek treatment for drug use, these symptoms of executive dysfunction are often seen as a lack of motivation or factors that make a patient “treatment-resistant” (Kalbag & Levin, 2005).

The Complexity of Co-Occurring Diagnoses

While every person seeking SUD treatment will have different needs and obstacles that are specific to them, co-occurring ADHD and SUD are very common and unfortunately, often unaccounted for. Research into the co-occurrence of these disorders has found that almost 25% of SUD patients have co-occurring ADHD (van Emmerik-van Oortmerssen et al., 2012). ADHD symptoms are also associated with an increased risk of developing a SUD, regardless of the type of substance (Capusan et al., 2019). Despite this link between ADHD and SUD, SUD treatment has typically failed to address the challenges of treating people with executive dysfunction. Patients with severe symptoms of ADHD are less likely to fully abstain from drug use (Arias et al., 2008), more likely to end their treatment, and are more prone to relapse after treatment (Perugi et al., 2019; Spera et al., 2020). To better understand why people with both ADHD and SUD struggle to succeed in typical drug use programs, it’s important to understand how the symptoms of ADHD aggravate SUD as well as impede common intervention strategies.

Executive Functioning

Let’s go back to executive function, or rather, executive dysfunction. Executive functioning is responsible for how impulsive we are, how much self-control we’re able to exert. It helps us prioritize long-term goals over short-term desires. When these abilities are impacted by ADHD, they also affect behaviours that can help prevent initial drug use or misuse. Empirical studies looking into which ADHD symptoms may be the cause of reduced treatment success aren’t abundant, but researchers have some potential theories. Increased impulsivity has been reported as one reason for initial drug use in people with ADHD (Kronenberg et al., 2014), while lack of self-control and difficulties with conceptualizing future consequences are also believed to be possible factors (Kronenberg, Verkerk-Tamminga, et al., 2015). 

Self-medicating has also been theorized as a potential link between ADHD and SUD (Kronenberg, Goossens, et al., 2015). The use of stimulant drugs, like cocaine, is common in people with ADHD. A recent review of studies estimated that over a quarter of people with ADHD worldwide have used cocaine at some point in their life and 10% have suffered from a cocaine use disorder (Oliva et al., 2020). This may be due to stimulants reducing many ADHD symptoms (Young et al., 2015), implying that someone using stimulant drugs may be seeking relief or trying to address concerns like restlessness or inattention (Kronenberg, Verkerk-Tamminga, et al., 2015).

The Influence of Executive Functioning on Treatment

To understand how executive functioning may hinder treatment, it’s important to look at what most typical substance use disorder programs involve. Cognitive behavioural therapy (CBT) has been shown to work well in reducing substance use by addressing the relationships between thought processes and behaviours. CBT programs often include activities like tracking actions, feelings, and thoughts to address maladaptive patterns, learning to reframe experiences, and meeting with practitioners at regular intervals. But ADHD patients may have difficulty maintaining tracking sheets, remembering to try reframing their thoughts, or planning accordingly to arrive (on time or at all) to therapy appointments (Kalbag & Levin, 2005). These difficulties with treatment programs can lead practitioners to perceive the patient as having low motivation (Kalbag & Levin, 2005). The patient may feel ashamed for not completing what seems like simple tasks. These feelings of failure are common with ADHD and potentially responsible for other challenges with SUD.

Intense Emotions and Impulsivity

Let’s talk about emotional regulation. While emotional regulation is a part of executive functioning, its effect on drug use and treatment is different than other aspects of executive functioning. Emotional regulation is something everyone struggles with at times. Strong feelings can lead to outbursts of emotion, inappropriate responses, or cause us to make impulsive decisions. For most people, these moments are few and far between and limited to infrequent but significant events, such as intense grief from the sudden death of a loved one or fiery anger after a distracted driver rear-ends you in traffic. Often, we can curb strong urges to act on these intense emotions. Individuals with ADHD often experience heightened emotions, frequently in situations where their reaction may seem unnecessarily extreme. They have more difficulty resisting the urge to respond impulsively. For some, this means snapping at a coworker or shouting at an aggressive driver. For others, however, the impulses are more internal. As described earlier, difficulties associated with executive dysfunction can result in performance issues in not only therapy itself but also in school and work. Emotional dysregulation means these performance issues can feel much worse to someone with ADHD, resulting in demoralization, self-hate, or shame (Barkley & Fischer, 2010; Skirrow & Asherson, 2013). For many people, it’s common to reach for a drink, a cigarette, or another drug of choice to soothe intense feelings or cope with stress. For those with ADHD, this impulse can show up more often and be more difficult to ignore. The combination of these unique factors suggests substance use in people with ADHD is a coping behaviour (Kronenberg, Goossens, et al., 2015) and that emotional dysregulation in ADHD may exasperate these issues (Young et al., 2015; Zulauf et al., 2014). 

Why is this Connection Important?

Let’s recap: worldwide, a quarter of people seeking treatment for substance use also struggle with ADHD, often undiagnosed (van Emmerik-van Oortmerssen et al., 2012). People with co-occurring ADHD and SUD, often have less success in drug abuse programs (Arias et al., 2008; Perugi et al., 2019; Spera et al., 2020), likely due to ADHD symptoms like executive dysfunction (Kalbag & Levin, 2005; Kronenberg et al., 2014; Kronenberg, Verkerk-Tamminga, et al., 2015; Young et al., 2015) and emotional dysregulation (Barkley & Fischer, 2010; Skirrow & Asherson, 2013; Young et al., 2015; Zulauf et al., 2014). These complications in treating a dual diagnosis of SUD and ADHD have a significant influence on potential patient success. Many symptoms of ADHD appear to practitioners as signs that someone isn’t motivated to change, is treatment-resistant, or just not ready to engage in treatment in a meaningful way. This could potentially cause someone seeking treatment to feel they’re incapable of change, to leave programs before completion, or discourage them from returning after a relapse (Kalbag & Levin, 2005).

So What Do We Do? 

If co-occurring ADHD and SUD are so common, why haven’t more treatment programs for drug abuse accounted for these patients’ different needs? This is possibly due to many treatment-seekers not knowing they have ADHD and program facilitators being more likely to see the symptoms of ADHD as merely a lack of motivation. This is why more treatment programs need to screen new patients for ADHD (van Emmerik-van Oortmerssen et al., 2014; Wilens, 2006). By doing so, treatment facilitators will better be able to differentiate between executive dysfunction and low motivation, making it possible to target issues more effectively. For those with mild ADHD symptoms, teaching the use of tools like daily planners, reminder apps, and coping catalogues can improve treatment outcomes (Kolpe & Carlson, 2007). Practitioners that take a “coaching” approach to treatment are also preferred by individuals with co-occurring ADHD and SUD (Kronenberg, Verkerk-Tamminga, et al., 2015). For more severe ADHD symptoms, integrated CBT that targets SUD and ADHD simultaneously may be the best course of action (van Emmerik-van Oortmerssen et al., 2014).

Of course, every person struggling with drug use is going to have different strengths, weaknesses, and needs that should be considered but can’t always be accommodated. The concern worth considering here is that ADHD and SUD are frequently co-occurring, the symptoms of ADHD can aggravate the development or severity of substance use issues as well as inhibit treatment success, and the telltale signs of ADHD in adults look very similar to indicators of low motivation in typical SUD treatment-seekers. By addressing the specific needs of the large demographic of people with comorbid ADHD and SUD, treatment facilitators and health professionals can help more patients more effectively with longer-lasting maintenance and recovery.

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