Trouble du Déficit de l’Attention/Hyperactivité et Addictions : concepts et applications cliniques pour une meilleure prise en charge

Abstract

Background

Addictive disorders are responsible for a significant morbidity and mortality rates. These disorders often coexist with other psychiatric and neurodevelopmental disorders, explaining some of the severe consequences. The complexity of the mental disorders associated with addiction and the public health issue they represent have led researchers to develop a new field of research: dual disorders, which corresponds to a mental disorder (or several mental disorders) coexisting with addiction. Attention Deficit Hyperactivity Disorder (ADHD) is receiving an increasing attention from the clinical and scientific community. In France, ADHD has finally been fully considered a public health issue over the past decade, leading to a growing demand for training among health professionals. This neurodevelopmental disorder is common in the population suffering from addiction and pose major diagnostic and therapeutic issues. Addiction and ADHD have bidirectional causal links, which maintain and worsen the symptoms. ADHD population represents a key element for the treatment. However, screening and diagnosing ADHD in patients suffering from addictions pose serious challenges for clinicians because of the effect of substance use and gambling/gaming on executive functions and of other common psychiatric comorbidities, which can mimic or hide ADHD symptoms. Treatment strategies for this dual disorder remain understudied.

Objectives

To describe recent data concerning the diagnosis and management of the dual pathology of ADHD and addictions, eventually leading clinicians to better implement the most up-to-date and relevant diagnostic and therapeutic strategies relevant to their practice.

Material and methods

A narrative review of the international literature was carried out via MEDLINE for articles in English or French published without date limit, concerning the identification, diagnosis and management of ADHD comorbid with substance and non-substance addictions (gambling, video games).

Results

ADHD is identified in 23% of substance addicts and up to 40% of non-substance addicts. Similarly, the prevalence of substance and non-substance addictions reached 50% among ADHD sufferers. In these cases, the clinical picture is more severe. Identifying this dual pathology requires a specific diagnostic process. Standardized screening and diagnostic tools are useful, but not all of them have been validated. Medication and non-medication management must target both aspects in an integrated way. Some promising dedicated therapeutic strategies (psycho-education, cognitive-behavioral therapy) have been developed, based on their efficacy in each disorder alone. Unfortunately, their level of evidence remains low to date.

Discussion

As in other dual disorders, the reasons for the high co-occurrence of ADHD and addictions are multiple and incompletely understood. The first hypothesis is based on a shared vulnerability between the disorders, where risk factors for developing one are also at risk of developing the other. Large-scale genetic studies support this hypothesis, with bidirectional causality for SUDs. Childhood adversity is another major factor in shared vulnerability between ADHD and addiction. Interestingly, this shared vulnerability also involves certain cognitive functions such as, e.g., impulsivity, impaired executive functions. Emotional dysregulation also represents a plausible common pathway toward ADHD and addiction, especially with regard to the hypothesis that substance use or gambling/gaming may arise from the need to self-regulate ADHD symptoms (so-called “self-medication” processes). Evidence toward self-regulation is scarce and discrepant to date, including for stimulant drug use. Conversely, the latter have been associated with ADHD symptoms occurring late in adulthood, which are likely to resolve with abstinence form stimulant drugs. From a clinical perspective, the management of the dual disorder “ADHD and addiction” requires specific diagnostic and treatment strategies. To date, despite substantial progress in the past 15 years, validation studies are lacking regarding diagnostic procedures. Likewise, current data remain insufficient regarding therapeutic strategies. Overall, in France, existing care setting should develop and provide integrated treatment for ADHD and addiction to meet this public health challenge.

Conclusion

The management of the dual disorder “ADHD and addiction” requires specific diagnostic and treatment strategies. To date, despite substantial progress in the past 15 years, validation studies are lacking regarding diagnostic procedures. Likewise, current data remain insufficient regarding therapeutic strategies. Overall, in France, existing care setting should develop and provide integrated treatment for ADHD and addiction to meet this public health challenge.