Complex Attention-Deficit Hyperactivity Disorder in a 15-year-old With a Substance Use Disorder

CASE:

“JD” (identifying details have been changed), a 15-year-old Afro-Caribbean female sophomore student diagnosed with attention-deficit hyperactivity disorder (ADHD), was referred to an Adolescent Substance Use and Addiction Program after substance use disorder screening indicated a positive result, suggesting significant risk. The screening was part of a routine checkup by her primary care provider after noticeable declines in her academic performance and mood.

Previously a consistent student, JD's struggles with inattention, forgetfulness, and organizational challenges had become increasingly apparent. Teachers reported that JD seemed perpetually distracted, disengaged, and frequently excused herself to the bathroom. “It's like I'm there, but not really there,” JD explained during an evaluation, describing how disconnected she felt from her surroundings. Moreover, her involvement in extracurricular activities such as the debate club and soccer had waned, changes she vaguely attributed to “lack of energy.” JD's mother described the transformation as watching her daughter “slip away into someone unrecognizable. Every day brings a new worry.”

At home, JD's mother discovered JD vaping and found what appeared to be drug paraphernalia in her backpack. Distraught, she confided the ongoing strain these discoveries placed on the family. This period marked a significant emotional toll on the family, accentuating the urgent need for intervention. The sense of loss felt by JD's family was compounded by their fear of her potential decline into more dangerous behaviors, especially given that JD's maternal uncle died of an unintentional opioid-involved overdose.

In the initial consultation, JD was reticent to talk about her substance use but gradually disclosed her regular use of cannabis and nicotine via vaping. JD explained that nicotine temporarily enhanced her focus, whereas cannabis provided relief from overwhelming stress, albeit occasionally accompanied by episodes of paranoia. “Sometimes it feels like it's the only thing that calms things down in my head,” JD admitted. She voiced a readiness to quit nicotine but showed ambivalence about changing her cannabis use. Despite the adverse effects, JD perceived these substances as benign when compared with other drugs or alcohol (“weed is natural”).

Complicating the clinical picture, JD viewed her friends as support pillars, contrary to her parents' beliefs that these relationships exacerbated her substance use. Her parents advocated for a strict regimen of abstinence from all substances and a complete disassociation from her friends. “They think my friends are the problem, but they're not,” JD contested.

The cultural dimensions of JD's identity significantly influenced her engagement with treatment. JD articulated her desire for a treatment approach that respected her and asked for a clinician who could “see where I'm coming from… someone who understands me, not someone who just wants to change me.”

Considering JD's ADHD diagnosis, her escalating substance use, and the socio-cultural factors influencing her behavior, what approaches could best address the interplay of these elements to foster a holistic and effective treatment plan for her?

Kevin M. Simon, MD, MPH and Modar Sukkarieh, MD

The complex interplay between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs) in adolescents represents a critical challenge in behavioral health and necessitates nuanced management strategies. JD was screened with the Screening to Brief Intervention, 1 of several validated tools crucial for the early identification of these disorders within primary care settings, facilitating timely intervention.¹ Given the impulsive and risk-taking behaviors that are often hallmarks of ADHD, adolescents diagnosed with ADHD are particularly susceptible to developing SUDs as adults. This heightened risk underscores the critical need for targeted therapeutic interventions in this population.²

In developing a comprehensive treatment plan for JD, it is essential to recognize the role of first-line, evidence-based treatments for ADHD, such as extended-release stimulants (e.g., methylphenidate or amphetamine). These treatments improve core ADHD symptoms and reduce the risk of later-life SUDs without increasing the likelihood of substance use issues, highlighting the protective effects of effective symptom management.³ Four nonstimulant medications have Federal Drug Administration (FDA) approval for ADHD: the norepinephrine reuptake inhibitors atomoxetine and viloxazine extended-release, and the α-2 long-acting adrenergic agonists clonidine extended-release and guanfacine extended-release, which may be suitable options depending on individual patient factors.⁴

The importance of addressing ADHD symptoms with evidence-based interventions is further supported by recent genome-wide association studies, which highlight the bidirectional relationship between ADHD and SUDs.⁵ This relationship highlights the importance of viewing ADHD not only as a challenge in focus and behavior regulation but also as a significant risk factor for severe co-occurring conditions that can profoundly affect an individual's quality of life. Individuals with ADHD, particularly those who are untreated, are twice as likely to develop SUDs compared with those without ADHD.⁶ In addition, ADHD can complicate the progression of SUDs, making them more severe, complex, chronic, and challenging to treat.

The interaction between ADHD and SUDs presents distinct challenges within historically marginalized groups. Adolescents from minority backgrounds, such as the Afro-Caribbean community, often face significant disparities in health care access, diagnosis, and treatment, which complicate the management of these conditions. Research highlights these disparities, emphasizing the necessity for culturally sensitive and individualized treatment approaches.⁷ In addition, neurodiverse populations and gender and sexual minorities experience heightened risks for SUDs, including stigma and discrimination, underscoring the need for inclusive and empathetic care that addresses their needs and challenges.^8,9 Tailoring interventions to reflect the diverse experiences of these populations is essential for promoting equitable access to care and improving overall treatment outcomes.

Emmett Walsh, MSW, LICSW and Laurie A. Gates, MSW, LICSW

In engaging with JD and her family, practitioners must balance their expert knowledge with the understanding that the patient and the family are, in fact, the experts of themselves. Finding common ground concerning the patient's behavior and offering empathy for the struggle the patient and family have been experiencing for weeks or months before stepping into this clinical setting is the basis for building rapport.¹⁰ Emotions experienced by the patient and family likely include exhaustion, frustration, and possible hopelessness. These emotional dynamics necessitate a culturally sensitive approach to treatment. The diversity in family structures within Afro-Caribbean communities can significantly affect therapeutic engagement. It is crucial for sessions labeled as “caregiver support” to include all key family members who play a significant role in the patient's upbringing and care. Family roles may vary, with some members providing economic support while others, such as mothers or maternal figures, might predominantly manage daily caregiving and disciplinary actions. Recognizing and removing obstacles to understanding these family dynamics is key for clinicians to communicate and engage effectively.¹¹ Building on this foundation of cultural sensitivity and understanding of family roles, the next step involves integrating these insights into the therapeutic process. Furthermore, the Afro-Caribbean cultural context influences the application of interventions like motivational interviewing and contingency management, which are primary strategies for inducing behavioral change. Using rewards to meet behavioral expectations, a common technique in these therapies, may conflict with cultural norms that value intrinsic motivation and respect for authority rather than external incentives.¹² Recognizing the unique contributions of each family member not only facilitates a more inclusive treatment approach but also ensures that interventions are precisely targeted to address the specific challenges and needs of JD and her family. This tailored approach is crucial in managing JD's condition effectively because it aligns the treatment plan with the family's values, expectations, and daily realities. Doing so fosters a supportive environment that enhances the likelihood of successful outcomes and sustained engagement in the therapeutic process. Educating JD's parents about how they can improve communication will be essential. Challenging rigid beliefs and ineffective communication patterns will lead to family dynamics and communication practices that can help improve behavioral choices. Pairing psychoeducation about effective treatment methods with their cultural values may increase the likelihood that JD's caregivers will have success with alternative approaches to helping JD. These considerations will help both JD and her parents feel validated while simultaneously moving them toward treatment success.

Leslie Green, MSW, LICSW

Building trust with adolescents in therapeutic settings, particularly those engaging in high-risk behaviors such as SUDs, hinges significantly on maintaining confidentiality. Although parental rights grant caregivers the authority to protect and advocate for their children, they do not extend to accessing private information shared by the child with their mental health provider—unless these details suggest imminent risk to safety. This boundary can be challenging for parents to accept but is crucial for fostering a secure environment where adolescents feel safe to disclose sensitive information. Evidence suggests that adolescents who receive confidentiality assurances are more willing to disclose their use and to seek health care services.¹³ Adolescent self-report of substance use within a confidential assessment is valid, compares favorably to bioassay results, and is appropriate for universal screening.¹⁴

The legal framework supporting this practice is robust, governed by federal regulations such as 42 C.F.R. Part 2, which imposes a heightened duty of confidentiality on providers treating SUDs.¹⁵ Under this regulation, clinicians are prohibited from disclosing any substance-related discussions with patients aged 12 years and above to their parents without the patient's explicit written consent. This confidentiality is only breached if the adolescent reveals intentions that pose an immediate threat to safety, in which case the provider must act to protect all involved parties. When symptoms are unclear, or collateral history is missing, the complementary use of a biologic sample (e.g., urinalysis) from a consenting patient may help the provider with additional objective data (e.g., use vs. nonuse or quantifiable level). Biologic testing is not supported as a stand-alone screening or monitoring procedure for substance use.¹⁶

Engaging with JD necessitates acknowledging her struggles with inattention and disorganization from the outset. Rushing into discussions about her substance use without first addressing these underlying issues may lead her to feel misunderstood or unsupported, potentially undermining the therapeutic relationship. It is essential to explore and validate the perceived benefits JD gains from her substance use because this understanding can guide more tailored and effective intervention strategies. If alternatives that provide similar benefits are not presented, JD might be reluctant to alter her behavior, continuing in patterns that meet her needs in the short term but are detrimental in the long term. This approach respects JD's perspective and aligns with best practices emphasizing patient-centered care and integrating personal experiences into treatment planning.

Elizabeth A. Diekroger, MD and Jason M. Fogler, PHD

This case highlights the nuances and need for sensitivity in working with co-occurring ADHD and substance use disorder, including navigating confidentiality in adolescent care and culturally responsive practice. As highlighted by many of the cases in this series, Simon and colleagues leverage an interprofessional framework to effectively address all the drivers of JD's substance use, including academic stress stemming from ADHD-mediated learning difficulties, and the disconnect (and re-negotiation of roles) between dominant western educational culture and the values and concerns of recently immigrated families of color.^17,18 The Complex ADHD Practice Guideline reminds us that youth with ADHD are behaviorally and neurophysiologically vulnerable to developing SUDs (Key Action Statement 4) and that these issues should be addressed through the entire sensitive developmental period of adolescence through young adulthood (Key Action Statement 5).¹⁹ In other words, clinicians need to be mindful of the changing needs of their patients across these rapidly evolving developmental periods.