Attention Deficit Hyperactivity Disorder (ADHD) and Substance Use Disorders: Dr. Sarah Anderson

There is a strong relationship between Attention Deficit Hyperactivity Disorder (ADHD) and substance use disorders. Research indicates that up to 50% of individuals with a substance use disorder also have an ADHD diagnosis, and those with ADHD are estimated to be six times more likely to struggle with substance abuse compared to those without the diagnosis (Davis et al., 2015). So, what accounts for this connection? 

Some evidence points to personality traits associated with ADHD that may predispose individuals to substance use. Other research has examined differences in the dopamine reward pathway between those with and without ADHD. The impulsivity and self-regulation challenges linked to ADHD, along with difficulties in executive functioning, is another factor that potentially increases the risk of substance use. 

Although we may not be able to alter inherent personality traits or easily address the complexities of the dopamine system, therapy can play a vital role in supporting and enhancing executive functioning skills.

Executive Functioning and Its Role in Recovery 

Executive functioning encompasses the cognitive processes necessary for planning, organizing tasks, following through, and achieving long-term goals. Additionally, executive functioning skills are needed to maintain a job, live independently, and successfully engage in one’s daily life. Executive dysfunction can pose barriers to recovery. Individuals with executive dysfunction experience challenges in organizing their environment, accurately remembering facts/dates/appointments, and completing tasks (Barkley, 2015). 

Additionally, the inability to manage impulses, initiate tasks, and self-regulate can result in significant stress and hinder one’s ability to manage life independently, which may lead to relapse (Mannuzza et al., 2008).  Therefore, when it comes to designing a path for sustainable recovery, individuals struggling with both ADHD and substance use disorders must engage in therapy that focuses on building executive functioning skills.

Occupational Therapy, Executive Functioning & Substance Use Recovery 

As an occupational therapist specializing in mental health and substance use recovery, my role differs from that of other mental health therapists. My primary focus is on supporting the development of independent living skills, which includes a range of activities such as household management, job responsibilities, driving, grocery shopping, cooking, and budgeting. Executive functioning plays a crucial role in a person’s ability to live independently; I believe it is one of the most important skills necessary for successful independent living. Currently, I work at a mental health and substance use recovery center. Many of the clients I work with have difficulties maintaining employment, keeping their environment organized and clean, consistently taking their medications, engaging in basic self-care activities, managing their emotions, handling their finances, and structuring their time. I can confidently say, based on client reports, that the vast majority of clients I’ve worked with experienced challenges with executive functioning prior to their substance use. Furthermore, many clients who sought treatment before arriving at the center have mentioned that issues related to executive dysfunction, such as boredom—which is closely associated with difficulties in task initiation and time management—function as triggers for relapse.

Therefore, to ensure they can maintain their recovery, it is essential that we focus on fostering the development of their executive functioning skills.

Key Areas of Executive Functioning

Understanding the relationship between ADHD, substance use disorders, and long-term recovery requires an exploration of the key components of executive functioning that are often affected in individuals facing these co-occurring diagnoses. Below, I break down each of these areas, highlighting their impact on recovery and strategies that can help enhance these skills for improved outcomes.

Planning and Prioritizing

Individuals with ADHD often face challenges with planning and prioritizing, which can lead to difficulties in breaking tasks into manageable steps and organizing their responsibilities. Clients I have worked with who struggle with these skills often have trouble paying bills on time, cooking, grocery shopping, and arriving at work punctually. Additionally, they may find it difficult to balance their time between work, family, friends, and other responsibilities. 

Challenges with planning and prioritizing can pose significant issues in early recovery, as many individuals who are newly discharged are tasked with managing new responsibilities, including completing step work, regularly attending meetings, and independently handling everyday life activities. Effective strategies to assist clients in these areas include the use of planners or digital calendar tools, which help establish a structured framework for daily activities (Cole et al., 2024). Other strategies such as time-blocking and creating actionable task lists can further enhance the ability to stay organized. 

The Eisenhower Matrix is an incredibly useful tool for prioritizing tasks, as it allows individuals to categorize their responsibilities based on urgency and importance (Jyothi & Parkavi, 2016). The matrix divides tasks into four quadrants: 

1. Urgent and Important: Tasks that require immediate attention and are critical to achieving goals. These should be done right away. 
2. Important but Not Urgent: Tasks that are essential for long-term goals but do not require immediate action. These should be scheduled for later. 
3. Urgent but Not Important: Tasks that require immediate attention but are not necessarily tied to your personal objectives. These can often be delegated to others. 
4. Neither Urgent nor Important: Tasks that have little significance; these should be minimized or eliminated from your to-do list. 

Using the Eisenhower Matrix can help individuals visualize their tasks and prioritize effectively, ensuring they focus their time and energy on what truly matters. 

Organization:

Organization directly impacts a person’s ability to manage various aspects of daily life. Effective organization helps individuals create a structured environment, prioritize tasks, and manage important responsibilities, including appointments, medication schedules, and personal commitments. For those recovering from substance use, the ability to stay organized can significantly reduce feelings of overwhelm and stress, which are often triggers for relapse (Kitzinger et al., 2023). 

When I work with clients, I help them create systems to declutter their living spaces, use visual reminders, and implement paper or digital organizers to keep track of their tasks. I also support them in developing personalized routines that foster consistency and accountability, which ultimately empowers them to manage their recovery journey more successfully.

Task Initiation

A common hurdle for clients with ADHD is difficulty in starting tasks, which often leads to procrastination and avoidance, further exacerbating feelings of anxiety and overwhelm. Two of my favorite methods to use with clients are the “5-minute rule” and the “Pomodoro Technique,” as they encourage them to work on tasks in smaller, more manageable time intervals. 

The Pomodoro Technique, in particular, involves breaking work into 25-minute focused intervals, known as “Pomodoros,” followed by a 5-minute break (Biwer et al., 2023). After completing four Pomodoros, clients take a longer break of 15 to 30 minutes. This method not only makes tasks feel more manageable but also helps sustain attention and reduce distractions. By creating a structured approach to work, the Pomodoro Technique allows clients to cultivate a rhythm that can enhance productivity and concentration. 

Additionally, this technique promotes a sense of accomplishment as clients complete each interval, reinforcing positive behavior and making it easier to tackle larger tasks over time. The regular breaks also provide opportunities for clients to engage in self-care or relaxation, further reducing feelings of stress and anxiety that can often hinder their progress (Gnanavel et al., 2019). Implementing the Pomodoro Technique can be a powerful tool for fostering time management skills and improving overall task initiation. 

Impulsivity Control

Enhancing impulse control, particularly when it comes to making unhealthy choices during times of distress or dysregulation, is essential for recovery. Interventions aimed at improving impulse control involve teaching clients mindfulness techniques to help them pause and reflect before acting on their impulses (Zylowska et al., 2008). Incorporating games and activities that promote impulse control, such as Jenga and Simon, can also significantly aid in fostering self-regulation. Lastly, cognitive-behavioral strategies can be utilized to help clients identify and challenge the thought patterns that contribute to impulsive decisions. 

Emotional Regulation

Improving emotional regulation is crucial for reducing ADHD symptoms and minimizing substance use behaviors. Difficulty in managing emotions effectively can result in increased stress, strained relationships, and other life challenges, all of which can potentially contribute to relapse. Teaching clients techniques like sensory modulation strategies, deep breathing exercises, and coping skills can empower them to manage their emotions more effectively. Incorporating expressive arts, such as drawing or painting, or physical activities, such as exercise, can also serve as healthy outlets for emotions (Hasegawa et al., 2017).

Working Memory 

Deficits in working memory significantly affect a person’s ability to engage in daily life. Difficulties in short-term memory can lead to issues such as forgetting important appointments, mismanaging medication schedules, or failing to recall coping strategies during stressful situations, all of which can increase the risk of relapse. To address this area, therapists implement memory aids, such as written reminders or digital apps, that assist in retaining important information and instructions. Training in mnemonic devices and visualization techniques can also enhance memory recall (Martin & Marsh, 2009). 

Additionally, engaging in mindfulness practices has been shown to enhance short-term memory. Research indicates that mindfulness can improve cognitive functions, including memory retention and recall abilities, by promoting focused attention and reducing distractions (Zeidan et al., 2010; Killingsworth & Gilbert, 2010).

Self-Monitoring 

Self-monitoring skills are important because they help individuals notice how they are doing and make changes to their behavior when needed. Clients often benefit from learning how to evaluate their performance on tasks and reflect on their emotions and thoughts throughout the process. Journaling or using mobile apps can facilitate self-reflection by allowing individuals to document their thoughts, feelings, and experiences regularly. 

For example, someone might use a journal to reflect on their daily challenges and successes, helping them identify patterns in their behavior over time. Similarly, mood tracking apps can encourage clients to log their emotions throughout the day, providing insights into triggers for anxiety or stress. This process of self-reflection can lead to more effective self-regulation, as they become more aware of their emotional responses and can devise strategies to manage them (Barkley, 2015).

Comprehensive Assessment and Goal Setting

To help clients enhance their executive functioning skills, the process begins with a thorough assessment aimed at identifying both strengths and weaknesses. This assessment is crucial, as it not only reveals specific executive functioning deficits but also ensures that the interventions used are relevant and effective. Without a comprehensive evaluation, important areas of need may go unrecognized, resulting in interventions that do not adequately address the client’s deficits. Standardized tools, interviews, and observations provide valuable insight into how these limitations impact daily life engagement. Once the assessment is complete, establishing goals collaboratively is essential. This process empowers clients to choose goals that are meaningful to them, fostering a sense of ownership in their recovery journey. 

By creating a collaborative environment, clients are more likely to make significant progress. This tailored approach not only addresses specific challenges associated with ADHD and substance use disorders but also promotes a greater sense of agency and self-efficacy. When clients feel that their needs are understood and prioritized from the start, they are better equipped to engage in the therapeutic process and achieve lasting change.

Key Points

The significant connection between ADHD and substance use disorders presents unique challenges that require a comprehensive approach to support sustainable recovery. Addressing executive functioning skills — such as organization, time management, impulse control, and emotional regulation — is essential for individuals with these dual diagnoses. By focusing on enhancing these skills, individuals in recovery can learn how to manage their daily lives more effectively and navigate the complexities associated with both ADHD and substance use.

Recognizing the specific needs of individuals with this dual diagnosis is crucial for developing effective treatment strategies. Tailored interventions that target executive functioning can lead to improved recovery outcomes and a better overall quality of life. A holistic focus on these skills not only helps individuals address the symptoms of ADHD but also empowers them to take control of their lives, establish meaningful goals, and create a sustainable path toward lasting recovery.