Comorbid conditions and complex symptom presentations can make the diagnosis and treatment of ADHD patients challenging. Clinical experts Jess Brunet, Penny Lazell, Matt Tutt, and Amy Sara discuss what it means to have clarity in complex cases across the patient lifespan. In this episode of the Rethinking ADHD Podcast, they share their experiences with common ADHD co-occurrences. This includes substance misuse, trauma, and how solutions like objective testing and multidisciplinary team approaches to care can help.
Co-occurring ADHD and Substance Use Disorder
What clinicians need to know
Patients with ADHD have a much greater risk of substance misuse disorders than the general population. Clinicians may observe drugs and alcohol used to regulate emotions or causing dopamine seeking or impulsive behaviors. Amy Sara, Clinical Advisor, shares her experiences working with ADHD patients who had a history of substance misuse.
“9 times out of 10, it was always just to feel normal, being able to function and do normal things that most people are able to do without drugs. This is the reason why they take it, to regulate their emotions and give them that reward effect that people with ADHD don’t have.”
When you see patients with SUD, it can be difficult to differentiate drug side effects from ADHD symptoms. During a clinical interview, it can help to focus on how patients feel when not using drugs, and what their behaviors and mental state were like before substance misuse.
Parents or partners may be able to provide feedback on whether ADHD symptoms appeared before the onset of substance use in adults.
Does ADHD increase vulnerability to criminal exploitation?
Individuals with ADHD may be at increased risk of exploitation, grooming for County Lines involvement, and entry into gang culture, according to our panel. Impulsivity traits and impaired decision-making, according to their discussion, could contribute to exploitation risk. Evidence of this may be identified during clinical interview if patients describe social interactions that indicate they are vulnerable to criminal influence.
“That instant gratification or adrenaline, of being vulnerable to this criminal culture, is something that we need to keep in mind.”
Is it ADHD or trauma?
Understanding symptom overlap
Trauma and ADHD can often overlap or may present similarly in patients.
Trauma during developmental phases can have a physical impact, impairing frontal lobe development. This can affect a patient’s ability to manage impulsivity and emotional regulation. However, these symptoms can also present in a patient with ADHD.
Why is it difficult to distinguish trauma and ADHD? Our experts tell us that trauma is often thought of as a singular major event. However, a buildup of smaller traumas can have just as significant an impact on someone's behavior.
Regular house moves, changes in family dynamics, and perceived threats within the home can all lead to traumatic outcomes. Unfortunately, these smaller cumulative traumas may not be identified or recognized by patients to the extent that they would discuss them during an assessment.
How can you distinguish ADHD and trauma symptoms in patients?
As ADHD and trauma symptoms can often overlap, you need to pay attention to nuances in how symptoms present during assessment, says Jess. The difference between ADHD symptoms vs trauma symptoms is that there’s often a switch with trauma symptoms, even if it’s been a small buildup.
A patient may present as inattentive and appear not to be listening. However, this may be a dissociative trauma response, rather than an ADHD symptom. Jess Brunet shares further insights on the subtle clues that differentiate dissociation and inattention or mind-wandering –
‘Dissociation presents slightly differently from mind-wandering. With mind-wandering, you're on a thread, and you start thinking about something else, like “What am I going to have for dinner?” Dissociation seems to be more of a blank, like "I’m physically in the room, but my brain has shut down to protect me."
Differential diagnosis of ADHD and comorbid conditions
The role of objective testing and technology
Penny Lazell, Senior Clinical Advisor, highlights that in complex cases, the data from an objective test like QbCheck can help differentiate between conditions and guide clinicians in identifying what questions to ask during clinical interview:
“The use of objective testing can quite often pull out these other nuances, which can then support you in raising those questions to ask. Particularly with dysregulation, we can often see that on objective testing. We can then think, why is this person showing up as though they’re dysregulated, and maybe start asking those other questions. We’re seeing something that’s maybe in addition to ADHD; perhaps there’s a question we need to dig a little bit deeper.”
Are there links between ADHD and physical health?
ADHD is a neurodivergent condition, so it’s often thought of purely in terms of mental health. However, there can be strong links between ADHD and a patient’s physical health.
The panel highlights how ADHD has been linked to issues with diet, obesity, binge eating, and an increased risk of Type II diabetes. ADHD traits such as impulsivity may lead to compulsions to eat, while inattentiveness may lead to forgetting to eat or prepare food. There can also be strong connections with disordered eating as a form of emotional regulation.
“When we consider those co-occurring needs where the impulsivity is ‘I need to eat now.’ If we’re thinking about food or eating disorders, it’s more difficult to turn that off if ADHD is also part of the picture. It’s very easy to be very impulsive, or even forgetful, if we think about some of the executive functioning.”
Matt Tutt and Jess Brunet share their experiences from working with ADHD patients, where there are impacts on physical health. Jess notes that clinicians quite often identify lower iron levels, particularly low ferritin levels, which can be linked to ADHD. This may worsen inattentiveness and restlessness.
ADHD, physical and sexual health:
What clinicians can do to improve patient care
When assessing patients for ADHD, questions around physical health and even sexual health often don’t come up. However, we know that there are strong links. For example, ADHD patients may have different experiences of sex and relationships. They may act impulsively, and potentially these behaviors could lead to increased risk of teenage pregnancy, less safe sex, and STIs.
When assessing patients, taking a more holistic approach to their health and experiences may identify some important behaviors that can help with diagnosis. You can ask about diet, sex and relationships. Additionally, inquire about interactions with GPs, and whether they have regular check-ups.
The discussion mentions opportunities for closer working with other agencies and co-production of services, like linking with sexual health services, for example.
The future of ADHD assessment:
Integrated, needs-led, and multidisciplinary
The challenges of diagnosing and treating complex ADHD cases require all of us working in the field to start thinking and working differently. The ADHD Taskforce is already considering digital approaches and developing a more structured, detailed ADHD assessment process.
There are also opportunities around multidisciplinary teams. More GPs are engaging with ADHD diagnosis, and ADHD is increasingly moving into primary care in some health services.
Jess Brunet discusses her experience of working in an MDT, which included speech and language therapists and occupational therapists. She found that their perspectives helped the team adopt a more holistic approach to ADHD. There is real opportunity in strengthening the relationship with GPs. They have greater insights into a patient’s overall and physical health, she adds.
“That feels like a really powerful stance to broaden our multidisciplinary team to meet the needs of our patients. But also, when we’re thinking about complexity, we’re not waiting for the referral to the specialist service. We’re getting insight at each point along the way.”
A strong vision for the future of ADHD care is a needs-led approach. Patients interact with experts throughout their journey, rather than being referred to a specialist and waiting on a list for support.
“If we can empower people to access, through digital tools or waitlist initiatives, earlier intervention, by the time they’ve been on their waitlist for ADHD—which we understand is long in the UK at the moment—the problem is not so chronic that the individual’s symptoms become exacerbated and worse because they’ve not been treated at any point in that journey.”
The clinician’s role in shaping the future of ADHD care
The panel concluded their discussion by reflecting on the role of clinicians in managing complexity through system change, adopting a more holistic approach, and strengthening multidisciplinary teams. Clinicians can drive change by working “with our primary care colleagues, our sexual health colleagues, our dietitian colleagues. Additionally, consider the person as a whole to empower them, have the right care plan for their symptoms.”
Never miss clinician insights on diagnosing ADHD, comorbidities, and the future of ADHD care.
Key takeaways from the podcast
- ADHD in complex cases often involves comorbidities such as trauma, substance use, and physical‑health issues, all of which can complicate accurate assessment
- Trauma vs ADHD differentiation requires attention to dissociation, which presents as a “blanking out” rather than ADHD‑related mind‑wandering
- Validated, objective ADHD technology improves diagnostic safety by providing standardized, quantitative data to support clinical decision-making
- Objective ADHD testing helps identify dysregulation patterns, supporting clearer differential diagnosis in patients with overlapping symptoms
- Physical and sexual health concerns are common in ADHD, including diet‑related issues, low iron levels, impulsive sexual behavior, and increased risk‑taking
- Multidisciplinary, needs‑led ADHD assessment models improve outcomes, integrating GPs, therapists, and specialists to provide holistic patient care