How should I diagnose and manage adult combined‑type ADHD in a 36‑year‑old woman, one month sober from long‑standing Alcohol Use Disorder, currently taking oral naltrexone, with symptoms starting at age 10 and causing impairment at home, work, and socially?

Diagnosing and Managing ADHD in a Patient with Recent Alcohol Use Disorder

Defer ADHD Diagnosis Until Sustained Sobriety

You should wait at least 3–6 months of sustained sobriety before making a definitive ADHD diagnosis, because chronic alcohol use produces cognitive and executive function deficits that are clinically indistinguishable from ADHD symptoms. 1

Why Waiting is Critical

• Alcohol use disorder causes neurobiological changes that mimic ADHD inattention, impulsivity, and executive dysfunction—symptoms that may resolve with sustained abstinence 2
• At one month sober, your patient's brain is still recovering from years of around-the-clock alcohol exposure; cognitive symptoms at this stage cannot reliably distinguish true ADHD from alcohol-induced impairment 2
• The collateral from her spouse describes current symptoms, but these observations occurred during active drinking or very early recovery when alcohol's neurotoxic effects persist 1
• Her mother reported "nothing, was completely normal" for childhood symptoms, which directly contradicts the DSM-5 requirement for clear evidence of impairment before age 12 1, 3

The Diagnostic Dilemma You Face

• Approximately 10% of adults with recurrent substance use disorders have comorbid ADHD, making the overlap clinically significant 1
• However, ADHD is also highly attributable to substance use—meaning untreated ADHD increases addiction risk, but active addiction also produces ADHD-like symptoms 1
• Your patient's childhood history is weak: she reports mild symptoms at age 10, but her mother (the most reliable childhood informant) denies any impairment 1, 3
• The spouse's collateral describes adult symptoms during active alcoholism, which cannot establish childhood onset 1, 3

What to Do Right Now (Month 1 of Sobriety)

Continue Addiction Treatment as Priority

• Keep her on oral naltrexone and engaged with her recovery program—this is your primary intervention. 2, 4, 5
• Naltrexone reduces heavy drinking days and supports abstinence; optimizing AUD treatment may resolve many "ADHD" symptoms as her brain heals 4, 5
• Combined behavioral intervention plus medication management (what she's receiving at her program) shows superior outcomes for AUD 2

Conduct Provisional ADHD Screening Without Committing to Diagnosis

• Administer the Adult ADHD Self-Report Scale (ASRS) Part A and Part B to document her current symptom burden 1, 3
• Use the Weiss Functional Impairment Rating Scale–Self (WFIRS-S) to quantify impairment in household tasks, work, and social domains 1, 3
• Document these baseline scores but explicitly tell the patient you cannot diagnose ADHD until she achieves sustained sobriety 1, 3

Obtain Better Childhood History

• Request childhood report cards, school records, or teacher comments to corroborate (or refute) childhood ADHD symptoms 1, 3
• Re-interview her mother with specific DSM-5 symptom questions (not just "was she normal?")—ask about talking during class, parental frustration with listening, difficulty focusing at home 1, 3
• Have her spouse complete the Conners' Adult ADHD Rating Scale–Observer Report (CAARS-O) to provide structured collateral data, but note this reflects her functioning during active drinking 1

Screen for Psychiatric Mimics

• Rule out major depressive disorder, bipolar disorder, anxiety disorders, personality disorders (especially borderline), and sleep disorders—all of which produce inattention and executive dysfunction. 1, 3
• Approximately 10% of adults with recurrent depression have ADHD, but depression alone causes concentration problems that resolve with mood treatment 1
• Substance-induced mood and anxiety symptoms are common in early recovery and may take months to clear 2

The 3–6 Month Sobriety Checkpoint

Reassess Symptoms After Sustained Abstinence

• At 3–6 months sober, repeat the ASRS and WFIRS-S 1, 3
• If her impulsivity, procrastination, phone scrolling, and task initiation problems persist unchanged despite sobriety, this supports a true ADHD diagnosis 1, 3
• If symptoms improve significantly with sobriety alone, they were likely alcohol-induced cognitive deficits, not ADHD 2

Establish DSM-5 Criteria Rigorously

• For adults ≥17 years, you need at least 5 symptoms from either inattentive or hyperactive-impulsive categories, present for ≥6 months, causing impairment in ≥2 settings, with onset before age 12. 1, 3, 6
• The childhood onset requirement is non-negotiable: without documented impairment before age 12 (from report cards, parent interviews, or school records), you cannot diagnose ADHD per DSM-5 1, 3
• Her mother's denial of childhood problems is a red flag—pursue objective childhood documentation before proceeding 1, 3

If ADHD Diagnosis is Confirmed After Sustained Sobriety

First-Line Treatment: Stimulants with Caution

• Stimulants (methylphenidate or lisdexamfetamine) are first-line for ADHD, achieving 70–80% response rates, but require extreme caution in patients with substance use history. 2, 1, 7
• Use long-acting formulations (Concerta, Vyvanse) that have lower abuse potential and are resistant to diversion 7
• Start low (e.g., methylphenidate 18 mg OROS or lisdexamfetamine 20–30 mg) and titrate slowly with weekly follow-up 2, 1, 7
• Implement urine drug screening at every visit to monitor for relapse and ensure medication adherence 1

Alternative: Non-Stimulant First-Line (Safer for AUD History)

• Atomoxetine (60–100 mg daily) is the safest first-line option for ADHD with substance use history because it has zero abuse potential. 1, 7, 6
• Atomoxetine requires 6–12 weeks for full effect (much slower than stimulants) but avoids relapse risk 1, 7, 6
• Alpha-2 agonists (guanfacine 1–4 mg or clonidine) are additional non-controlled options, especially if sleep disturbances persist 1, 7

Multimodal Treatment is Essential

• Combine any ADHD medication with cognitive-behavioral therapy specifically designed for adult ADHD—medication alone is insufficient. 1, 7
• Continue her addiction recovery program alongside ADHD treatment; stopping AUD treatment to focus on ADHD would be catastrophic 2
• Psychoeducation about ADHD, organizational skills training, and behavioral interventions improve outcomes beyond medication 1

Common Pitfalls to Avoid

• Do not start stimulants at 1 month sober—you risk triggering relapse and cannot distinguish ADHD from alcohol-induced deficits this early 2, 1
• Do not diagnose ADHD based solely on adult symptoms and spouse collateral without objective childhood evidence 1, 3
• Do not assume bupropion will treat both depression and ADHD—no single antidepressant is proven for dual treatment 7
• Do not prescribe benzodiazepines for anxiety in this population—they reduce self-control and have disinhibiting effects 7
• Do not ignore the weak childhood history—her mother's report of "completely normal" contradicts her self-report and requires resolution 1, 3

When to Refer to Psychiatry

• If she relapses to alcohol use while pursuing ADHD evaluation 1, 3
• If you confirm ADHD and need to prescribe stimulants but feel uncomfortable managing addiction + ADHD simultaneously 1, 3
• If she develops new psychiatric symptoms (mania, psychosis, severe depression) during early recovery 1, 3
• If childhood history remains unclear after exhaustive collateral gathering and you cannot meet DSM-5 onset criteria 1, 3