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Introduction
The
article "Pathways to Pathological Gambling: Identifying Typologies"
(Blaszczynski, 2000) in the first issue of the Electronic Journal of
Gambling Issues suggests that there are three main subgroups of problem
gamblers: (1) "normal," (2) emotionally vulnerable and (3) biologically-based
impulsive gamblers. This last group consists of individuals who, due to
the presence of neurological or neurochemical dysfunction, are impulsive
and/or have difficulty sustaining attention.. Blaszczynski outlines evidence
suggesting that neurological differences are precursors to problem gambling.
Attention-deficit hyperactivity disorder (ADHD) is one particular condition,
which is often present in the third subgroup of problem gamblers.
There
is no question that a percentage of clients who seek treatment for problem
gambling have symptoms of ADHD. Specker, Carlson, Christenson and Marcotte
(1995) found that 20% of pathological gamblers studied met the criteria
for ADHD. Clinical experience suggests that at least this number are triggered
to gamble by impulses and issues related to this disorder. This article
will explore the interface between ADHD and problem gambling through case
studies, with a focus on identification and treatment.
What Is ADHD?
ADHD,
according to the Diagnostic and Statistical Manual — fourth edition
of the DSM-IV (American Psychiatric Association, 1994), is the most common
psychiatric disorder in childhood, with three main impairing symptoms:
impulsivity, inattention and motor hyperactivity. Motor activity tends
to subside by adulthood, although an individual may present as restless
and fidgety. Some outcome studies (Barkley, 1990; Weiss & Hechtman,
1989) suggest that ADHD is robust into adulthood with a prevalence rate
around 3% to 5% of all adults.
Common
symptoms and characteristics in adults with ADHD include low self-esteem,
underachievement, poor concentration, lack of organization, impulsive
behaviour, emotional lability, chronic boredom, and interpersonal relationship
problems.. Impulsivity is a central feature of the disorder and seems
to result from disruptions in the brain’s inhibitory control processes.
Individuals
with ADHD have difficulty maintaining adequate levels of stimulation in
some brain centres. They apparently compensate for this by having a heightened
sensory arousal system that draws in more information than usual from
the environment and tends to process it indiscriminately. This results
in distractibility, racing thoughts and a scattered presentation. Individuals
act impulsively on sensory information before they consider consequences.
They also seek out novel or changing stimulation from the environment
and without such stimulation they are easily bored. When they engage in
this type of activity, and gambling is a good example, they tend to become
excessively involved to the point of hyperfocus and the exclusion of other
stimuli. Novelty seeking and high exploratory behavior, as in gambling
and ADHD, can be akin to self-medication for a low mood state.
Case examples
Case
examples may illustrate some of the ways in which ADHD interacts with
problem gambling. These individuals all present somewhat differently,
but they typify the issues found in clients with ADHD: (Note: Client names
and identities have been changed.)
James, a 32-year-old man, related a story of lifelong underachievement,
inability to sustain attention, frequent job changes and susceptibility
to boredom. The difference between his abilities and his actual accomplishments
was frustrating, depressing and continuous. He was about to embark
on another attempt at a new career, but he reflected pessimistically
on his inability to follow through and attend classes. He noted that
his mind raced from one thing to another, making it difficult for
him to focus on tasks. Throughout his school history he had struggled
with boredom, had trouble focusing on reading and had a tendency to
bother other children. James saw gambling as his only area of achievement
since high school. Generally, he managed to make money at it, usually
by hustling at poker.
Ryan, a single man aged 27, reported only a six-month history
of problem gambling with a rapid financial decline. He was a bright,
high-energy individual, with a great deal of drive and creativity,
particularly around initiating new projects. However, he was so disorganized
and bored with detail that he was poor at following his projects through
to completion. He developed a business that was initially very successful
until he won $25,000 at a casino, lost it within two weeks and began
to gamble $1000 a week. Ryan described himself as having ADHD and
wanted to address the resulting disorganization and impulsivity.
Eve, a 57-year-old divorced woman, had a long history of problem
gambling, depression, mood swings and difficulties in concentrating
and making use of her considerable talents. Her extremes of mood and
her feelings of vulnerability caused serious relationship difficulties
and often left her living from one emotional crisis to another. Although
well able to be intensively introspective on personal philosophy and
psychological issues, at times she had great difficulty accomplishing
day-to-day tasks. She went to bingo or casinos on impulse when depressed
or upset and had failed to be consistent in her long-term plan to
avoid all gambling.
Jack, a 48-year-old married man, presented as restless, talkative,
and impatient when others were speaking. He changed subjects frequently.
Jack described himself as "scattered" and somewhat depressed.
He had poor self-esteem. He had had an alcohol problem off and on
and had started gambling in his teens – it supplied "action"
when he was bored. (His initial experiences with gambling was so exciting
that he described it as "what he had been waiting for all his
life.") His marriage was in trouble due to these and other problems,
and his wife had asked him to get help. His occupational history was
unstable. Jack quit gambling when he entered treatment but his resultant
boredom increased the depression he was already experiencing. His
fights with his wife intensified. Although relieved that he was not
gambling, she complained of Jack’s mood swings and his intense,
negative persistence when angry.
ADHD and Problem Gambling: Clinical Issues
The depression overlap
Poor
self-esteem and depression are extremely common in people with ADHD. Their
poor performance and their impulsive behaviour often baffle them and those
around them and may be attributed to lack of will or laziness. Constant
disapproval and negativism from others creates a sense of failure. Symptoms
of chronic boredom or an "I don’t care" attitude are consistent
with the learned helplessness model of depression. A lack of stimulation
can lead to depression in individuals with ADHD.
Gambling
is an antidote to depression. The variable stimulation it provides is
exciting and challenging, which can lead to intense over involvement in
the activity. An appearance of success, at least in the short term, counters
feelings of failure and depression. Exaggerated levels of confidence (i.e.,
feelings of omnipotence or an "I can’t lose" mentality)
are common in this population of gamblers and are highly rewarding. Such
feelings provide escape from a life in which lack of control and failure
are common experiences. Arguably, gambling by a person with ADHD could
be seen as an attempt to self-medicate.
Personality issues
ADHD
of the hyperactive-impulsive or combined subtypes seems to have a connection
with the dramatic cluster of personalities (Jain, 1999). There is a strong
tendency to antisocial, narcissistic, histrionic and borderline personalities.
Inherently, these personalities have a common feature of being self-centred,
superficially omnipotent, though with fragile coping strategies. Interpersonal
issues around trust, abandonment, rejection and attachment are constant
factors. There are issues around emotional isolation and lack of empathy
for others. When these personality issues exist, the act of gambling may
be a self-serving and destructive behaviour with grave consequences for
an individual’s loved ones and associates.
However,
it is important to note that not all individuals with ADHD behave destructively
or experience chronic failure, as symptoms vary in severity. Gambling
counsellors are familiar with the extroverted, optimistic, somewhat egocentric,
somewhat impulsive client who is highly focused on the present and does
not worry much about past gambling losses or future plans. These clients
often have a great deal of success in their lives, including a loving,
if exasperated, family. They may be more vulnerable than average to developing
addictions or other problems but they have compensating resources and
skills. Such clients appear to have milder forms of ADHD. Blaszczynski
(2000) describes impulsive gamblers as having many antisocial features;
however, a client who physiologically tends toward impulsivity is not
necessarily antisocial.
Identification and Intervention
Checklists
available in self-help manuals can be helpful in identifying clients with
ADHD. There are also longer screens available (e.g., Brown, 1996). It
helps to take a developmental history with collateral information. At
the Centre for Addiction and Mental Health, 62% of all referrals to the
adult ADHD clinic were parents of children who had been recently diagnosed
with ADHD. Therefore, it is worth asking gambling clients about their
children’s behaviour, or indeed, about any family history of learning
or impulsivity problems.
Education
When
working with clients that have gambling problems with concurrent ADHD,
the first strategy is always education. Of the four clients described
above, only one had been diagnosed with ADHD as a child and yet all four
had suffered years of frustration and failure. It was extremely helpful
to discuss the possibility of a neurochemical basis for some of their
experiences and to give them information about ADHD. The central issue
for these individuals was the sense that some of their impulses, thoughts
and feelings were simply out of their control in ways that outward circumstances,
history, and so forth were insufficient to explain. It was a tremendous
relief for them to have an explanation that validated their perceptions
and one that offered more effective solutions than they had found to date.
Case studies continued
James
was referred to a specialist, and was diagnosed as having the disorder.
He was prescribed both stimulants and fluoxetine (Prozac). The results
were dramatic. James found he was able to concentrate and learn steadily
for the first time in his life. He was able to continue with his course,
organize himself and plan ahead. His interest in gambling faded and he
noted that he was much less impulsive in other ways as well. His self-esteem
improved markedly.
Jack
finally agreed to an assessment for ADHD at his wife’s insistence.
He was diagnosed and placed on stimulant medication. He experienced greatly
improved levels of concentration. His relationship with his wife improved,
as he was able, at least sometimes, to listen, to react more calmly to
stress and to think before he acted. They began to work more successfully
on managing their finances together. His impulses to gamble lessened,
particularly as he experienced more success in other areas of his life.
Ryan
was not unhappy with his high-energy, creative approach to life. He was
interested, however, in acquiring some help in staying organized. He began
looking for a business partner who could provide the solid backup and
attention to detail that would complement his own vibrant salesmanship.
He was not concerned that he would gamble again because he was experiencing
no urges. Typical of the overly optimistic segment of this population,
he tended to focus on his immediate experiences rather than on any examination
of the past or anticipating problems in the future. Thus, he had no interest
in relapse prevention efforts.
A
lengthy counselling process was necessary with Eve who was preoccupied
with her internal processes and had difficulty focusing on behavioural
change. She finally attended an assessment with an ADHD clinic and was
given a trial of Ritalin (methylphenidate). She noted that she could tolerate
more stress without becoming reactive. She had to go off Ritalin for medical
reasons, and began to look at antidepressant medications instead to address
both her depression and her ADHD. Cognitive-behavioural strategies were
somewhat successful in reducing her gambling binges. Interestingly, focus
on her emotional issues tended to make her feel worse as she would become
overly focused on her current misery. Like Jack, Eva tended to perseverate
on negative feelings, elaborating and catastrophizing until she was exhausted.
Changing the focus, although difficult, often helped her to gain some
distance from her problems, and thus, deal with them more effectively
through behavioural strategies.
Eve
and Ryan typify two common, contrasting temperamental characteristics:
one was highly ruminative and steeped in negativity, and the other was
positive in outlook, no matter what the circumstances, and uninterested
in the past or the consequences of his actions. Both had a characteristic
affective response at either end of the continuum. Although life history
may play a part in such characteristics, neurodevelopmental precursors
are also likely. Helping individuals to see the other side of the seesaw
is usually achievable.
Medical intervention
It
is vital that a doctor who specializes in this area investigate concerns
about ADHD. Self-diagnosis and self-medication are to be discouraged.
Connecting to ADHD clinics may not be easy but they are available by referral
from family doctors. A minimal assessment should involve a psychiatric
interview to exclude other disorders, self-report questionnaires that
establish a threshold for including ADHD as a diagnosis, a collateral
history to establish childhood symptoms and some assessment of functioning
to establish impairment in various domains.
Individuals
with ADHD often seek medical treatment. Stimulants such as Ritalin are
often the treatment of choice to address impulsivity. For depression,
the addition of a serotonin-based medication is likely. Of course, careful
monitoring and an evaluation of the efficacy of this intervention are
indicated.
Other intervention approaches
The
many emotional issues resulting from a history of ADHD cannot be resolved
simply by identifying a neuropsychological disorder, even if treatment
is successful. Therapy in either individual or group settings can help
resolve some of these issues and help the person move forward. Groups
are particularly valuable as they give a person the opportunity to share
experiences and cognitions that previously may have seemed unique to the
individual. Due to their interpersonal relationship problems and a lack
of internalized structure, a therapeutic relationship that based strongly
in cognitive-behavioural strategies is helpful. More importantly, the
therapeutic alliance may be critical in helping clients with ADHD achieve
a sense of security and trust that was missing in their childhood.
There
are many ways to manage the symptoms of ADHD, apart from or in addition
to medication, which address the specific nature of the problem. Self-help
manuals and Web sites offer many techniques that can help someone with
ADHD function more effectively. Suggestions include strategies such as
reducing distractions, keeping lists and notes, and finding ways to make
tasks stimulating. Some people find mentors to help them organize each
day.
Gamblers
need to acknowledge their requirements for stimulation and challenge and
find new avenues to achieve them. Specific day-by-day planning can reduce
their vulnerability to impulsive behaviour. They can benefit from practice
controlling their impulses, starting with life areas easier to handle
than gambling urges. For instance, one client characteristically rolled
through stop signs. He took up the suggestion to come to a full stop each
time and practiced this new way of driving. He found that the learning
generalized; he was more able to pause and think before acting.
As
mentioned above, impulsive individuals may never have developed the circuitry
to effectively say "no" to impulses. Even average individuals
(such as Blaszczynski’s "normal" subgroup) can experience
deterioration in the inhibitory circuitry if they do not use it. It is
not unusual to see gamblers with a good previous history of self-control
having difficulty dealing with their impulses after a long period of self-indulgence.
Gamblers with ADHD have obeyed innumerable impulses; this habit would
be hard to break even if their inhibitory processes had originally been
strong. These clients can benefit from changing any habit; the learning
will likely carry over to other areas, and it can be used in the counselling
process to promote self-efficacy.
Additional resources
There
are organizations offering education and support such as the national
chapter of Children and Adults with Attention Deficit Disorder (CHADD)
and the local support group Attention Deficit Disorder Organization (ADDO).
The ADDO has monthly meetings for adults as well as for parents of children
with the disorder. There are over 44,000 Web sites on the topic of ADHD,
which can be overwhelming, however, it is a useful forum to deal with
some issues. Popular texts on the subject include Driven to Distraction:
Recognizing and Coping with Attention Deficit Disorder from Childhood
Through Adulthood (Hallowell & Ratey, 1996) and You Mean I’m
Not Lazy, Crazy or Stupid?!: A Self-Help Book for Adults with Attention
Deficit Disorder (Kelly & Ramundo, 1995). Centres that offer resources
on learning disabilities can be helpful with referrals and materials.
References
American Psychiatric Association. (1994). Diagnostic and Statistical
Manual of Mental Disorders (4th ed.). Washington, DC: Author.
Barkley, R.A. (1990). Attention-Deficit Hyperactivity Disorder: A
Handbook for Diagnosis and Treatment. New York: Guilford Press.
Blaszczynski, A. (2000, March 13). Pathways to pathological gambling:
Identifying typologies. Electronic Journal of Gambling Issues [On-line
serial], 1. Available: http://www.camh.net/egambling/feature/
Brown, T. (1996). Attention Deficit Disorder for Adults. San Antonio,
TX: The Psychological Corporation.
Hallowell E.M., Ratey J.J. (1996). Driven to Distraction: Recognizing
and Coping with Attention Deficit Disorder from Childhood Through Adulthood.
New York: Pantheon Books.
Jain, U. (1999, October 16). Personality characteristics in adult ADHD.
Paper presented to the American Academy of Child and Adolescent Psychiatry,
Chicago, IL.
Kelly, K. & Ramundo, P. (1995). You Mean I'm Not Lazy, Crazy or
Stupid?!: A Self-Help Book for Adults with Attention Deficit Disorder.
New York: Scribner.
Specker, S.M., Carlson, G.A., Christenson, G.A. & Marcotte, M. (1995).
Impulse control disorders and attention deficit disorder in pathological
gamblers. Annals of Clinical Psychiatry, 7(4), 175—179.
Weiss G. & Hechtman L. (1986). Hyperactive Children Grown Up:
Empirical Findings and Theoretical Considerations. New York: Guilford
Press.
Submitted May 31, 2000
Accepted June 21, 2000
Nina Littman-Sharp is the manager of the Problem Gambling Service
of the Centre for Addiction and Mental Health. She has worked in addictions
for 14 years and with gamblers for six. Nina is involved in a wide variety
of clinical, research, training, outreach and public education efforts.
She presents and writes on a number of topics, including strategies for
change and relapse prevention, couples work and on the Inventory of Gambling
Situations, an instrument which assesses areas of risk for relapse. Nina
is recognized as a Certified Gambling Counsellor and Supervisor by the
National Council on Problem Gambling based in Washington, D.C.
Dr. Umesh Jain is the Head of the Adult and Adolescent ADHD Program,
director of the Children’s Medication Clinic and Staff Psychiatrist
at the Centre for Addiction and Mental Health, Clarke site. He is an Assistant
Professor of Psychiatry at the University of Toronto and is completing
his PhD at the Institute of Medical Sciences. Dr. Jain is a nationally
recognized scientist in this area with his media appearances, publications
and numerous presentations. Dr. Jain was the Scientific Head of the Organizing
Committee of the Canadian Academy of Child Psychiatry (1997—1998)
and a past member of the scientific boards of the Canadian and American
Academies of Child Psychiatry.
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