Co-Occurring Disorders in Adolescents
It is estimated that between 60 to 75 percent of adolescents with mental health and/or substance abuse issues have co-occurring disorders. Commonly documented co-occurring disorders include conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, anxiety, post-traumatic stress disorder, and substance dependence. This co-occurrence exacts a heavy toll on adolescents and their families.
This course will explore the prevalence, warning signs, specific disorders, the role trauma plays, treatment options, and school-based supports.
Mental health and substance issues seem to go hand in hand with adolescents. There is always much speculation about what presents first in the youth’s life, substance use, or mental health challenges. It can happen either way and what we do know is that undiagnosed mental health problems can lead to self-medicating with substances.
- Youth who experience a major depressive episode were twice as likely to begin using alcohol or an illicit drug compared to youth who had not experienced a major depressive episode.
- Youth who experienced serious depression were twice as likely to use alcohol as their peers who had not been seriously depressed. Over 29 percent of youth who had not used alcohol previously initiated alcohol use following a major depressive episode within the past year, compared with 14.5 percent of youth who had not experienced a major depressive episode in the past year.
- Similarly, much more youth who had not previously used illicit drugs did so after a major depressive episode. Sixteen percent of youth who had not used an illicit drug in the past year initiated illicit drug use after a major depressive episode, compared with 6.9 percent of youth who had not experienced a major depressive episode in the past year.
Approximately one in every four adolescents meets the criteria for a mental disorder that is associated with severe role impairment and/or distress.
11.2 % with mood disorders
8.3 % with anxiety disorders
9.6 % of behavior disorders
An average of 17% of young people experience emotional, mental, or behavioral disorders.
Substance abuse or dependence was the most commonly diagnosed group of young people, followed by anxiety disorders, depressive disorders, and attention deficit hyperactivity disorder.
The presence of both substance use and mental health concerns places teenagers at risk for a range of problems, from traffic accidents to high-risk sexual behavior and school dropout. The relationship between substance use and externalizing behavior is well-documented, but more attention needs to be paid to the substantial risks created by the co-occurrence of substance use and internalizing disorders. For instance, depression and substance use—particularly in combination—serve as primary risk factors for adolescent suicide.
According to a study published in the Journal of Abnormal Psychology, between 2009 and 2017, rates of depression among kids ages 14 to 17 increased by more than 60%.
The increases were nearly as steep among those ages 12 to 13 (47%) and 18 to 21 (46%), and rates roughly doubled among those ages 20 to 21. In 2017—the latest year for which federal data are available—more than one in eight Americans ages 12 to 25 experienced a major depressive episode, the study found.
Among young people, rates of suicidal thoughts, plans, and attempts all increased significantly as well, and in some cases, more than doubled between 2008 and 2017.
- 13.8 percent reported that they had seriously considered attempting suicide;
- 10.9 percent had planned how they would attempt suicide;
- 6.3 percent reported that they had attempted suicide one or more times within the past year; and
- 1.9 percent had made a suicide attempt that resulted in an injury, poisoning, or an overdose that had to be treated by a doctor or nurse.
Youth from low-income households are at increased risk for mental health disorders:
- Twenty-one percent of low-income children and youth ages 6 to 17 have mental health disorders.
- Fifty-seven percent of these low-income children and youth come from households with incomes at or below the federal poverty level.
Those involved in the child welfare and juvenile justice systems are at even higher risk for having a mental health disorder:
- Fifty percent of children and youth in the child welfare system have mental health disorders.
- Sixty-seven to seventy percent of youth in the juvenile justice system have a diagnosable mental health disorder.
- The risk for mental health problems, especially traumatic stress, is greatly increased for children who are living in foster care as a result of abuse and neglect. Children often suffer from traumatic stress after experiencing or witnessing the injury or death of someone else, or otherwise feeling seriously threatened.
Access to appropriate mental health care is a significant issue. Most of the youth with mental health disorders (75-80%) do not receive services. Whether insured or not, over 75% of adolescents who could benefit are considered to have unmet mental health needs.
Youth with substance use disorders are also under-served, with less than 10% of those who could have benefited from it receiving specialty care.
Over time, numerous terms have been used to describe co-occurring disorders and their treatment.
In the DSM-IV-TR, substance-related disorders are divided into substance use disorders and substance-induced disorders.
Substance use disorders are further divided into substance abuse and substance dependence.
There are 11 categories of substance use disorders (e.g., disorders related to alcohol, cannabis, cocaine, opioids, nicotine), which are separated by criteria into abuse and dependence. The term “substance abuse” has come to be used informally to refer to both abuse and dependence. By and large, the terms “substance dependence” and “addiction” have come to mean the same thing, though debate exists about the interchangeable use of these terms.
Finally, the system of care for substance-related disorders is usually referred to as the substance abuse treatment system.
Substance-induced disorders are important to consider in a discussion of co-occurring disorders. Although they represent the direct result of substance use, their presentation can be clinically identical to other mental disorders. Therefore, individuals with substance-induced disorders must be included in co-occurring disorder planning and service delivery.
Substance abuse, as defined in the DSM-IV-TR, is a “maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances.
Classes of Substance Use Disorders:
Amphetamine or similarly acting sympathomimetics
Phencyclidine (PCP) or similarly acting arylcyclohexylamines
Sedatives, hypnotics, or anxiolytics
Substance dependence is “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems. This maladaptive pattern of substance use includes all the features of abuse and additionally such features as:
- Increased tolerance for the drug, resulting in the need for ever greater amounts of the substance to achieve the intended effect.
- An obsession with securing the drug and with its use
- Persistence in using the drug in the face of serious physical or psychological problems
Substance-induced disorders include substance intoxication, substance withdrawal, and groups of symptoms that are “more than those usually associated with the intoxication or withdrawal that is characteristic of the particular substance and are sufficiently severe to warrant independent clinical attention.
Substance-induced disorders present a wide variety of symptoms that are characteristic of other mental disorders such as delirium, dementia, amnesia, psychosis, mood disturbance, anxiety, sleep disorders, and sexual dysfunction.
To meet diagnostic criteria, there must be evidence of substance intoxication or withdrawal, maladaptive behavior, and a temporal relationship between the symptoms and substance use must be established. Clients will seek care for substance-induced disorders, such as cocaine-induced psychosis, and co-occurring disorder systems must be able to address these conditions.
The National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders created a conceptual framework that classifies clients into four quadrants of care based on relative symptom severity, not a diagnosis. The four quadrants are
- low addiction/low mental illness severity
II. low addiction/high mental illness
III. high addiction/low mental illness
IV. high addiction/high mental illness
The four-quadrant model provides a structure for moving beyond minimal coordination to foster consultation, collaboration, and integration among systems and providers to deliver appropriate care to every client with co-occurring disorders.
Co-occurring mental health and substance use problems have the potential to more strongly influence both life outcomes and treatment for adolescents than either problem alone. Intervention needs to be early.
Findings have revealed that compared to adolescents with substance use disorders only, those with co-occurring disorders:
- Have an earlier onset of substance
- Use substances more frequently.
- Use substances over a longer period
- Have greater rates of family, school, and legal problems
- Have early life issues
Signs and behaviors to look for include, among others:
- Marked fall in school performance
- Poor grades in school despite trying very hard
- Severe worry or anxiety, as shown by regular refusal to go to school, go to sleep, or take part in activities that are normal for the child’s age.
- Frequent physical complaints
- Marked changes in sleeping and/or eating habits
- Extreme difficulties in concentrating that get in the way at school or home
- Sexual acting out
- Depression showed by sustained, prolonged negative mood and attitude, often accompanied by poor appetite, difficulty sleeping, or thoughts of death
- Severe mood swings
- Strong worries or anxieties that get in the way of daily life, such as at school or socializing
- Repeated use of alcohol and/or drugs
Research has revealed that the most common co-occurring diagnoses involve the presence of conduct disorders, mood disorders, and attention-deficit hyperactivity disorders (ADHD). Once a conduct disorder develops, it becomes one of the strongest predictors of progression from experimentation with drugs to the development of a substance use disorder.
One study of co-occurring disorders has shown evidence that 64% (of a sample of 992 adolescents) had at least one co-occurring mental illness, with 59% meeting the criteria for conduct disorder. Fifteen percent (15%) of the sample had depression, and 13% met the criteria for ADHD. Importantly, almost all of those with any form of psychiatric co-occurrence had conduct disorder, with only 5.2% not meeting the criteria for a conduct disorder diagnosis. In substance abuse treatment settings, adolescents with juvenile-onset of bipolar disorders and schizophrenia will also be seen. Although they will not present at the same rates as adolescents with conduct disorder, ADHD, or depression, they must be evaluated fully and treated for their still-evolving mental illnesses.
Described below are some of the most common and most challenging mental health syndromes that co-occur with substance use disorders and are seen in settings treating adolescent populations.
Aggression to people or animals; destruction of property; lying and theft; serious rule violations; bullying or intimidation; initiation of fights.
Associated Issues or Characteristics:
Childhood-onset (before age 10) may have more aggression, a family history of antisocial behavior, and early temperamental difficulties. In males, more evidence of direct behaviors; in females, more relational or ‘indirect’ forms may be observed. Strong association with the development of substance use disorders in adolescence.
Attention-Deficit/Hyperactivity Disorder (ADHD)
Two core categories:
1. inattention (difficulties in sustaining attention, listening, following instructions, attending to details, forgetfulness, impaired organization, and
2. Hyperactivity/Impulsivity (squirming or fidgeting, running and climbing excessively, difficulty in playing quietly, talking excessively.
Associated Issues or Characteristics:
The impairment must be observed in two or more settings; typically diagnosed in school years; features of motor activity may diminish in late adolescence/early adulthood. Consistently found more often in males. Co-occurring association with CD or Bipolar disorder predicts substance use in adolescence. Focus on immediate over delayed gratification may increase substance use risk.
Sad or irritable mood, changes in sleep, appetite, or body movement; not interested in previous activities; guilt or worthlessness, decreased energy; frequent thoughts of death or suicide; difficulty concentrating.
Associated Issues or Characteristics:
Suicide attempts are possible—a loss of interest in activities. Substance use may occur as an attempt to reduce or modify symptom experience or may be associated with peer group influences.
General unhappiness, pessimism, negativity, hypersensitivity to criticism, and dissatisfaction, may be hard to please, always remember feeling this way.
Associated Issues or Characteristics:
The majority of children/adolescents with dysthymia (70%) go on to develop major depression; appears to interfere more with normal development than does major depression.
Cycling of manic and depressive episodes; manic symptoms include irritability and agitation, sleep disturbance, distractibility/ impaired concentration, grandiosity, reckless behavior, and suicidal thought.
Associated Issues or Characteristics:
Presentation in youth may be characterized by ‘very rapid, brief, recurrent episodes lasting hours to a few days; Early-onset appears to have a greater frequency in males; Stronger association with co-occurring substance abuse, anxiety, and CD than with unipolar depression.
Little range of emotion, few facial expressions; poor eye contact, delays in language, unusual motor behaviors, odd speech, both in content and tone; may hear voices, ‘see’ things, problems with abstraction; may demonstrate confusion, suspicion, paranoia; unusual fears; may have few friends or be withdrawn from peers.
Associated Issues or Characteristics:
The onset of the full disorder before age 6-7; difficulty in school functioning may be an early sign; Substance use may facilitate otherwise impaired peer group interactions.
Social trepidation and doubt, bedwetting, anger, frustration, phobias, and physical symptoms such as headaches, chest pain, tummy aches, and fatigue all can be symptoms of anxiety.
Associated Issues or Characteristics:
The average age of diagnosis is between four and eight years old, or around the time a child enters school.
It’s often impossible to say which problem came first. A person may experience anxiety from childhood trauma and turn to drugs to cope, developing an addiction. Someone else may use heroin and have negative experiences that could lead to post-traumatic stress disorder. The important thing is to get help for both problems—drug problems and any other mental health disorders. Treating co-occurring disorders can be challenging because it is difficult to understand how the two impact each other.
Many times in treatment, substance abuse is viewed only as a means of coping with internalized mental health issues. Other times, mental illness is viewed as a risk factor for relapse, as youth with these disorders are considered to be at risk for using substances to cope with both symptoms and consequences of their mental health disorders, including school failure, issues related to self-esteem, and difficulties in peer relationships.
Treatment should address the whole person through integrated treatment that addresses both substance use and other mental health disorders.
As issues begin, early intervention is key to successful treatment. Researchers have found that half of all lifetime cases of mental illness begin by age 14 and that an untreated mental disorder can lead to a more severe, more difficult-to-treat illness, and even to the development of co-occurring mental illnesses. The onset of a mental disorder may precede substance abuse disorder.
- Almost 90% of those with a lifetime co-occurring disorder had at least one mental disorder before the onset of a substance abuse disorder.
- Generally, the mental disorder occurred in early adolescence (median age 11), followed by the substance abuse disorder 5 to 10 years later (median age 21).
- The time between the onset of a mental disorder and a subsequent substance abuse disorder represents an important “window of opportunity” in which a co-occurring disorder may be prevented.
Prevention programming for children who have risk factors for the development of substance use disorders and mental health disorders should be considered as a part of any treatment continuum. The benefit of early intervention may not only forestall or limit the likelihood that mental health disorders will be expressed but also help to derail the development of substance use disorders.
Successful prevention efforts may limit the need for more costly integrated treatment after addictions, and serious mental health disorders have developed. Early intervention strategies, which can be school or community based, should include a focus on:
- Pre-School students: aggressive behavior, poor social skills, academic difficulties
- Elementary School: self-control, emotional awareness, social problem solving, academics (particularly reading)
- Middle/High School: oppositional/defiant behavior, study habits, peer relationships, appropriate assertiveness, drug refusal skills, anti-drug attitudes.
Once significant symptoms of substance abuse or dependence and concurrent mental health disorders emerge, treating adolescents with co-occurring disorders becomes a more complex task. Treatment methods typically will include not only a focus on the individual’s psychological processes through group and/or individual interventions, but will vocational/educational components, and an evaluation of the family and home environment.
Treatment needs for co-occurring disorders need to be focused on:
- Building a strong relationship and motivating clients to attend treatment
- Creating a treatment plan that centers on client-generated goals
- Applying empirically supported treatments, focused on interventions specific to the client’s diagnostic presentation
- Using culturally and developmentally sensitive content
- Focusing on client strengths, with an emphasis on impulse control, communication, problem-solving, and regulation of effect
- Designing goals and objectives focus on change that is sustainable over the long term.
- Monitoring motivation, substance use, and medication compliance, if utilized.
- Increasing intensity if the intended response is not achieved; • Using relapse prevention strategies
- Fostering peer group influences
- Conducting psychoeducation for parents.
Engagement of the family in any intervention is strongly recommended as they offer the possibility of increasing the adolescent’s self-efficacy, can encourage treatment compliance, and are the primary support system for the client.
Treatment modalities frequently used with adolescents with co-occurring disorders include:
- Multisystemic Therapy
- Family Behavior Therapy
- Individual Cognitive Problem Solving
- Cognitive Behavior Therapy
- Family Psychoeducation
- Behavioral Family Counseling
- Community Reinforcement Approach
Multisystemic Therapy focuses on the social and familial aspects of behavior. Treatment is thought to be best addressed by engaging multiple systems, including the family, peers, teachers, and neighbors. The treatment model focuses on:
- Low caseloads (5-6 families)
- Intensive treatment
- 24/7 availability of counselors
- Services delivered at home, school, and neighborhood centers
- Time-limited structure (4-6 months)
Family Behavior Therapy focuses on substance abuse and behavior problems using behavioral techniques. The intervention targets multiple domains that influence behaviors, including the family, cognitions, verbal behaviors, and social interactions. Treatment elements include:
- Efforts at treatment engagement (calling before and after the first session, using food and drinks to engage)
- A comprehensive assessment that is reviewed and analyzed with clients
- Engaging siblings and peers in treatment
- Offering a choice among other behavioral interventions, including contracting, stimulus control, and communication skills.
Individual Cognitive Problem Solving (ICPS) is focused on developing self-control and improving problem-solving. Problem-solving steps include:
- Identifying the problem
- Identifying choices for a response
- Considering the consequences
- Choosing the best option.
Cognitive Behavior Therapy (CBT) is focused on the premise that behavior is adaptive, and interaction exists between thoughts, feelings, and behaviors. Treatment focuses on learning new behaviors and using behavior modification techniques. This model focuses on the antecedents that trigger symptoms, thoughts that then arise, and feelings and behaviors that become associated with these thoughts. Clients are taught to monitor their maladaptive and irrational thoughts and are trained to replace them with thoughts that will produce more adaptive, healthy behaviors.
Family Psycho-education programs were developed to improve treatment coordination, assist with medication management, reduce familial conflicts, and improve problem-solving. A consistent goal is to improve symptoms and psychosocial functioning in the individual and to reduce expressed emotion. The effort is made to engage the family within the first week of contact, to teach them about their family member’s mental illness, discuss issues in relapse, and provide ongoing problem-solving support, over multiple years, if required. After the initial didactic period, the patient and family may attend sessions together.
Behavioral Family Counseling (BFC) emphasizes the role of the family in improving substance abuse outcomes. This involves engaging family members in behavioral contracting around remaining abstinent, attending 12-step meetings, and taking medication where indicated. Sessions emphasize improving positive communication and shared activities inconsistent with substance use. Attention is given to factors that predict relapse, and training is given to facilitate coping with associated stresses.
The community Reinforcement Approach is a multi-method intervention that includes Behavioral Family Counseling when family members are available to participate. The overarching goal of this method is to reorganize the individual’s environment so that becoming abstinent from substance use is more rewarding than continued drug use. Internal and external triggers to substance use are identified, and behavioral skills training is focused on their interruption. Job support and alternative social activities inconsistent with substance use are developed.
Group therapy provides a forum for discussion of the interrelated problems of mental disorders and substance abuse, helping participants to identify triggers for relapse. Clients describe their psychiatric symptoms (such as hearing voices) and their urges to use drugs. They are encouraged to discuss, rather than act on, these impulses. Groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, and adherence to scheduled activities. These groups can provide a constant framework for assessment, analysis, and planning. Through participation, the individual with COD develops a perspective on the interrelated nature of mental disorders and substance abuse and becomes better able to view his or her behavior within this framework.
Treatment planning should be individualized. Regardless of the therapy utilized, treatment planning is an essential component of therapy.
- Integrate all assessment info, including patient’s goals, into a problem list.
- Engage the adolescent in treatment, initially through collaborating on goals.
- Determine medication needs, requiring at least weekly therapy appointments, emphasizing motivational techniques, and cognitive-behavioral interventions in early treatment.
- If substance use or symptoms of psychiatric illness do not significantly improve: 1) reassess diagnosis; 2) increase the intensity or frequency of treatment.
- Convey from the beginning, an understanding of the need for long-term monitoring of psychiatric disorders, and continued attention to factors related to substance use relapse.
To achieve therapeutic gains:
- A focus on the client’s environment, shifting away from rigidly-delivered clinically-based care.
- A broad perspective in which life habits are modified, rather than limited, focuses on substance abuse alone.
- The movement toward shared decision-making in the selection and delivery of treatment.
- Establishing a strong therapeutic relationship to engage and retain clients.
- Recognition that treatment involves a long-term process, extending months to years.
Co-occurring mental health disorders and substance use complicate the treatment process and negatively affect outcomes in both areas. Comorbid adolescents generally show poorer treatment outcomes, more frequent treatment dropouts, and higher rates of relapse when it comes to treatment, the earlier, the better.
Recognizing that these clients are at greater risk for drop out if their mental health disorders are not addressed, professionals in the field have to prioritize that an equivalent emphasis is placed on both categories of disorder in all treatment efforts. Knowing that adolescents may lack the maturity to understand the significant problems that can arise from unaddressed mental health problems, service settings have to develop the capacity to format their services around a long-term perspective and develop effective means to sustain these clients in treatment as they transition to programs serving adults.
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