Adolescent Co-Occurring Disorders

Hope (not her real name) is a 17-year-old young lady in the 9th grade. She was physically abused by her mother at ages 9-10, kidnapped at age 14, held hostage with a friend over a two-day period, and was continually sexually victimized and watched her friend also be victimized. Hope has anger issues; she will yell, hit and throw things. She has been charged with domestic violence and felonious assault. An inability to sleep at night and nightmares are haunting Hope. She began using marijuana at age 13, progressed to two to three times per week at age 15, then began using daily at age 16. She smokes cigarettes and drinks occasionally. Hope finds herself in a residential treatment center after continual outpatient failures, medication non-compliance and probation violations. Her life trajectory is looking dim. Can we help Hope?

We have a cataclysmic collision of data and science that is motivating professionals to better assess and treat adolescents with co-occurring disorders.

Over 25% of alcohol consumed in Ohio is by underage drinkers.1 In 1965, the average first use of alcohol was at 17 years of age; now it is 12_-13 years. Individuals treated for substance abuse are 10 times more likely to die by suicide than the general population.2 Over 50% of adolescents seeking substance abuse treatment have received prior treatment for trauma, ADD, ADHD or anxiety disorders.3

What came first: the chicken or the egg? Or is it the cart before the horse? Either way, adolescent clients with co-occurring disorders have usually been diagnosed and treated within the mental health or substance abuse system of care as a result of the circumstances their life threw them into. Most treatment options available are only recently becoming integrated, still leaning to the historical nature of the provider organization, whether it is mental health or substance abuse/addiction treatment or criminal justice. While we had a movement of “no wrong door” for entering treatment, the doors in the past have been defined as juvenile justice, high school dropouts, learning disabilities, emergency rooms, psychiatry, mental health or substance abuse treatment, and in only rare instances were these systems coordinated or connected.

To effectively provide services to adolescents and their families with co-occurring disorders, professionals need to have a broad knowledge and competency in assessment of alcohol, drug and mental health disorders in adolescents.

Specific areas professionals should be familiar with, minimally, include the following:

1. Adolescent psychiatric disorders, specifically trauma, ADHD, PTSD, depression and anxiety disorders.

2. Alcohol and drug disorders, trends in drug abuse, and causes, symptoms and effects of addiction.

3. Relationship between mental health issues and substance abuse.

4. The impact of familial history in mental health disorders and substance abuse, especially trauma, cultural and criminal aspects.

5. The ability to prioritize substance abuse and mental health disorders.

6. The ability to network with other service providers, since many adolescents have multiple psychosocial needs and challenges.

7. General understanding of the biochemistry of the brain and developmental stages of growth in adolescence.

Initial assessment involves the combination of the following aspects of an adolescent: review of current problems, symptoms and reasons for the referral, psychiatric history including trauma, current and past drug use and abuse, history of treatment, mental status exam, medical history, family history of mental health and substance abuse, developmental history, past and present prescribed medications, current or past homicidality and suicidality, aggression history, school performance, spirituality, employment, legal issues, and motivation of the young person.

Science is providing evidence to what we have long suspected: that addiction and dependency is caused by powerful biochemical changes in the brain. This simple analysis understates the facts of adolescence in normal development; however, there are powerful co-occurring factors that must be considered when treating a substance-abusing youth. The presence of co-occurring or pre-existing mental health conditions such as trauma, depression, PTSD, ADHD, conduct disorder, to name a few, will lead to multi-level interventions by the professionals who recognize these. The power of peer relationships, along with culture and multi-generational mental health and addictions, must be a part of an ongoing assessment and treatment planning, if we are to be successful in serving adolescents. For example, substance abuse is linked to close to 66% of all sexual assaults and date rape in adolescents and young adults.4

Trauma is becoming a major rallying point between mental health and substance abuse providers. The National Scientific Council on the Developing Child identifies wide adolescent variations on the perception and reactivity to adversity and stress. Citing positive, tolerable and toxic stress parameters that intermix with an adolescent's social-emotional buffers is key to determining the effect of trauma. Stress-induced changes in the brain architecture can lead to chronic or toxic stress, which may lead to unhealthy lifestyles as a means of coping. Compared to those without adverse childhood experiences (ACEs), respondents with ACEs were more likely to report that they drank or used drugs to cope. So when a substance abuse client comes into treatment, what do we address first? What do we address concurrently? How do we do this?

How are we really going to help Hope?

Recovery, resiliency and relapse are aspects of treatment now being used interchangeably in both mental health and substance abuse treatment. For adolescents we might become aware that many professionals are looking to provide habilitation rather than rehabilitation. Understanding the concepts of resiliency, relapse and how to facilitate and motivate youth in acquiring the supports that will help them move to become productive young adults is essential if we are to appropriately treat adolescents.

Neuroscience informs us that the adolescent brain is sculpted by activity. The implication is an adolescent is, and easily will be, what they do. Brain maturation is not complete until 24 years of age, it is never “too late” to help a struggling youth.

Family engagement and retention are important aspects of adolescent treatment. It is widely accepted that although adolescents spend most of their time with peers and out of their homes, away from family, parents still have the most significant influence in their lives.

In families, there are usually multi-generational aspects of mental health, spirituality, criminology and substance abuse. These aspects must be acknowledged openly to begin the process of unraveling these familial influences.

Michael E. Matoney, MBA, LICDC, is the Executive Director of New Directions, Inc. a treatment center for adolescents and families in Northeast Ohio. Matoney has over 30 years experience in the non-profit sector of Great Cleveland in senior management and clinical positions and has consulted, via the National Leadership Institute (NLI), with various non-profit agencies including organizations in Iowa, Massachusetts and Ohio. He is also a consultant, presenter and surveyor for The Joint Commission.

References

1. PIRE 2005 Pacific Institute for Research and Evaluation, January 2005, Cost of Underage Drinking and Savings Prevention.
2. Underage Drinking in the United States: a Status Report, 2005, the Center on Alcohol Marketing and Youth.
3. Internal agency statistics at New Directions, www.newdirect.org, 2011.
4. www.ama-assn.org/ama1/pub/upload/mm/39/proceedingsalcohol.pdf, 2008.

Addiction Professional 2011 March-April;9(2):N3