Guide to Co-Occurring Disorders in Adolescents
Around six in ten people with a substance use disorder also suffer from a mental health condition. This is known as co-occurring disorders. For adolescents, co-occurring disorders can present unique challenges and the changes caused by these disorders can be troubling for both teens and their family.
When substance use and mental health are both factors, it can be difficult to determine the reasons behind an adolescent’s changes in behavior. Is their moodiness a sign of a mental health issue? Or a side effect of substance use? Looking out for the signs of co-occurring disorders, and understanding how these challenges can create new issues or complicate treatment is essential to helping your child stay healthy and safe.
What Are Co-Occurring Disorders?
When a child struggles with both a substance use disorder and a mental health disorder, they have co-occurring disorders. It may also be called comorbid disorders or a dual diagnosis.
Up to 45 percent of adolescents and young adults with mental health disorders have a co-occurring substance use disorder, and 65 percent or more of youth with substance use disorders also have a mental health disorder. The most common mental health disorders are anxiety disorders, depression and attention-deficit hyperactivity disorder (ADHD), but bipolar disorder, schizophrenia, and borderline personality disorder may also occur.
It’s often difficult to determine which issue came first. An adolescent may experience anxiety and turn to drugs to cope, developing an addiction. In another case, a teen may use drugs and have negative experiences that lead to post-traumatic stress disorder.
What Are the Risk Factors of Co-Occurring Disorders?
When a mental health disorder goes undiagnosed or untreated, an adolescent will often attempt to self-medicate or self-treat with drugs or alcohol. Studies show that depression, ADHD, anxiety disorders, and post-traumatic stress disorder increase the risk of drug use in adolescents.
However, substance use is also a serious risk for developing a mental health disorder. Marijuana use has been shown to be a risk factor for triggering episodes of psychosis, especially in those with a family history of psychotic disorders. Misuse of prescription medications can cause manic or irritable states.
Research shows that identifying and treating mental health disorders can reduce the risk for developing a substance use issue. Reducing substance use can improve treatment outcomes for mental health disorders.
What Are the Signs of Co-Occurring Disorders?
Substance use often causes physical, emotional, and behavioral changes. However, the signs can vary depending on the type of substance. Stimulants can cause irritability, insomnia, and unexplained weight loss. Opioids can cause a lack of enthusiasm and energy, pinpoint pupils, and nausea.
Behavioral Changes that Can Occur with Substance Use
- Loss of interest in hobbies or activities
- Mood swings
- Irritability or argumentativeness
- Agitation, restlessness, or hyperactivity
- Lethargy or lack of motivation
- Changes in friendships
- Declining grades or skipping school
- Engaging in risky behaviors
- Locking doors, isolating themselves, or missing family events
- Becoming more accident-prone
- Borrowing or taking money or valuables
Signs and Symptoms of Mental Health Disorders
The signs and symptoms of a mental health disorder vary by disorder.
Symptoms of Depression
The symptoms of depression can include:
- Consistent depressed or irritable mood
- Lack of pleasure in daily activities
- Marked weight loss or gain
- Sleeping too much or too little
- Restlessness, lethargy, or fatigue
- Feelings of worthlessness or excessive or inappropriate guilt
- A preoccupation with death, plans of suicide, or an actual suicide attempt
Symptoms of Anxiety Disorders
The symptoms of anxiety disorders can include:
- Overly self-conscious behavior
- Trouble sleeping
- Avoiding certain situations
- Stomach aches or other physical problems
- Clingy behavior around parents or caregivers
- Trouble focusing in class or restlessness
- Disruptive behavior and explosive outbursts
Symptoms of ADHD (Attention-Deficit Hyperactivity Disorder)
The symptoms of ADHD can include:
- Being easily distracted
- Difficulty staying organized and frequently losing things
- Appearing to not listen when spoken to
- Excessive talking or interrupting
- Making careless mistakes
Symptoms of Bipolar Disorder
The signs of bipolar disorder present as both depression and mania. Symptoms can include:
- Loss of interest or pleasure in previous hobbies or activities
- Marked weight loss or gain
- Lethargy or fatigue
- Feelings of hopelessness, helplessness, or worthlessness
- Excessive or inappropriate guilt
- Preoccupation with death, plans of suicide, or an actual suicide attempt
- Drastic personality changes
- Excitability and irritability
- Inflated self-confidence
- Grandiose or delusional thinking
- Decreased need for sleep
- Increased talkativeness and scattered attention
- Psychotic episodes
Symptoms of Schizophrenia
The symptoms of schizophrenia can include:
- Disorganized thinking, such as jumbled speech or jumping between topics
- Odd behavior, such as sudden agitation, disheveled appearance, or excessive motor activity
- Apathy or reduced emotional expressiveness
- Social withdrawal
- Loss of interest or pleasure in previous hobbies or activities
Symptoms of Borderline Personality Disorder (BPD)
The symptoms of BPD can include:
- Efforts to avoid abandonment, real or imagined
- A pattern of unstable and intense relationships
- Unstable self-image or sense of self
- Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
- Emotional instability
- Feelings of emptiness
- Intense anger or difficulty controlling anger
Many of the signs of substance use overlap with mental health disorder symptoms. For example, it can be hard to tell if a child is becoming withdrawn due to depression, alcohol use, or both.
Behavioral Signs that Can Result from Both Mental Health Disorders and Substance Use
- Erratic behavior
- Sleeping more or less than usual
- Avoiding friends and family
How Are Co-Occurring Disorders Treated?
The first step to treating co-occurring disorders is determining which symptoms come from mental health and which come from substance use, and which issue developed first. This process is called differential diagnosis. This is an important step because the treatment for a mental health disorder can be very different from the treatment for a substance use disorder. Providers will use reports from the patient, family, teachers and other doctors, and their own observations to perform an evaluation. This will help them provide a diagnosis and determine the best course of treatment.
The most effective treatment for co-occurring disorders is integrated care, which means both mental health and substance use are treated at the same time. A multidisciplinary team of providers - such as a psychiatrist, psychologist, social workers, and clinicians - develop and implement an integrated treatment plan that addresses the physical, emotional, and mental symptoms of both conditions.
Treatment for co-occurring disorders may include therapy, medication, or a combination of the two. The therapies that are often recommended include:
- Cognitive Behavioral Therapy (CBT) - Focuses on changing negative behaviors, improving emotional regulation, and developing healthy coping strategies
- Trauma-Focused CBT (TF-CBT) - Focuses on addressing the specific needs of children and adolescents with post traumatic stress disorder and other traumatic life events
- Contingency Management - Uses motivational incentives and rewards to reinforce positive behavioral changes
- Dialectical Behavioral Therapy (DBT) - Focuses on emotional and social aspects to help regulate unstable emotions and harmful behaviors
- Motivational Interviewing (MI) - Focuses on resolving ambivalent feelings and insecurities to find the internal motivation to change negative behaviors
- Multisystemic Therapy (MST) - A family and community-based therapy that addresses adolescents’ homes and families, schools and teachers, neighborhoods and friends
- Acceptance and Commitment Therapy (ACT) - Uses acceptance and mindfulness strategies, combined with commitment and behavior change strategies
As a parent or family member, you are an important part of treatment as well. Family therapy is often used to engage the family in helping to manage difficult symptoms and foster success in recovery.
How Does the Family Play a Role in Co-Occurring Disorders Treatment?
Parents and other family members are essential to supporting a child with co-occurring disorders as they work towards recovery. You can play an important role by learning the signs and symptoms of the disorders, recognizing that there is an issue, motivating your child to get help, helping your child navigate their treatment, and helping them maintain their positive changes. Studies have shown that positive family involvement improves outcomes of treatment.
Some of the ways you can help support a child with co-occurring disorders include:
- Participating in family education to learn more about mental health symptoms, signs of substance use, treatment options, medications, and warning signs of relapse
- Attending individual counseling or family therapy to address any concerns, improve family interactions, learn how to respond to your child effectively, and find solutions to issues
- Managing your child’s medication to ensure prescriptions are filled and taken correctly, to take note of any side effects and symptom reduction, and to discuss how the medication is working
- Encouraging healthy involvement and structure, as getting back into school, work, volunteer activities, hobbies, sports and other activities can motivate your child to manage their mental health, help them to stay sober, and provide a daily structure
- Joining family support groups to hear from other families in similar situations, learn about additional resources, and feel supported by others in the community
- Knowing the signs of relapse so you can get help as soon as possible and get your child back on track to wellness
You and other family members play an important role in helping your child get the help they need, supporting them through treatment and recovery, and encouraging them to recognize that change is possible and that they can lead a fulfilling life.