Comorbid disorder
Prevalence rate
Conduct disorder (CD)
60–80 %
Attention deficit hyperactivity disorder (ADHD)
30–50 %
Depression
15–25 %
Anxiety disorders
15–25 %
Bipolar disorders
10–15 %
Boys are more prone to illegal drug use, have more risk of polysubstance abuse or dependence (Johnston et al. 2007), and are more diagnosed with externalizing disorders. Girls are more likely to have comorbid internalizing problems (Latimer et al. 2002); older children were more likely to have dual disorders than younger ones (Turner et al. 2004).
It seems that a conduct disorder problem plays a mediating role with respect to the association between ADHD and substance problems. Young people with comorbid conduct disorder and substance abuse are characterized by frequent polydrug use, delinquent behavior, and a worse (therapeutic) prognosis (Deas 2006). Among Dutch incarcerated boys, Vreugdenhil and colleagues (2003) reported a prevalence rate of SUD of 55 %, of which 90 % had at least one comorbid disorder. Within youngsters with a first psychosis, there is also often a problematic cannabis use (60 %). Cannabis use increases the risk of a psychotic disorder and substance abuse has a negative effect on the course of a psychosis (Milin 2008).
22.3 Etiology
Mueser and colleagues (2003) examined four theoretical models: common factor models, secondary SUD models, secondary psychiatric disorder models (self-medication), and bidirectional models (Table 22.2).
Theoretical model | Explanation |
|---|---|
Common factor modela | Genetic or environment factors predispose both disorders |
Secondary SUD modela | Mental health problems precede SUD |
Secondary mental disorder model | SUD precede mental health problems |
Bidirectional model | The two disorders develop independently, but have a significant impact on each other |
They found modest support for the common factor model and the secondary SUD model. In the common factor model, high rates of comorbidity are the result of shared risk factors, including family history, individual personality variables, environmental factors, and traumatic events. In the secondary SUD model, mental disorders preceded SUD in over 80–90 % of dual disorder cases, particularly in those that developed during adolescence. The mental disorder usually occurred first in early adolescence (median age 11), followed by the SUD 5–10 years later (median age 21). Specific risk factors for substance abuse in young people are shown in Table 22.3.
• Children of addictive parents or families where addiction occurs |
• Children of parents with mild intellectual disability |
• Young people with mental health problems (regulation of emotions and behavior) |
• Particularly those with ADHD and a behavior disorder, depression, or anxiety |
• Traumatized children/young people (maltreatment or abuse) |
• Children who are exposed to high stress |
• Children from multi-problem families |
• Young people with a low socioeconomic status, living in poverty or marginalized |
• Young people who deal with delinquent or deviant peers |
• School dropouts, truants |
• Young people who have already begun to substance use in early childhood |
22.4 Course
Substance use has a negative impact on the functioning of the brain as long as the youngster is under influence, but also afterwards. Substance use leads to an imbalance of neurotransmitters and the reward system is affected. Since the brain is still in development, substance use can stagnate this development causing permanent brain damage. In case of damage, the impact is more serious as the youngster starts at an early age. The development of experimental use of cannabis to cannabis addiction lasts among young people 6 up to 18 months, and in adults 2 up to 7 years. It would be most desirable if a youngster would not use alcohol, nicotine, or other drugs till full maturation of the brain.
Compared to youngsters with only one psychiatric problem, youngsters with dual disorders are more severely impaired, have a higher risk for medical problems, trauma, and sexual and physical abuse, have higher rates of hospitalization, incarceration, suicide attempts, and academic difficulties (Lewinsohn et al. 1996), have an earlier onset of substance use, use substances more frequently and over a longer period, and have poorer drug treatment outcomes (Grella et al. 2001). Clinical interview and presentation of youngsters with SUD is respectively shown in Tables 22.4 and 22.5.
• Onset of substance use |
• Progression, patterns, and frequency of use |
• Use in combination with other substances |
• Presence of tolerance of withdrawal symptoms |
• Response to any previous treatment |
• Triggers for craving and use • Context of use |
• Perceived motivation for using |
• Positive and negative consequences of use |
• Current motivation and goals for treatment |
• Many young people come from complicated family situations with disturbed relationships. There is a higher prevalence of psychiatric disorders in the family |
• Many young people have a developmental disorder (ADHD, autism spectrum disorder) |
• There are often traumatic experiences and there are regular symptoms of a PTSD |
• Many youth are worrying and have mood swings, symptoms of depression, lack of future perspective, and suicidality |
• Social anxiety symptoms occur regularly |
• Many young people have trouble sleeping and their day-and-night rhythm is often disturbed |
• Several young people had psychotic experiences, whether or not under the influence of drugs |
• The socio-emotional development has stagnated. Many young people have an identity problem |
• Many young people suffer from behavioral problems |
22.5 Treatment
22.5.1 In General
There is evidence that co-occurring mental health problems are moderators that affect adolescent treatment participation and outcomes. Adolescents with these problems are considered more difficult to engage and retain in treatment.
Ongoing and active support from system members is essential for the treatment of youngsters with a dual disorder. The system members are primarily the parents or caregivers and other family members and friends, but also professionals. Motivating the youngster and his system, and building a working relationship, requires a lot of attention. At the start of the process, there is often no intrinsic motivation to go to another counselor or therapist. Moreover, the various system members are in different motivational stages. Therefore, there is a big need of building a working relationship with each of the family members and come to a jointly supported treatment program. Much more than in adults, the youngster is very sensitive if someone really listens to him.
In the early stages, it is essential to build good contact and to prevent people from dropping out, while simultaneously realistic therapeutic expectations will be made.
As in the treatment of adults with a dual disorder, the attitude of the care workers is of great importance. Sincere personal interest in young people and their system, real commitment, and respect for the autonomy of the youngster are key components in the therapeutic relation. Moreover, patience and tenacity, humor, honesty, and transparency are essential in the treatment of youngsters with a dual disorder.
The treatment of young people with a dual disorder requires an integrated multimethod treatment program, where both mental health problems and SUD should be considered primary and treated as such (Cleminshaw et al. 2005; Mueser et al. 2003; Riggs and Davies 2002). Currently, youth with dual disorders tend to intermittently drift between primary care, mental health, substance abuse, and criminal justice systems.
Treatment should focus on the psychiatric problems, the problematic substance use, and the related factors. Therefore, treatment aims at stopping substance abuse, maintaining abstinence, and reducing the comorbid psychiatric problems (Kaminer and Bukstein 2008). An integrated treatment should at least consist of a combination of psycho-education, motivational interviewing, cognitive-behavioral therapy and systemic interventions, and psychopharmacotherapy if indicated.
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