Module 2: Screening and Assessment

1C. Co-occurring Disorders Among Youth Involved with Juvenile Justice

Although there are youth involved with the juvenile justice system who have a mental health disorder or a substance use disorder, many youth have both types of disorders.

The term co-occurring disorders describes two independent medical disorders that occur at the same time. Within the mental health and substance abuse fields, the term typically describes the simultaneous presence of a mental health and a substance use disorder. There are a variety of terms to describe a youth with co-occurring disorders; however, they all refer to the youth having both a major mental health disorder and a substance use disorder. Terms that are used interchangeably with co-occurring disorders are:

Dual Diagnosis

Coexisting Disorders

Co-occurring Disorders

Double Jeopardy

MICA - Mentally Ill, Chemically Abusing

The frequency of co-occurring disorders is very high in the juvenile justice system. The relationship between mental health and substance use disorders is variable and the prognosis is poor if youth are left untreated. The assessment, treatment, and management needs of a juvenile offender with co-occurring disorders are different from the needs of a juvenile offender who has only one of these types of disorders.

Frequency of Co-occurring Disorders in the Juvenile Justice System

Seventy-five to ninety-five percent of youth in the juvenile justice system with a mental health disorder also have a substance use disorder, as compared to 16 percent of youth in the general population (Cohen et al., 1993; Milin et al., 1991; Otto et al., 1992).

Relationship Between Mental Health and Substance Disorders

There are several ways in which substance use and mental health disorders affect each other.

CREATE—Substance use can create psychiatric symptoms. Example: Alcohol is a depressant—if any youth uses alcohol long enough, the youth could develop depressive symptoms and eventually meet criteria for major depression.

TRIGGER—Substance use can trigger the emergence of some mental health disorders if a youth is predisposed to mental illness. Example: A youth whose mother has bipolar disorder may have never experienced symptoms of mania until the youth uses PCP.

EXACERBATE—Symptoms of mental illness may get worse when a youth uses alcohol and drugs. Example: A youth with suicidal ideation may make an actual suicide attempt after drinking alcohol because the youth becomes more depressed and less inhibited.

MIMIC—Substance use can look like symptoms of a psychiatric disorder. Example: A youth with no history of psychiatric symptoms can develop paranoid delusions after heavy methamphetamine use.

MASK—Symptoms of mental illness may be hidden by drug and alcohol use. Example: A youth with attention-deficit/hyperactivity disorder may be less distractible when using cocaine. Psychiatric symptoms may not emerge until the youth stops using substances for a significant period of time.

INDEPENDENCE—A mental health disorder and substance use disorder may not be related to each other, but a common factor may underlie them both. Example: A youth’s genetic makeup may make the youth vulnerable and more likely to develop mental illness and/or substance abuse.

Some have suggested that mentally ill youth are self-medicating with alcohol and drugs. Others suggest drug and alcohol use is a major risk factor in the development of psychiatric symptoms. It may be that both disorders are caused by the same underlying factor. At this time, the exact relationship between mental illness and substance use is unclear. However, what is clear is that a youth with co-occurring disorders is at greater risk for multiple problems.

Common Combinations of Mental Health Disorders and Types of Substance Use

Currently, there is little to no empirical data regarding whether adolescents with certain mental health disorders prefer to use particular types of substances. For example, do youth who have attention-deficit/hyperactivity disorder prefer methamphetamines because they may help them focus or do they prefer marijuana because it helps slow them down?

Think About Given your experience with youth who have co-occurring disorders in the juvenile justice system, what relationship have you noticed between a youth's mental health diagnosis and the youth's drug of choice? How have youth with mental health disorders described their drug use to you, particularly the desired effects they obtain by using the substance?

Prognosis for Youth with Co-occurring Disorders

Youth with co-occurring disorders are likely to experience:

• Quicker progression to substance abuse after initial substance use
• Higher dropout rates in substance abuse treatment (particularly if they have conduct disorder)
• Higher rates of suicide