Youth with Co-occurring Mental Health and Substance Abuse Disorders in the Juvenile Justice System

Co-occurring substance abuse and mental health disorders are a significant problem for youth in the nation’s juvenile justice system. While much is known about this problem, there is still a need for research about prevention and treatment and for effective policy and program development.

Studies show about half of all adolescents receiving mental health services have a co-occurring substance use disorder, and as many as 75-80 % of adolescents receiving inpatient substance abuse treatment have a coexisting mental disorder.[1] Adolescents with emotional and behavioral problems are nearly four times more likely to be dependent on alcohol or illicit substances than are other adolescents, and the severity of a youth’s problems increases the likelihood of drug use and dependence.[2] Among adolescents with co-occurring disorders, conduct disorder and depression are the two most frequently reported disorders that co-occur with substance abuse.[3]

Substance-abusing delinquents are at especially high risk for co-occurring mental health disorders.[4] Specifically, among youth in the justice system:

•   Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder.[5]
• A number of studies have shown an association between conduct disorder, attention deficit hyperactivity disorder (ADHD), and substance abuse.[6] For example, as many as 50% of substance abusing juvenile offenders have ADHD.
• Youth who have co-occurring conduct problems, ADHD, and substance use disorders have higher than normal rates of anxiety and depressive disorders, and the presence of ADHD in particular worsens the prognosis of both the substance use disorder and the conduct disorder, increasing the likelihood of these persisting into adulthood.[7]
• Among the juvenile justice population, mood disorders such as depression appear to co-occur with substance abuse problems more frequently than among youth generally.[8]
• Among incarcerated youth with substance use disorders, nearly one third have a mood or anxiety disorder.[9]
• Delinquents with substance abuse and behavioral disorders such as conduct disorder and ADHD engage in higher rates of crime and exhibit more alcohol and illicit drug use than do youth with mood disorders and are at higher risk for out-of-home placement and other poor outcomes.[10]
• Many incarcerated youth are exposed to high levels of traumatic violence which may result in symptoms of posttraumatic stress as well as increased rates of substance abuse.

Understanding Co-ocurring Disorders
Various explanations have been offered to explain substance use by people who have mental disorders. Many professionals believe that youth “self-medicate” with drugs or alcohol in order to relieve emotional states such as anxiety and depression. This may be especially true of youth with mood disorders. Some researchers attribute drug use to sensation-seeking, risk-taking, and impulsive behavior that is usually associated with the disruptive disorders or disorders such as conduct disorders and ADHD. (Risk-taking behavior is also characteristic of adolescence in general.) Finally, some professionals point to the role that stress plays in bringing on both addiction and symptoms of mental illness in many vulnerable individuals.[11] Studies have suggested that the mental disorder preceded the addictive disorder in over 80% of cases where there are co-occurring disorders, particularly those that develop during adolescence.[12]

Regardless of the reasons why people with mental disorders use substances, adults with severe mental illness and substance abuse often experience more negative outcomes—such as higher rates of hospitalization, incarceration, housing instability, and homelessness. They also tend to drop out of traditional outpatient treatments more often, use more services, and cost more to serve than individuals with single disorders. Many of these negative outcomes are similar for youth with co-occurring disorders. In fact, recent research shows that youth with co-occurring disorders have worse outcomes than youth with substance abuse problems alone.[13]

It is critically important to conduct a comprehensive assessment of a youth when he or she first enters the justice system that takes into account cultural factors, as well as education level, exposure to trauma, and family strengths. People treating dual disorders must have extensive training in both disorders. Effective interventions must be related to the school, peer, and family systems where adolescents routinely socialize and receive reinforcement for their behavior. Treatment options that show the best evidence of effectiveness are behavioral therapies, intensive case management, cognitive-behavioral skills training, family-oriented therapies, and Multi-systemic Therapy.[14]

Because adolescents often return to the peer, family, and community environments that supported and promoted their initial drug use, aftercare and relapse prevention services are also vitally important. Treatment programs designed primarily for people with substance abuse problems may not be appropriate for people who also have a diagnosed mental illness because of their reliance on confrontation techniques and their counsel against the use of prescription medications. Special self-help groups may be needed based on the principle of treating both disorders together.

Effective, Integrated Treatment
Often people with co-occurring substance abuse and mental health disorders must receive treatment from two different sets of clinicians in parallel treatment systems. Unfortunately, people sometimes find themselves excluded from one or both systems because of the complicating features of the second disorder. Some mental health professionals are uncomfortable treating co-occurring mental and substance abuse disorders, telling the person seeking help to return for treatment of the mental health conditions after the substance abuse has been resolved. This is unfortunate and unnecessary.

Recent research has shown that integrated treatment is superior to sequential or parallel treatment.  In integrated treatment, mental health and substance abuse treatments are provided by the same clinician or team of clinicians in the same program to ensure that the patient receives a coherent prescription for treatment rather than a contradictory set of messages from different providers.[15]

Since many people with dual disorders do not recognize their substance use as a problem, integrated treatment programs tend to provide more extensive efforts at engagement and motivation of the individual than do traditional mental health treatment programs. They also incorporate assertive outreach, intensive case management, individual counseling, and family interventions.[16]

Women and girls with co-occurring disorders also have substantially different treatment needs than men and boys. Females with co-occurring disorders may engage in high-risk sexual behavior, have more complicated health conditions, and have histories of exposure to physical and sexual violence.[18] In fact, there is growing evidence that women with co-occurring disorders are more likely to have experienced childhood physical and sexual abuse than severely mentally ill women without substance use problems.[19]

Girls’ experience of abuse and trauma needs to be addressed in assessment and treatment decisions. Treatment for girls with co-occurring disorders must include competency-building and empowerment in safe, accessible, community-based environments and single-gender support groups.[20]

Comprehensive assessment for youth when they first enter the justice system is essential. People treating dual disorders must have extensive training in both disorders, and treatment must be tailored to the young person’s gender, culture, exposure to trauma, and family strengths. Treatment is best if it is offered in the youth’s natural context, that is--the school, peer, and family systems. Aftercare and relapse prevention services are very important.

More information about youth with co-occuring mental health and substance abuse disorders in the juvenile justice system and other information related to juvenile justice and mental health issues can be obtained from the National Mental Health Association.

Please contact:
National Mental Health Association
2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Phone 703/684-7722
Fax 703/684-5968
Mental Health Resource Center 800/969-NMHA
TTY Line 800/433-5959