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Module 12: Dual Diagnosis in Children and Adolescents

On this page:

Overview
Objectives
Key Terms
Content
Assigned Readings
Review
References


Overview

The existence of an emotional or behavioural disorder concurrently with a substance abuse disorder creates diagnostic and treatment difficulties for the mental health and substance abuse professional. Substance abuse may mask or exacerbate the emotional/behavioural difficulties. This module will explore the multiple and overlapping signs and symptoms of emotional/behavioural disorders and substance abuse, and potential treatment strategies for the young person and his/her family or guardian.

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Learning Objectives

  1. Be familiar with the range of overlapping symptoms and behaviours that may indicate an emotional or behavioural disorder, a substance use/abuse disorder or both.
  2. Recognize that adolescents with an emotional or behavioural disorder are at high risk for substance abuse.
  3. Understand the importance of treating both the emotional/behavioural and substance abuse problems simultaneously.
  4. Be familiar with the various levels of treatment that may be required for the dually diagnosed young person.
  5. Recognize the importance of involving the family or guardian in the treatment of the dually diagnosed young person.
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Key Terms and Concepts

  • Co-morbidity
  • Affective disorders
  • Anxiety disorders
  • Attention deficit disorders
  • Learning disorders
  • Eating disorders
  • Psychotic disorders
  • Classification of Substances
  • Risk factors
  • Familial factors
  • Genetic Susceptibility
  • Social factors and peer pressure
  • Treatment Continuum
  • Levels of Care
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Content Notes

Dual Diagnosis Known also as Coexisting Disorders
Substance Use and Abuse
The Extent of the Problem
The Prominent Mental Health Disorders of Adolescence
Factors That Place Adolescents at Risk for Using Alcohol and Drugs
Behavioural and Mood Issues
Family factors
Social factors
Genetic susceptibility
Assessment
Lethality
Treatment
The Basics
Guidelines
Components
The Role of the Case Manager
Early on-set Schizophrenia
Dual Diagnosis and the Gifted Child; Cultural and Ethnic Considerations

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Dual Diagnosis known also as Coexisting Disorders

The classic definition of dual diagnosis is the presence of at least two co-occurring disorders. Strictly speaking, any two physical, mental, or behavioural conditions would fall under this rubric. Thus an individual with both a diagnosis of mental retardation and of a major mental illness would have a dual diagnosis. Likewise, a person with a chronic physical illness and a mental disability or a substance abuse problem would be considered to have a dual diagnosis. In the delivery of mental health services the most frequently encountered diagnostic combination in the adolescent population is that of substance abuse and mental illness. The following material is presented in this context.

"Adolescence is a time of unparalleled threat, change, challenge, and opportunity. Nowhere else in human development do we encounter such a major transformation in such a shot time in so many domains: our bodies, minds, abilities, and interpersonal relationships.

Our bodies go through rapid growth and development. Our muscle mass seems to increase overnight. Secondary sex characteristics appear and become the source of attention and concern. Our appearance, for many years quite stable becomes altered to such an extent that sometimes we have difficulty in recognizing ourselves. And yet we cannot stop looking at ourselves in the mirror. Our minds begin their steady expansion to adult scope. When teachers demand that we perform unprecedented feats of learning, we discover to our amazement that we are indeed able to deliver contrary to our expectations. We note a new tone in our interactions with adults. They now sometimes treat us as equals. They even solicit and earnestly consider our opinions. And, most important, there is a new current in our social interactions, an added new dimension and new excitement that suddenly turns age-old play mates and acquaintances into objects of desire."

Hans Steiner (1996).

The biological, psychological and social upheavals of adolescence contribute individually and collectively to the dramatic rates of psychopathology through the adolescent years. Syndromes that first appear in childhood take on new shapes and manifestations while other syndromes makes their first appearance during this tumultuous period of development. With growing independence young people venture further away from the family home, spend increasingly more time with peers and other adults and are presented with a growing array of opportunities and dangers. Tobacco, alcohol and drugs constitute the most prevalent forms of risk taking behaviour in the adolescent years.

Within the context of rapid physiological changes, erratic social and emotional states, faced with the desire for independence, the fear of the unknown, the frustration of uncertainty of personal moods and that of peers, the already troubled adolescent can present a confusing and constantly changing picture of feelings and behaviours which make clinical assessment and diagnosis challenging at best. When compounded with the immediate and prolonged effects of substance use and abuse assessment and treatment become a challenge of continual evaluation and modification.

Substance use and abuse can have different etiologies depending on the age of the child. That is, the reasons for use may change over time in normal adolescents. For those with underlying emotional and/or behavioural problems age-related dynamics add another component in the assessment conundrum.

The decade of adolescence:

Areas of predominant concern
10 to 13 early adolescence puberty, physical maturity, the changing body
14 to 17 mid adolescence development of individual identity separate from parents, increasing importance of peers
18 to 20 late adolescence consolidate identity, develop vocational plans, establish patterns of interpersonal relationships and intimacy

In adults, the combinations of Alcohol and Other Drugs (AOD) problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary. However, in adolescents, severity and degree of impairment in functioning are the primary considerations since chronicity and long-term disability have not yet had opportunity to develop.

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Substance Use and Abuse

The Extent of the Problem:

The spectrum of alcohol and other drugs includes mood and mind-altering substances that are inhaled, ingested and injected. They may be legally purchased prescription or over-the counter drugs, solvents and inhalants legally sold but used for other than their intended purpose (such as solvents and airplane glue); alcohol, legal for purchase by adults but not by most adolescents, and a vast array of illegal substances. Since many adolescents who use/abuse drugs have an underlying emotional or behavioural disorder, the specific effects of a drug, or class of drugs, and the appeal can offer important insights into possible self-medicating aspects of drug use.

Drugs, Effects and Appeal (Table1)

Class of Substance

Some Examples

Specific Effects

Appeal

Alcohol: CNS depressant

Wine, beer, spirits (hard liquor)

Sedation

Impaired coordination

Impaired concentration

Rapidly fluctuating moods

Disinhibition

Reduces anxiety

Social lubricant

Disinhibition

Other CNS Depressants: sedatives, hypnotics, anxiolytics

Hypnotics, Sedatives, Minor tranquilizers, including barbiturates and benzodiazepines

Reduces anxiety

Sedates

Lowers muscle tone and coordination

Sedation

Reduces anxiety

CNS Stimulants

Amphetamines, Dexedrine, Ephedrine Cocaine (crack), Ritalin

CNS arousal

Anesthesia

Increased energy

Decreased appetite

Improved mood

Euphoria

Agitation, belligerence, paranoia, hallucinations (high doses/prolonged use)

Sense of competence

Euphoria

Sexual arousal

Sense of increased energy and alertness

Narcotocs and opiods

Opium, Heroin, Morphine, Methadone, Analgesics (all pain-killers)

Sedation

Reduced anxiety

Euphoria

Apathy

Reduced sensitivity to physical and emotional pain

CNS depression of breathing, coughing, circulation

Reduced sensitivity to emotional and physical pain

Reduced anxiety

Initial "rush" of euphoric feelings

Cannabinols

Marijuana, Hashish

Decreases anxiety

Produces shift in concentration and dissociative reaction

Alters perception of time and space

Alters judgment of speed and distance

Decreases motivation and concentration

At high concentrations, produces hallucinations

Dispels boredom

Narrow focus of concentration

Exaggeration of senses and emotions

Anxiety reduction

Dissociative effects

Hallucinogens or Psychedelics

LSD, Mescaline, Psilocybin (Mushrooms) MDMA (Ecstasy), Designer Drugs

Visual illusions

Perceptual changes

Dissociative

Altered sense of time

Hallucinations, depersonalization, derealization

Euphoria

Alters sensory input

Accentuates mood

Creates illusions

Synesthesia (cross-over from one sense to another)

Sense of affiliation and bonding (MDA)

Inhalents/Solvents

Glue, Paint, Paint thinners, cleaning agents, aerosol propellants, other petroleum products

Mild intoxication

Hallucinations

Loss of memory, confusion

Visual disturbances

Decreased appetite

Intoxicated state

Immediate effect

Readily available legally

Phencyclidine (PCP)

PCP (Angel Dust)

Note: the drug can be stored in the body, unmetabolized, for days or weeks. The drug effect can be re-experienced as though the drug had just been ingested, even months after last use.

Characteristics of depressants and stimulants

In high doses: hallucinations, paranoid delusions

Depression

Disorientation and confusion

Relaxation

Euphoria

Dissociation

Sensory distortion

Blocks physical pain

The extent of alcohol and drug use by adolescents is still imprecisely known. Most studies attempting to measure use at any given time (incidence) or lifetime use (prevalence) have targeted specific groups of youth. Thus the use across the entire population can only be approximated. The majority of studies have originated in the U.S.. While Canada shares many similarities with the United States, it is not known if they extend to the type and extent of substance abuse reported in the U.S.. Rates of mental illness appear to be approximately the same in both countries.

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The Prominent Mental Health Disorders of Adolescence

  • Affective disorders, especially depression
  • Anxiety disorders
  • Attention deficit, with or without hyperactivity
  • Learning disorders
  • Eating disorders
  • Victims of physical, sexual or psychological abuse or trauma
  • Psychotic disorders (less frequently seen)

 

Note: With the increased use of drugs that can mimic psychotic symptoms, psychosis, although not frequently seen in adolescents, has become a significant concern.

 

Signs and symptoms of emotional and behavioural disequilibrium
Sad or flat affect
Mood irritability
Isolation from family and/or peers
Preoccupation with death
Suicidal ideation
Lack of interest in activities
Low energy
Reduced appetite
Increased sleep, decreased sleep, disrupted sleep pattern
Nightmares, nightwalking
Lack of interest in participating in significant activities
Avoidance of certain places/ people
Poor concentration and indecision
Hypervigilance
Exaggerated startle response
Sense of detachment from others
Feelings of hopelessness, worthlessness, or inappropriate guilt
Little or no eye contact
Frequent verbalizations of low self-esteem
Hypersensitivity to criticism, disapproval or perceived signs of rejection by others
Mood-related hallucinations or delusions
Heightened anxiety
High energy and restlessness
Flighty thoughts
Pressured speech
Reduced need for sleep and a denial of emotional or physical pain
Poor attention span and susceptibility to distraction
Disorganized impulsivity
Impulsive, self-defeating behaviours that reflect a lack of recognition of dangerous consequences (shop lifting, alcohol or drug abuse, sexual promiscuity)
Negativistic, hostile and defiant behaviour towards most adults
Consistently angry or resentful
Often spiteful or vindictive
Defies or refuses to comply with rules and reasonable requests
Blames others for his/her misbehaviour
Consistently argues with adults
Bizarre thought content
Illogical forms of thought or speech
Disturbances of perception (auditory, visual or olfactory hallucinations)
Affect blunted, flat or inappropriate
Psychomotor blunting
Inadequate control over sexual, aggressive, or frightening thoughts, feelings or impulses (blatant fantasies or acting out)
Psychomotor retardation

 

Considerable overlap exists between the signs and symptoms of emotional disorders and substance abuse. Consider the following list of signs and symptoms of alcohol and drug abuse and compare it with the preceding list of mental and emotional symptoms.

Signs and symptoms of alcohol or drug use:
Sad or flat affect
Mood irritability
Isolation from family and/or peers
Preoccupation with death
Suicidal ideation
Lack of interest in activities
Low energy
Reduced appetite
Increased sleep, decreased sleep, disrupted sleep pattern
Lack of interest in participating in significant activities
Avoidance of certain places/ people
Poor concentration and indecision
Hyper-vigilance
Sense of detachment from others
Feelings of hopelessness, worthlessness, or inappropriate guilt
Little or no eye contact
Frequent verbalizations of low self-esteem
Hypersensitivity to criticism, disapproval or perceived signs of rejection by others
Hallucinations or delusions
Heightened anxiety
High energy and restlessness
Flighty thoughts
Pressured speech
Reduced need for sleep and a denial of emotional or physical pain
Poor attention span and susceptibility to distraction
Impulsive, self-defeating behaviours that reflect a lack of recognition of dangerous consequences (shop lifting, alcohol or drug abuse, sexual promiscuity)
Negativistic, hostile and defiant behaviour towards most adults
Consistently angry or resentful
Often spiteful or vindictive
Defies of refused to comply with rules and reasonable requests
Blames others for his/her misbehaviour
Consistently argues with adults
Bizarre thought content
Illogical forms of thought or speech
Disturbances of perception (auditory, visual or olfactory hallucinations)
Affect blunted, flat or inappropriate
Psychomotor blunting
Inadequate control over sexual, aggressive, or frightening thoughts, feelings or impulses (blatant fantasies or acting out)
Psychomotor retardation

 

The list of signs and symptoms of psychiatric disturbance and alcohol or substance abuse are almost (but not quite) identical.

All of these disorders present an array of symptoms that can mimic or exacerbate typical adolescent emotional turmoil. Their severity and persistence provide major warning signs for the existence of a more serious disturbance.

The emotional and behavioural sequellae of these disorders place adolescents at greater risk for initiating alcohol and/or drug use and thus developing dual or coexisting disorders.

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Factors That Place Adolescents at Risk for Using Alcohol and Drugs

Behavioural and Mood Issues

  • Psychological disturbances: mood or anxiety disorders, attention deficit and learning disorders, eating disorders,
  • Disturbances created by trauma and abuse: including, but not limited to: depression, anxiety, hypervigilance, sleep disturbance, low self-esteem
  • Need to fit in/be accepted
  • Yet need to feel different from the way they are feeling
  • Struggles to manage and modulate intense feelings
  • Difficulty controlling anger, disappointment, or embarrassment
  • Antisocial behaviour: rebellious, oppositional, argue, yell, blame and annoy others, defy rules, be spiteful and vindictive, give lots of excuses for staying out late, intercept the mail, steal from others, sell own things, set fires, be cruel to animals, get in fights, use weapons, run away, destroy others' property
  • Become defensive
  • Be abusive to others
  • Have low self-esteem
  • Inadequate personal skills

 

Family factors:

  • Conflict, arguments,
  • Family crisis or high stress
  • Less shared authority
  • Poorer communication
  • Less shared problem solving
  • Parental uses of alcohol or other drugs
  • Teetotaling, overdemanding or overprotective parent
  • Absent parent
  • Unconventional (non nuclear) family structure: stepparent, parents and partner living together, parent with multiple partners
  • Little identification with positive role models
  • Little religious commitment
  • History of alcohol or drug abuse by either parent
  • Legal history or antisocial behaviour of parent or children
  • Lack of closeness between parent and child

 

Social factors:

  • Poor school performance: low grades, spend less time reading, less time doing homework, place a low value on achievement or be a dropout
  • Legal problems: delinquency and/or criminal activity
  • Unique socioeconomics
  • Unique and risky peer involvement
  • Lack of social responsibility

 

Genetic Susceptibility:

  • Alcoholism runs in families: a strong genetic component
  • Alcoholism and some psychiatric disorders are strongly associated.
  • E.g. Conduct disorder
  • Depression
  • PTSD and trauma
  • Problems of AOD: the path from
    1. Experimentation: initial use with "gateway drugs" - alcohol, cigarettes and marijuana. Subsequent use more often includes marijuana, cocaine, hallucinogens, designer drugs such as PCP and MDD, heroin and opiods.
    2. Occasional social or recreational use when the substance is available.
    3. Regular use or abuse: the adolescent seeks out opportunities for use and "keeps own supply".
    4. Dependence.
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Assessment

Adolescents generally use alcohol and other drugs for multiple reasons. Ascertaining these reasons can indicate the type of treatment and the type(s) of motivator(s) that will help the young person discontinue use. When the possibility of an underlying psychiatric disorder exists it is of paramount importance to separate the effects of the substance use from the possible underlying disorder. Abstinence from use is essential in this diagnostic process. At the same time, it is incumbent on the clinician to acknowledge the possibility of an underlying disorder which must be treated concurrently if the adolescent is to have a sufficient reduction in distressing symptoms and be willing to comply with treatment and abstinence recommendations.

As with all adolescent mental health disorders, the accurate identification of dual or coexisting disorders involves a multi-person perspective: the adolescent, parent, physician, teacher, school nurse, child welfare and legal authorities. Assessment should cover a complete mental health history, a substance abuse profile and include the following:

  • Demographics
  • Chief complaint: history of the complaint and major presenting problems provided separately by parents and adolescent.
  • Developmental history: pregnancy, birth, developmental milestones and problems
  • Medical, surgical and injury history. Note especially head injuries and traumatic injuries. Include family medical history, allergies and current medications (including over- the -counter medications)
  • Past psychiatric history
  • Family psychiatric history: parents, grandparents, siblings, aunt and uncles
  • School history
  • Relationship with family members, relatives, friends
  • Alcohol and drug use: type of substance, amount, consequences
  • Alcohol and drug use by significant others and friends
  • History of violence: the adolescent, parents, relatives, friends
  • Sexuality and sexual activity, pregnancy (past or present), and sexually transmitted diseases.
  • Additional problems: money, religious/spiritual, hobbies, long-term/short-term goals.
  • Values and attitudes of the families ethnic/cultural group
  • Mental Status Exam
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Lethality

  1. How dangerous is the substance abusing behaviour?
  2. How serious are the emotional symptoms?
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Treatment

The Basics:

The traditional division between substance abuse and psychiatric services has placed the adolescent either in a substance abuse treatment facility when abuse of substances appears to predominate the behavioural picture, or a psychiatric treatment facility when emotional disturbance and psychotic symptoms appear to predominate. Because of the complex interplay of factors, signs, and symptoms of both disorders, the only effective therapeutic approach provides both psychiatric and substance abuse treatment concurrently. Additionally, the complexities of adolescent care demand a multidisciplinary treatment team consisting of psychiatrist, nurse, social worker, addictions counselor, psychologist and parents. Teachers, school counselors, significant others, and other health care professionals should also be included where indicated.

Focus of all treatment: the primacy of the alcohol or substance abuse/dependency while simultaneously looking for underlying psychiatric disorders.

Guidelines:

Complete a thorough evaluation of all components of the substance abuse and psychiatric history. Re-evaluate this assessment at frequent intervals.

  1. Treat the substance abuse.
    Alcohol and other drugs can cause or mimic psychiatric problems. Often emotional and behavioural problems can only be treated effectively in the absence of alcohol and drug use. With abstinence other problems may improve or disappear. For example, abstinence may reduce anxiety, depression, irritability and mood swings. Because psychiatric symptoms may often lead a young person to attempt to "self-medicate", cessation of substance use can lead to the emergence of more prominent psychiatric symptoms. These can then be identified more precisely, and effective therapeutic interventions more appropriately initiated.

    Evaluate during detoxification and early abstinence.

    Re-evaluate after 30 days.

  2. Treat the substance-abusing adolescent within the context of the family system.
    Family involvement and engagement are critical for the structure and support the young person requires. In those situations where the family is impacted by substance abuse or psychiatric problems in other members that makes them unavailable, a residential treatment program is the next most viable treatment milieu.

Components:

Treatment can be provided at various levels of care ranging from the least to the most restrictive.

Where

  1. Hospitalization - medical inpatient unit. Intensive medical management for serious medical complications.
  2. Inpatient dual disorders unit in a medical facility: providing medical, psychiatric and substance abuse treatment concurrently.
    • The young person is at risk of harm to self or others (e.g., a history of self-injurious behaviour).
    • Pre-existing medical condition requires close monitoring during detoxification and early treatment (e.g., diabetes, eating disorder).
    • Emerging and escalating psychiatric symptoms which may be exacerbated by or ameliorated by substance use.
    • Pre-existing psychiatric condition for which symptoms may intensify when substance use ceases. (e.g., serious depression).
  3. Residential Treatment Center with a program philosophy, staffing structure and therapeutic components that address co-existing disorders.
    • Can be a step-down for an adolescent initially hospitalized
    • Provides a therapeutic milieu for the person with a chaotic or fractured family system
    • Provides an intensely monitored environment where continual assessment can more readily and definitively determine the extent and relative importance of the substance abuse issues and the psychiatric problems
    • Provides structure and control for the adolescent with behavioural (especially conduct disorder and ADHD) diagnoses.
  4. Structured Day (or Evening) Hospital:
    A step-down from more intense treatment or
    An initial entry into treatment
    When there is a lower risk of harm, less relapse potential, and a strong family support system, a partial hospital program may be the appropriate initial intervention.
    • Provides a therapeutic milieu for the person with a chaotic or fractured family system
    • Provides an intensely monitored environment where continual assessment can more readily and definitively determine the extent and relative importance of the substance abuse issues and the psychiatric problems
    • Provides structure and control for the adolescent with behavioural (especially conduct disorder and ADHD) diagnoses.
  5. Structured Outpatient Treatment
  6. Outpatient psychotherapy - with a strong focus on substance abuse counseling.
  7. Alcoholics Anonymous (AA) an important adjunctive approach

The medical necessity for treating life-threatening condition, the severity of the substance abuse, reported high risk behaviour, psychiatric symptoms and the availability of a strong, supportive family structure comprise the key determinants for deciding the level of care required in each situation.

What

Therapeutic Contract

  1. Agreement to remain sober
  2. Agreement for family involvement in treatment
  3. Commitment to remain in the recommended level of care for the prescribed duration

Assessment:

  1. Physical history and exam, including drug testing where appropriate
  2. Social work assessment of family, social network, current living situation, etc.
  3. Psychological testing
  4. Educational/vocational assessment

How

Therapeutic Modalities

  1. Detoxification
  2. Psychotherapy - where indicated
  3. Psychotherapy - individual
  4. Group therapy
  5. Family therapy
  6. Psycho-education: individual, group, family
  7. Multi-family therapy
  8. Case management
  9. Recreational, occupational, art, music, and experiential therapies
  10. Journaling
  11. Psychodrama and family sculpting

Therapeutic Content

  1. Alcohol and substance abuse
  2. Identification and articulation of feelings
  3. Anger management
  4. Interpersonal communication
  5. Adolescence in the developmental cycle
  6. Value clarification
  7. Vocational/career counseling
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The Role of the Case Manager

To assure that the adolescent is receiving all indicated care.

To act on behalf of the young person in interfacing with any and all relevant systems involved in his/her life.

  • To assure all identified issues are addressed: medical, substance abuse, psychiatric, educational/vocational, legally.
  • To assure that there is continuity of treatment between the different levels of care.
  • To assure that both the adolescent and the family system remain involved with treatment at each stage.
  • To assure continued treatment for both disorders beyond the acute phase of care.
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Early-onset Schizophrenia

"Brains of teens with early onset schizophrenia are ravaged by a back-to-front wave of gray matter loss that parallels the progression from hallucinations and delusions to thinking and emotional deficits, National Institute of Mental Health (NIMH) - supported scientists have discovered. This loss of critical working brain tissue begins in rear perception processing areas, and over 5 years engulfs frontal areas responsible for functions like planning and reasoning. Although some loss of neurons and their branch-like extensions is normal during the teen years, as the brain prunes unused connections, the researchers had earlier shown that teens with childhood onset schizophrenia lose 4 times the normal amount in their frontal lobes. The new study is the first to visualize such a pattern of progressive tissue loss in schizophrenia." NIMH - Child and Adolescent Mental Health . Paul Thompson, M.D., University of California, Los Angeles (UCLA), Judith Rapoport, M.D., NIMH, and colleagues, reported these findings in the September 25, 2001 issue of the Proceedings of the National Academy of Sciences.

Using magnetic resonance imaging (MRI), the researchers periodically scanned 12 teens with schizophrenia and 12 age-matched healthy teens over 5 years, beginning at age 14. The wave of gray matter loss began in an area above the ear and then spread forward. Since losses in the rear areas are thought to be caused by environmental factors, the findings are consistent with the notion that activation of some non-genetic trigger contributes to the onset and initial progression of the illness, suggests the researchers. The wave of loss correlated with worsening psychotic symptoms and mirrored the progression of neurological and cognitive deficits associated with the disorder. The final profile was consistent with the loss pattern in adult schizophrenia. Another group of 10 teens, taking anti-psychotic medications for a different disorder, did not show the same pattern of changes, reducing the likelihood that the gray matter losses were drug-induced.

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Dual Diagnosis and the Gifted Child

Cultural and Ethnic Considerations:

Societal attitudes towards the use of alcohol by the adolescent population varies considerably across cultures and religious groups. Some prohibit or strongly discourage alcohol consumption by all members (e.g., some fundamental Christian groups). Others accept moderate alcohol consumption by mid-adolescence (western European nations such as France, Germany, The Netherlands). Likewise, attitudes towards drug use varies across cultures - from complete prohibition (U.S.) to marked tolerance (The Netherlands). Additionally, some cultures and religions incorporate alcohol (e.g., Catholic Church) or drugs (some aboriginal communities) into religious ceremonies, adding further sanction to their use.

The recognition of mental illness as a treatable entity does not have universal acceptance. Many ethnic groups continue to regard psychiatric symptoms as indicative of moral lassitude, and a condition that brings shame on the family. Many cultures do not subscribe to the classification of mental illness promulgated by the American Psychiatric Association (DSM-IVR) or the International Classification of Diseases (ICD-10) promulgated by the World Health Organization. In many cultures, symptoms of depression continue to be frequently dismissed as a "personal weakness" (Japanese). Delusional and hallucinatory experiences may still be regarded as signs of "spirit possession" or "special powers" (Haiti). The reluctance to seek psychiatric help continues as a pervasive factor, especially in many third world and emerging countries. These attitudes compound the difficulty in providing appropriate treatment to the dually diagnosed adolescent.

Determination of the cultural mores regarding alcohol, substance abuse and mental illness is an important component to understanding family attitudes, leniencies and prohibitions against alcohol and other mood and mind-altering substances, and the family's willingness to accept psychiatric treatment. This, in turn, influences the nature of familial involvement in substance abuse treatment (from overly permissive to extremely punitive).

Another often over-looked fact is that some ethnic groups (such as Aboriginal (Native) Canadians and Asians) have a markedly lower tolerance for the effects of alcohol. Similar studies on tolerance of drugs in the adolescent population do not presently exist. Current research efforts in the United States have begun to address this issue (NIMH, 2001).

Immigrant and refugee populations also pose added diagnostic and treatment problems. Problems of language, cultural clashes between parents and youth, and conflicting attitudes over the role of alcohol and substances may severely impede the engagement of the family in treatment. Family members may also be suffering from the sequellae of trauma and war in their country/culture of origin. This may make them psychologically unavailable to assist the adolescent. Simultaneously, their own mental health and coping mechanisms may be in jeopardy or severely compromised.

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Assigned Readings

Steiner, H. & Yalom, I.D. (Eds.). (1996). Treating adolescents. San Francisco, CA: Jossey-Bass

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Review Questions

  1. What is the most common co-occuring emotional disorder in young persons?
  2. Explain the rationale for level of intensity of care in treating the dually diagnosed young person?
  3. What role does the family or young person's guardian/caretaker play in treating the dually diagnosed young person?
  4. What are the various combinations of diagnosis that may result in a dual diagnosis?
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References

Steiner, H., & Yalom, I.D. (Eds.). (1996). Treating adolescents. San Francisco, CA: Jossey-Bass

Thompson, P., Rapoport, J., & colleagues. (2001) NIMH - Child and Adolescent Mental Health . In the Proceedings of the National Academy of Sciences , September 25, 2001.

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Updated November 10, 2007