James Donaldson on Mental Health – Parents Guide to Co-occurring Substance Use and Mental Health Disorders (Pt.2)

What’s the Attraction?

Teens and young adults use substances for a variety of reasons. They may begin because of curiosity and peer pressure. Often, those who become habitual users are trying to “solve a problem.” Substances can help them relax, alleviate boredom, fit in socially, escape emotional or physical pain, deal with traumatic memories, relieve anxiety, go to sleep, get up in the morning, lose weight, etc. Substance use is “reinforcing,” which means that a child is more likely to keep taking them when they seem to help with a given problem or need. It’s important for parents to understand what it is specifically that makes substances appealing to their child in order to address his or her use. And when substance use is severe, it can be difficult for any parent to address these causes and keep a child safe without professional help.

Substance Use Basics

It’s helpful to have a basic understanding of the different kinds of substances, their effects and how to recognize signs of use. Common substances used by adolescents and young adults include alcohol, tobacco (JUUL, cigarettes), marijuana (leaf, THC oils, dabs and vape pens), hallucinogens (LSD and PCP), sedatives (Xanax, Ambien), stimulants (Adderall, cocaine) and opioids (Vicodin, heroin, Percocet).

How do you know if a child is using alcohol and/or drugs? Aside from direct evidence (such as bottles, bags or other paraphernalia), parents often see physical, emotional and behavioral changes. Of course, the specifics of these changes depend directly upon the substance being used. For example, stimulants can cause an irregular heartbeat, insomnia, irritability and unexplained weight loss. Opioids, like Vicodin, Percocet, and heroin, can cause a lack of enthusiasm and energy, constipation, slowed breathing, pinpoint pupils and nausea.

Some behavioral changes that may occur with substance use:

• Loss of interest in hobbies or extracurricular activities
• Comments from teachers, classmates or friends
• Changes in friendships
• Mood swings
• Irritability or argumentativeness
• Unusual agitation, restlessness or hyperactivity
• Lethargy or lack of motivation
• Locking doors, demanding more privacy, isolating or missing family events
• Declining grades, skipping school or poor work performance
• Becoming more accident-prone
• Engaging in risky behaviors (such as sex or driving under the influence)
• Borrowing or taking money or valuables
• Missing prescription drugs or missing alcohol

Many of these symptoms overlap with mental health disorders. For example, it can be hard to tell if a child who becomes withdrawn and isolated is depressed, using alcohol, or both. You can learn more about differentiating between substance and mental health disorders in Section 3.

What Is a Substance Use Disorder?

The term “substance use” exists along a spectrum from initial use to greater frequency (and usually more consequences) and eventually to addiction.

Regardless of the substance, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (known as the DSM-5) defines a substance use disorder as a problematic, recurrent use of drugs or alcohol that causes significant distress or impairment in a person’s life. There are four categories of behaviors that are used to determine the severity of the problem: impaired control, social impairment, risky use, and tolerance and withdrawal.

A person needs to meet two or three of these criteria to be diagnosed with a mild substance use disorder. Meeting four or five of the criteria is considered a moderate substance use disorder, and six or more is deemed a severe substance use disorder.

Even if a child’s use of alcohol and/or other drugs doesn’t rise to the level of an “official” substance use disorder, it can interfere with functioning. There is a trend in the field moving away from categorizing severity by dependence or withdrawal criteria and looking instead at the impact on one’s life. A young person does not need to be dependent on drugs or go through withdrawal symptoms for the substance to have a huge impact on academic and/or social functioning.

What’s Causing These Symptoms?

Are your child’s concerning thoughts, emotions, and behaviors the result of a mental health disorder or a substance use disorder? Figuring out which symptoms come from which disorder, and which problem started first, is called differential diagnosis. Determining differential diagnosis is important because treatment for a mental health disorder can be very different from treatment for a substance use disorder.

You may be concerned about mood swings and suspect your child has bipolar disorder, when in fact he or she has been using opioids and cocaine. Similarly, a child could be diagnosed with cannabis (marijuana) use disorder without considering that there may be something else going on or at the root of the issue, like anxiety or a traumatic experience.

Finding the right treatment becomes complicated when adolescents or young adults don’t report everything that is going on in their lives. When young people are referred for help for a mental health disorder, they often can be reluctant to talk about their substance use. Similarly, young people being evaluated for substance use problems will often avoid discussing emotional or behavioral problems.

This lack of information can make it hard to get an accurate diagnosis. That’s why it is critical for clinicians to get a full picture of what symptoms occurred first and when substance misuse began. You can help encourage your child to talk about what’s truly going on in his or her life, and help fill in the gaps, as well. You can share information about your child’s and family’s history as well as other factors, such as recent problems (e.g., missing school, changes in sleep or eating patterns, etc.).

Behavioral symptoms that can result from both mental health disorders and substance use include:

• Moodiness
• Sleeping more or less than usual
• Paranoia
• Avoiding friends and situations
• Erratic behavior

Getting an Evaluation

There are no laboratory tests to diagnose mental health or substance use disorders, so differential diagnosis depends on reports from the patient, his or her family, teachers and other doctors, and the clinician’s observations. This picture of what’s happening is then compared to criteria in the DSM-5, which professionals use to help diagnose.

Here are some examples of questions a clinician tries to answer:

• Is sadness related to a loss, or just out of the blue?
• Is the adolescent using substances as a way of coping?
• Is substance use a response to stressful life events?
• Is impulsivity part of a child’s personality, or tied to hyperactivity, or is it more manic and self-destructive?
• Is the goal of substance use to seek excitement or to escape reality?

Examples of Results

Differential diagnosis may reveal that substance use is a consequence of a mental health disorder. Here are just a few examples of how substance use can grow out of a mental health disorder:

• Alcohol can be a self-treatment for anxiety, depression or bipolar disorder.
• Marijuana use is often tied to psychotic disorders, ADHD and anxiety.
• Opiates (Percocet, Tylenol w/Codeine) and benzodiazepines (Xanax, Ativan) are more likely to be used by young people with oppositional defiant disorder, conduct disorder, and borderline personality disorder.
• Amphetamine (Adderall) use can be a response to overwhelming anxiety and stress related to academic performance.

On the other hand, psychiatric mental health symptoms might result from the direct effect of the substance on the brain. Again, here are just a few examples:

• Alcohol use can cause significant mood fluctuations.
• Nicotine use can mimic anxiety symptoms.
• Psychedelic drugs can cause psychotic states.

Even if it turns out that a young person’s substance use and mental health symptoms are not related to each other, they can still make each other worse.

The next few sections introduce adolescent mental health disorders, their symptoms and treatment, and substance issues that commonly co-occur with these disorders.