Adolescence is a critical developmental phase for the onset and recognition of psychiatric disorders and substance use disorders (SUD). The term “dual diagnosis” (DD) describes the co-existence of a comorbid mental disorder with SUD. While we’ve known for a while that a significant segment of adolescents with SUD are dually diagnosed (Kaminer, 1994), one recent study concludes that multiple co-occurring problems are the norm among adolescents with substance abuse problems (White, White, & Dennis, 2004).

DD among adolescents has considerable clinical, public health, and research implications (Kaminer, 1994). From the clinical perspective, subgroups of dually diagnosed adolescents may respond differentially to specific therapeutic and more costly services resources (e.g., medications, physicians, mental health clinicians) to meet their dual needs. From the public health perspective, subgroups of adolescents with comorbid disorders may be at a higher risk of contracting or manifesting additional disorders and of increased severity of the course of each one of the index disorders. The implications for research are that more homogenous subgroups within a given diagnostic category can be more accurately studied to provide better patient-treatment matching.

In light of these various implications, it is essential for addiction professionals to increase their knowledge about DD. This article reviews the nature of the relationship between SUD and psychiatric comorbidity, the epidemiology of specific comorbid psychiatric disorders, and the assessment and treatment of dually diagnosed adolescents.

The nature of psychiatric comorbidity
While the causes of psychiatric comorbidity have not yet been researched systematically, a number of possible relationships exist between SUD and comorbid psychopathology. Psychopath-ology may precede SUD, may develop as a consequence of preexisting SUD, may influence the severity of SUD, may not be related, or may originate from a common vulnerability (Hovens, Cantwell, & Kiriakos, 1994).

The comorbidity issue adds a level of complexity to understanding substance abuse. Two factors have continued to pose a challenge for clinicians and researchers: (1) whether substance abuse is primary or occurs secondary to another disorder, and (2) how the interaction of coexisting disorders influences the onset, identification, course, and assignment to treatment and aftercare setting (i.e., placement criteria) and/or modality (i.e., patient-treatment matching).

Psychiatric disorders in childhood — most commonly featured by disruptive behavior disorders such as conduct disorder and oppositional defiant disorder, as well as internalizing disorders such as mood or anxiety disorders — confer an increased risk for the development of SUD in a majority of the cases in adolescence (Loeber, 1988; Bukstein, Brent, & Kaminer, 1989). In the majority of cases (75 percent), the onset of psychopathology precedes the development of SUD (Christie, Burke, Regier, Rae, Boyd, & Locke, 1988). This is what commonly has been referred to as the “self-medication” model.

Specific psychiatric disorders
The most prevalent psychiatric comorbidity in adolescents with SUD is conduct disorder. It and constituent criteria, such as aggression, usually precede and accompany adolescent SUD (Loeber, 1988; Milin, Halikas, Meller, & Morse, 1991; Myers, Brown, & Mott, 1995). Clinical populations of adolescents with SUD show rates of conduct disorder regularly ranging from 50 percent to almost 80 percent. Conduct disorder is negatively correlated with successful treatment outcome (Hser, Grella, Hubbard, Hsieh, Fletcher, Brown, & Anglin, 2003; Kaminer, Tarter, Bukstein, & Kabene, 1992; Kaminer, Burleson, & Goldberger, 2002). Furthermore, aggressive behaviors are present in many adolescents who have SUD (Milin et al., 1991).

Consumption of such substances as alcohol, amphetamines, and phencyclidine may increase the likelihood of subsequent aggressive behavior (Moss & Tarter, 1993; Tuchfield, Clayton, & Logan, 1982). The presence of preexisting psychopathology, the use of multiple agents simultaneously, and the frequent relative inexperience of the adolescent substance user may further exacerbate the direct pharmacological effects, resulting in aggression.

Although attention-deficit/hyperactivity disorder (ADHD) is commonly noted in substance-using and substance-abusing youth, the observed association in most cases is likely due to the high level of comorbidity between conduct disorder and ADHD (Barkley, Fischer, Edelbrock, & Smallish, 1990; Kaminer, 1992; Wilens, Biederman, Spencer, & Frances, 1994). An earlier onset of conduct problems and aggressive behavior, in addition to the presence of ADHD, may increase the risk for later substance abuse (Loeber, 1988). A prospective follow-up study found that adolescents with and without ADHD had a similar risk for SUD that was mediated by conduct and bipolar disorders (Biederman, Wilens, Mick, Farone, Weber, Curtis, Thornell, Pfister, Jetton, & Soriano, 1997).

Because the risk for SUD has been shown to be elevated in adults with ADHD without comorbidity of the adult form of conduct disorder (i.e., anti-social personality disorder), it remains to be seen whether a sharp increase in SUD rate will occur in the grown-up ADHD children included in this cohort during the transition from adolescence to adulthood. The commonly expressed notion that youth or adults with “masked” or “residual” ADHD abuse stimulants such as cocaine in order to self-medicate has not been empirically supported (Coetzee, Kaminer, & Morales, 2002; Kaminer, 1994). It is noteworthy that juvenile onset bipolar mood disorder, characterized by irritability and mood swings, may frequently co-occur with ADHD. Some adolescents with ADHD reported using drugs for mood adjustment rather than to achieve a “high” (Wilens, 1998).

Mood disorders, especially depression, frequently have onsets both preceding and consequent to the onset of substance use and SUD in adolescents (Bukstein, Glancy, & Kaminer, 1992; Deykin, Buka, & Zeena, 1992; Hovens et al., 1994). Mood disorders is second only to conduct disorder as the most prevalent comorbid psychiatric disorder. The prevalence of depressive disorders in these studies ranged from 24 percent to more than 50 percent. Triple diagnosis of conduct, mood, and substance use disorders constitute the third most prevalent combination of comorbidities.

The literature supports adolescents’ SUD as a risk factor for suicidal behavior, including ideation, attempts, and completed suicide (Crumley, 1990; Kaminer, 1996). Possible mechanisms for this relationship include acute and chronic effects of psychoactive substances. Adolescent suicide victims are frequently using alcohol or other drugs at the time of suicide (Brent, Perper, & Allman, 1987). The acute substance use may produce transient but intense dysphoric states, disinhibition, impaired judgment, and increased level of impulsivity or may exacerbate preexisting psychopathology, including depression or anxiety disorders.

A number of studies of clinical populations show high rates of anxiety disorders among youth with SUD (Clark, Bukstein, Smith, Kaczynski, Mezzich, & Donovan, 1995; Clark & Sayette, 1993). In clinical populations of adolescents with SUD, the prevalence of anxiety disorder ranged from 7 percent to more than 40 percent (Clark et al., 1995; Stowell, 1991). The order of appearance of comorbid anxiety and SUD appears to be variable, depending on the specific anxiety disorder. Social phobia usually precedes abuse whereas panic and generalized anxiety disorder more often follow the onset of SUD (Kushner, Sher, & Beitman, 1990). History of physical and sexual abuse is common among youth with posttraumatic stress disorders (PTSD), which in turn may lead either directly or through the mediation of anxiety or depression to SUD (Clark & Neighbors, 1996). The prevalence of comorbid PTSD has been estimated at up to 25 percent of males and up to 75 percent of females with SUD.

The study of the following five disorders has lagged far behind compared to internalizing and externalizing disorders. With respect to eating disorders, bulimia nervosa is commonly associated with adolescents having substance use disorders. However, anorexia nervosa is rarely diagnosed with substance abuse (Bulik, 2002). There is nevertheless a lack of nosological clarity (nosolgical referring to the classification diseases) regarding whether, when, how long, and how much abuse of medications (e.g., diuretics, prescribed stimulants) or even drugs (e.g., cocaine) for the sole purpose of dieting qualifies as SUD (Kaminer, 1994).

Regarding the psychotic disorder spectrum, SUD are very common among individuals who are diagnosed with schizophrenia or bipolar mood disorder (Kutcher, Kachur, & Marton, 1992). Personality disorders among adolescents with SUD are highly prevalent, in particular cluster B, which includes narcissistic and borderline personality disorders (Grilo, Becker, Walker, Levy, Edell, & McGlashan, 1995). Gambling behaviors are common among adolescents with SUD. Griffith (1995) reported that gambling behavior (i.e., per definition a spectrum of pre-pathological behaviors) in British youth preceded substance abuse. However, Kaminer, Burleson, and Jadamec (2002) did not find elevated rates of pathological gambling among adolescent substance abusers. With respect to learning disabilities, studies have suggested language deficits in youth affected by or at high risk for SUD. Learning disabilities or disorders may also show an increased incidence of comorbidity (Moss, Kirisci, Gordon, & Tarter, 1994).

A study regarding ethnic differences in comorbidity indicated that both African-American and Hispanic youths presented with high-above-threshold symptom rates for co-occurring disorders (Robbins, Kumar, Walker-Barnes, Feaster, Briones, & Szapocznik, 2002). Hispanic youths demonstrated greater rates of externalizing symptoms than did African-American youths. Latimer and colleagues (2002) replicated previous findings regarding gender differences that males have higher rates of disruptive disorders while females had higher rates of depression.

Assessment of the adolescent
It is important to conduct a thorough assessment in order to ensure a focused and specific treatment plan to meet the needs of the dually diagnosed adolescent. By recognizing the assessment and treatment of SUD as a multiphasic task, the field has taken a significant step toward addressing the need for better therapeutic interventions for adolescents with SUD. The expert committee of the Institute of Medicine report (1990) of the Adolescent Assessment/Referral System developed by the National Institute on Drug Abuse (Tarter, 1990) recommends a three-phase process.

The initial screening phase involves identification of health disorders, psychiatric problems, and psychosocial maladjustment. Based on this first phase, a minority of adolescents is required to go through the second phase, which includes an extensive assessment necessary for initiating integrated, problem-focused, and comprehensive treatment. This assessment provides a diagnostic summary which identifies the adolescent’s treatment needs within specific life domains, such as substance use, psychiatric status, physical health status, school adjustment, vocational status, family function, peer relationship, leisure and recreation activity, and legal situation. The third phase involves the preparation and implementation of an integrative treatment plan. Determining treatment setting (i.e., placement criteria), treatment and aftercare modality (i.e., psychosocioecological, psychopharmacological), and which patients respond best to what treatments (i.e., patient-treatment matching) may increase treatment effectiveness (Kaminer, 2001).

Substance use disorders are multidimensional behaviors that demand a thorough assessment of several dimensions of substance use behavior in addition to quantity and frequency of use. Within the domain of substance use behavior, important dimensions include the pattern of use (quantity, frequency, onset, and types of agents used), negative consequences (school/vocational, social/peer/family, emotional/behavioral, legal and physical), context of use (time/place, peer use/attitudes, mood antecedents, consequences, expectancies, and overall social milieu), and control of use (view of use as a problem, attempts to stop or limit use, other DSM-IV dependence criteria).

Comprehensive assessment instruments usually provide more detailed information about substance use behavior as well as other domains of functioning. The format for comprehensive instruments vary, with some being self-report questionnaires (e.g., Personal Experience Inventory [PEI]; Winters & Henly, 1988), others being structured interviews (e.g., Adolescent Drug Abuse Diagnosis [ADAD]; Friedman & Utada, 1989), and others semistructured interviews (e.g., Adolescent Problem Severity Index [APSI]; Metzger, Kushner, & McLellan, 1991, Teen-Addiction Severity Index [T-ASI]; Kaminer, Bukstein, & Tarter, 1991; Kaminer, Wagner, Plummer, & Seifer, 1993). The most commonly used diagnostic instruments for youth psychopathology are the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS) and the Diagnostic interview Schedule for Children (DISC; Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone ME, 2000).

Treatment for the dually diagnosed adolescent
Treatment strategies for dually diagnosed adolescents consist of psychosocial interventions with or without concomitant psychopharmacological interventions. Psychosocial interventions for dually diagnosed conduct disordered youths have included family, contingency management reinforcement (CM), and cognitive behavioral (CBT) therapies.

The most common family intervention strategy employed with adolescent SUD has been the multisystemic therapy (MST). This is an intervention that focuses on the individual, family, peer, school and social network variables linked with identified problems as well as on the interface of these systems (Henggeler, Clingempeel, & Brondino, 2002). MST views engagement and overcoming family resistance as the therapist’s and program’s responsibility (Pickrel & Henggeler, 1996). Virtually all services are provided in the natural environment of the youth and family, and may include up to 60 hours of intervention. Henggeler, Clingempeel, and Brondino (2002) reported the findings from a four-year follow-up of this trial. The study did not obtain significant MST effects for reduced property crimes, biological indices of drug use or internalizing and externalizing behaviors. Self-report indications of substance use at this follow-up did not differentiate conditions. However, MST was associated with significant reductions in aggressive criminal behavior. The findings for adolescents with diagnosed substance use problems were not as favorable as Henggeler’s earlier trials of MST with chronic and violent juvenile offenders who did not necessarily have substance abuse problems. It appears that MST might benefit from the addition of a CM component. Indeed, ongoing study is targeting the integration of these two strategies.

CM reinforcement procedures provide rewards for clean (i.e., negative) urinalysis. Drug abstinence can be improved by providing tangible incentives that are contingent on providing objective evidence of abstinence. An abstinence reinforcement system used in combination with an intensive behavioral treatment program has produced impressive outcomes (Kaminer, 2000). CM can also be applied to drug-seeking behaviors, improved attendance, and aggressive or inappropriate behaviors. Petry (2000) recommended the following checklist when designing and implementing CM procedures:

1) Target the most important behavior to be changed. Choose one that can be quantified objectively and occurs frequently (e.g., marijuana abstinence).

2) Choose a reinforcer. Vouchers, cash, and prizes are desirable reinforcers by clients’ standards and agreeable to staff.

3) Utilize behavioral principles. Keep it simple so that staff can apply the system consistently and clients can understand it.

4) Draw up a time-limited behavioral contract. Be specific regarding the targeted behavior, monitoring procedures, and reinforcement schedule.

5) Ensure consistent implementation of the contract by staff and clients.

6) Continue improving CM procedures by keeping records, consulting with staff, and receiving feedback from clients regarding problems in the implementation process and what does or does not work.

The use of adolescent-centered CBT manuals focusing on a range of cognitive processes and behavioral coping skills represents a recent trend in the treatment of adolescent SUD (Kaminer, Blitz, Burleson, Sussman, & Rounsaville, 1998; Kaminer et al., 2002; Waldron, Slesnick, Brody, Turner, & Peterson, 2001). CBT offers a logical strategy for treating adolescent SUD given that the high-risk behaviors and maladaptive thoughts place adolescents at risk for drug use. The goal of CBT is to diminish factors contributing to drug involvement (e.g., the most common one is peer/social pressure) and promote factors that protect against (re)lapse (e.g., coping skills, and drug-free social network). Evidence for the contribution of cognitive behavioral process to treatment outcome in youth has been accumulating. Further, coping factors have been identified as significant predictors of treatment outcome (Myers & Brown, 1990).

Research evaluating CBT for behavioral problems and disorders associated with adolescent substance abuse, such as conduct problems, depression, anxiety, and PTSD is well established (see review by Kaminer & Waldron, in press). Empirical support for CBT with adolescent disorders known to co-occur with adolescent substance use would seem to lend support to CBT for adolescents with comorbid disorders including SUD. Surprisingly, few systematic studies have been conducted evaluating CBT for dually diagnosed youth. Research evaluating CBT for other psychiatric disorders, then, provides a critical foundation for future clinical trials. Only one pilot study examining the feasibility and preliminary symptomatic efficacy of CBT for depressed, substance-abusing adolescents has been reported so far with promising results (Curry, Wells, Lochman, Craighead, & Nagy 2003).

Psychopharmacotherapy, or medication treatment, potentially targets several areas, including treatment of withdrawal, use to counteract or decrease the subjective reinforcing effects of illicit substance use, and treatment of comorbid psychopathology. The high prevalence of coexisting psychiatric symptoms and disorders in adolescents with SUD presents safety, acceptability, and utility challenges for pharmacological intervention (Bukstein & Kithas, 2003). For example, the clinician might have to differentiate between symptoms associated with a withdrawal syndrome compared to psychiatric symptomatology such as mood lability, anxiety, or irritability. Few data in the literature have yet demonstrated the efficacy of pharmacological agents prescribed for dually diagnosed adolescents.

In general, addictions clinicians should use the same caution in considering pharmacological treatment for dually diagnosed adolescents as they do with youth with psychiatric symptoms alone. Potential targets for pharmacological treatment include depression and other mood problems, ADHD, severe levels of aggressive behavior, and anxiety disorders. For example, adolescents with conduct disorder may manifest impulsivity, irritability, aggression, mood swings, or anxiety, all of which may be alleviated by medications. Stimulants such as methylphenidate (Ritalin®) or dextroamphetamine (Dexedrine®) are effective for ADHD with or without comorbid conduct disorder (Riggs, 1998).

Open trials with pemoline (Cylert®), clonidine (Catapres®), and bupropion (Wellbutrin®) for ADHD and fluoxetine (Prozac®) for depression in a population of drug-dependent delinquents have shown promise (Riggs 1998; Wilens, 1998). More recently, a double blind placebo controlled trial of a stimulant medication demonstrated the efficacy of medication improving ADHD symptoms in adolescents with comorbid ADHD and SUD. This study also showed that medication treatment of ADHD alone, without specific SUD or other psychosocial treatment, did not decrease substance use (Riggs et al., in press).

Fluoxetine has been shown to be effective for depression in adolescents (Emslie, Rush, Weinberg, Kowatch, Hughes, Carmody, & Rintelmann, 1997) and for comorbid alcohol dependence and depression in adults (Cornelius, Salloum, Ehler, Jarrett, Cornelius, Perel, Thase & Black, 1997). Open trials have produced significant improvements in adolescents with SUD and comorbid depression (Cornelius, Bukstein, Birmaher, Salloum, Lynch, Pollock, Gershon, & Clark, 2001; Riggs, Mikovich, Coffman, & Crowley, 1997). Lithium in a randomized controlled trial for dually diagnosed adolescents with bipolar disorder was effective as well (Geller, Cooper, Sun, Zimermann, Frazier, Williams, & Heath 1998).

Keep current, counselors
The epidemiological data presented here lead to the conclusion that dual diagnosis in youth is the rule rather than the exception (see also Kaminer, 1994). Careful assessment is necessary to diagnose the comorbid disorders (Shaffer et al., 2000). Whenever treatment plans are developed, a multidisciplinary team composed of addiction and mental health youth specialists should simultaneously address the SUD and the comorbid psychiatric disorders.
While the field is making significant progress understanding the needs of this population, it is necessary for addiction specialists to increase their awareness of, as well as theoretical and practical knowledge about, DD. Further research promises to advance the treatment of dually diagnosed adolescents by addressing matching between patient, environment, and treatment characteristics. To keep current, join the Society for the Adolescent Substance Abuse Treatment Effectiveness (SASATE) and refer often to SAMHSA’s Mental Health Information Center at http://mentalhealth.samhsa.gov and SAMHSA’s National Clearinghouse for Drug and Alcohol Information at http://ncadi.samhsa.gov.

Yifrah Kaminer, MD, MBA ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a Professor at the Department of Psychiatry & Alcohol Research Center, University of Connecticut Health Center, and the author of Adolescent Substance Abuse: A Comprehensive Guide to Theory and Practice.

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This article is published in Counselor,The Magazine for Addiction Professionals, April 2004, v.5, n.2, pp. 62-68.

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