It is important for clinicians, therapists, substance abuse counselors, mental health workers, and criminal justice workers who are encountering and working with adolescent girls who present with comorbid disorders to recognize and address several issues to ensure these girls will achieve success in treatment.

The etiology of substance abuse varies by gender and ethnicity, and there is a growing recognition that the meaning behind substance use in adolescents may also vary. Teenage girls appear more willing to share their feelings and experiences with others — a strength that could result in helpful feedback or support from others, thus, enabling girls to nurture and connect with other girls. Whereas boys tend to use alcohol for recreation and the known effect of the drug, girls have been found to use alcohol as a means of connecting to others (Donovan, 1996). When faced with a drug-using group, some girls will use substances to maintain comfort in a situation that might otherwise be strained by their lack of participation.

Depression has been identified as a factor strongly associated with substance abuse among adolescent girls. If drug use is understood as a mechanism to cope with emotional pain, it is not difficult to comprehend this connection. Several studies have supported the prevalence of significant comorbidity of depression and other psychiatric disorders. Depression is one of the most common comorbidities that accompany substance use for adolescent girls (Yule, 1992; Yule & Canterbury, 1994).

Although rates of major depressive disorder are equal for boys and girls during childhood, gender differences emerge during adolescence with rates among girls double that of boys, similar to the female-to-male ratio found in adults (Noken-Hoeksema, Gingus, 1994). Many adolescent girls who present for treatment meet criteria for two or more co-occurring diagnoses, a phenomenon referred to as comorbidity. In principle, an adolescent girl could meet criteria for two or more disorders; in practice, some combinations of disorders are much more likely to occur in girls than in boys. Disorders that frequently coexist are substance dependence and depression and anxiety disorders (Hovens, et al., 1998). Researchers continue to wonder how comorbid disorders emerge, and why some combinations of disorders are more prevalent than others — whether there are common features or simply overlap and ambiguities of various disorders. Many adolescent girls may suffer significant impairment in multiple domains and areas of functioning (Kazdin, 2000). It is important when determining comorbidity in adolescent girls to formulate a differential diagnosis — basically, finding out what is going on with her. This is accomplished by looking at: presenting symptoms; her history (some clinicians make the mistake of looking only at present symptoms); and stressors in her life that exacerbate symptoms (i.e., family, environmental, developmental).

Etiology of depression in adolescent girls
Clinicians have posited many models to account for behaviors in adolescent girls — depression being among them — regarding their psychological functioning, psychopathology, and psychobiological development. Research indicates several risk factors for depression for adolescent girls (Kazdin 1989; Weller and Weller; 1990). These risk factors can emanate from multiple sources, including the loss of a primary object or parent through death or abandonment. This can result in anger turned inward, which from this psychodynamic perspective, defines depression. This loss produces unsatisfied affection needs and diminished self-esteem.

Cognitively, depression is associated with an adolescent girl’s thinking or thought distortions. Seligman (1975) introduced the concept of “learned helplessness,” which basically posits the belief: “I do not have any control over my situation, and there is nothing I can do about it, so I surrender, acquiesce, because I can’t do anything about the situation.” Learned helplessness, which can result in depression, holds implications for domestic violence prevention. Learned self-helpfulness vs. learned helplessness are both cognitive constructs that can be learned and unlearned. “Cognitive distortions” can affect an adolescent’s judgment regarding the social environment and the world. For example, “I must be thin in order to be successful,” or “If I am not in a relationship with a boy, then I must be inadequate.” In the cognitive approach to depression, there are three types of negative thinking, according to Beck (1979) — negative views of oneself, the world, and the future. These views can eventually produce depression in adolescent girls. The whole point of learned helplessness is, “I give in and I am helpless.”

Behavioral formulations of depression are based on the notion that depressive symptoms are learned through interactions with the environment. Deficient social skills, as well as other skill deficiencies, may be a function of “reinforcement” histories. Specifically, according to the behavioral theory, an adolescent girl may become depressed due to lack of environmental reinforcement, and depressive symptoms in adolescent girls also may occur due to a lack of “reinforcers” in the environment. An example of depression caused by behavior reinforcement is: “If I drink with the other girls, I’ll be more acceptable to boys, because all the girls I know drink and also have boyfriends. So, I drink, and I now have a boyfriend.” An example of depression resulting from poor or lack of reinforcement is, “I go out of my way to please everyone and people still do not like me.”

Research demonstrates that depressed adolescent girls frequently report stressful life events, and the occurrence and number of stressors appear to be positively related to depression in children. It is crucial for individuals who are working with adolescent girls to understand the nature, importance, and implications of this and to see how the role of abuse, violence, and other gender-specific losses have not been addressed (i.e., physical or sexual abuse, or witnessing the abusive acts which makes the adolescent girl a co-victim). Depression may result when girls experience a loss of control regarding educational and vocational opportunities; health; childhood; their own bodies; home and sense of permanence; belief, trust, faith, hope; or credibility. It is apparent that for adolescent girls, a salient or acute loss, or multiple losses often lead to depression (Rutter 1997).

Pipher and others (Herman, 1981, 1992; Forman and Buck, 1988; Girls, Inc. 1996) contend that the lack of viable options for girls to express their true selves leads them to act in ways that appear self-destructive but are often logical, adaptive responses to the world in which they live. Their behavioral actions and symptoms can be understood as acts of resistance and strength against a society that ignores and frequently damages them. Running away, truancy, suicidal gestures, depression, excessive dieting, weight gain, prostitution, early pregnancy, and drug and alcohol use may all be signs that a girl is trying to protect herself from the onslaught of messages she receives on a daily basis — that she is bad, wrong, manipulative, frigid, unlovable, and weak. Lack of safety is definitely a cause for depression and anxiety.

This author’s work with children and adolescents indicates that in order to feel safe, the child must experience predictability (she knows what will happen everyday); consistency (she knows certain events will occur daily at the same time); and activity (we do this as a family).

Assessing adolescent girls with substance abuse and depression
Adolescent girls who abuse substances are prone to other emotional and behavioral problems, such as depression (Newcomb, 1995; Winters, 1999A). The major challenge for therapists is in differentiating problems related to substance use, from issues that are not drug-related. For instance, substance use symptoms such as depression, serious familial conflict, and chronic school truancy also are common mental health issues for adolescents. Regarding adolescents, substance abuse is best viewed on a continuum of drug use progression (Newcomb, 1995). Differentiating drug experimentation from substance abuse is a critical issue in conducting assessments with adolescent girls. Assessments for comorbidity (i.e., substance abuse and depression) should rule out other disorders or include features of other disorders (Chatlos, 1994). Feelings of depression, anxiety, and peer rejection have been found to be general predictors of drug disorders among adolescent girls.

Special attention also should be given to the potential threat of suicide. This is especially important when assessing marijuana users, as their rate of suicidal ideation is three times as high as that of non-users (Greenblatt, 1999). For purposes of establishing treatment intervention, it is important to examine the motivation for adolescent substance use, including: peer motive — wanting to be accepted or dealing with rejection; coping motive — addressing feelings of anger, anxiety, fear or depression about school or home life, or lack of safety or predictability; and a drug experience motive — a desire to experience the drug itself, which often is prompted by peer use. It may benefit the diagnosis/treatment plan to inquire directly what purpose or purposes her drug use serves.

To institute effective treatment for adolescent girls who present with substance abuse and depression, clinicians or therapists need to first understand the ways in which alcohol and drug use differs for girls and boys — their respective risk factors, and the ways in which depression manifests differently in girls and boys. This awareness allows for both clinically appropriate and gender responsive interventions. A major report issued in February 2003 by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, The Formative Years: Pathways to Substance Abuse Among Girls and Young Women Ages 8-22 outlined the following risks and consequences of smoking, drinking, and drug use, which are unique to girls and young women:

• Girls experiencing early puberty are at higher risk of using substances sooner, more often, and in greater quantities than later maturing peers; puberty is a time of higher risk for girls than for boys.
• Girls are more likely than boys to be depressed, have eating disorders, or be sexually or physically abused, all of which increase the risk for substance abuse.
• Girls are more likely than boys to abuse prescription painkillers, stimulants, and tranquillizers.
• Substance use can evolve into abuse and addiction more quickly for girls and young women than for boys and young men, even when using the same amount or lesser amounts of a particular drug.
• Girls and young women are more likely than boys and young men to experience more adverse health consequences, such as greater smoking-related lung damage. Women are more susceptible to alcohol-induced brain damage, cardiac problems, and liver disease, which occur more quickly and with lower levels of alcohol consumption than with males.
• Girls using alcohol and drugs are likelier to attempt suicide.
• Girls who move frequently from one home or neighborhood to another are at greater risk of using substances than boys who move frequently.
• Transitions from elementary to middle school, from middle to high school, and from high school to college are times of increased risk for girls. Girls making the transition from high school to college show the largest increases in smoking, drinking, and marijuana use.
• Girls are more likely to be offered substances by a female acquaintance, a young female relative, or a boyfriend, and are more likely to receive offers in private settings. Whereas boys are more likely to be offered drugs by a male acquaintance, a young male relative, a parent, or a stranger, and to receive these offers in public settings.
• Religion is more protective for girls than for boys.

The 2003 CASA report, which includes data obtained from 1,220 girls and young women, offers a tool for clinicians to work effectively with adolescent girls who present with substance abuse and depression. In the area of prevention, CASA’s formative years survey showed that most girls (61.6 percent) who had conversations with their parents about substance use said that those conversations made them less likely to smoke, drink, or use drugs. The report also concluded that prevention programs should target girls at times of highest risk and be sensitive to the reasons why girls use drugs and how they obtain them, as well as contributing factors (i.e., abuse, depression) that increase their risk. The report recommended that health professionals should screen young female patients for substance use, depression, sexual and physical abuse, poor school performance, eating disorders, and stress, and provide appropriate referrals.

Effects of alcohol and depression
Victor M. Hesselbrock of the Department of Psychiatry at the University of Connecticut, School of Medicine, co-authored “Alcoholism: Clinical and Experimental Research,” which examined teenage girls with a history of depression rather than active depression, to see if they exhibit a subtle abnormality in brain function. They also investigated the possibility that this abnormality was exaggerated by the presence of depression or alcoholism in the families of these girls. Researchers and clinicians have often raised the question of whether clinical depression is “a state or a trait,” said Lance O. Bauer, Professor of Psychiatry at the University of Connecticut, School of Medicine, and lead author of the study. Do patients with clinical depression possess normal brain function that only becomes abnormal when in a state of active depression, or do these patients possess a subtle brain abnormality that is always present?

The researchers examined 151 adolescent females between the ages of 15 and 20. The subjects were categorized as: depressed or non-depressed; being positive or negative for family history of alcoholism; and having a positive or negative history of depression. Of these 151 subjects, 58 met Diagnostic and Statistical Manual of Mental Disorders - Third Edition Revised (DSM-IIIR) criteria for a personal lifetime diagnosis for depression; only four subjects met the criteria for a current episode of depression. Results from the study indicated that a personal history of depression, and a family history of alcoholism had opposite effects on the EEG power spectrum. A family history of alcoholism was associated with a qualitatively different abnormality in brain function — an enhancement of 19 to 30 cycles per second. This is referred to as “beta” or “fast-wave” activity. Professor Adolf Pfeffer, Director of the Neuropsychiatry Program at SRI International, calls these findings both interesting and intriguing. Bauer and Hesselbrock noted, “This pattern of association and dissociation suggests potential and different biological markers for liability for alcoholism or depression.”

They further explained that this possibility for a predictor of alcoholism is strengthened when taken together with another recent publication of Bauer, in which he found increased beta power in alcoholics — more so in the men than the women. Based on findings regarding the effects of a family history of alcoholism occur in a different region of the brain (left frontal) than the effects of a personal history of depression; and with the presence of both depression and a family history of alcoholism, might call for a different or more intensive treatment strategy than would apply to a depressed patient without a family history of addiction.

The depression factor
Depression in adolescents can be a transient response to a situation or stressor, a reaction to a traumatic event, such as a romantic break-up or a death, or conflicts with parents. These depressed moods are common in teens because of the maturation process and the influence of sex hormones. These “normal” responses make true depression difficult to diagnose; thus, clinicians must distinguish between the two. Teens who have little control over negative events in their lives are at higher risk for true depression. MEDLINE Plus (a Service of the U.S. National Library of Medicine and the National Institutes of Health), lists several symptoms to help identify true depression and signs and tests to employ in its diagnosis, among them:
• depressed or irritable mood
• temper; agitation
• loss of interest or reduced pleasure in activities; apathy
• change in appetite or weight
• disruptive sleep patterns
• fatigue
• difficulty concentrating or making decisions
• memory loss
• preoccupation with self
• feelings of worthlessness, sadness, or self-hatred
• excessive or inappropriate feelings of guilt
• acting-out behavior (missing curfews, unusual defiance)
• thoughts of or attempts at suicide; or obsessive fears of worries about death
• irresponsible behavior pattern

If symptoms persist for two weeks or longer or result in significant distress or difficulty in functioning, professional intervention is necessary. Suicide attempts or threats should never be ignored.

Certain signs or tests should be conducted to assess for depression in adolescents. First, a physical examination and blood tests should be performed to rule out medical causes for symptoms of depression. Upon ruling out a medical cause, the adolescent should be evaluated for substance abuse — heavy drinking, frequent marijuana smoking, and other drug use can be both causes and consequences of depression.

Because addiction treatment used to assume depression was only a symptom of use, not a potential cause, it often went untreated. Research now shows that this leads to increased risk of relapse. If a substance abuse problem is found, a thorough psychiatric evaluation should be conducted to assess for depression and other potential psychiatric problems. Specifically, the evaluation should assess for a history of persistent sad, empty, or irritable mood, and any loss of interest or pleasure in normal activities. It should also serve as a screening for other potentially co-occurring psychiatric disorders, such as anxiety, mania, or schizophrenia.

Finally, the adolescent should be assessed for any suicidal/homicidal risks. Information from family members or school personnel is often helpful in identifying depression in teens.

Assessing adolescent substance abuse
Screening for adolescent substance abuse should be conducted by health care delivery systems, juvenile justice and family court systems, and community organizations, such as schools, vocational rehabilitation, and religious organizations. Adolescents who meet the following criteria should be screened for substance abuse: receive mental health assessments; enter the child welfare system; drop out of school; or stay at homeless shelters. Adolescents arrested or detained within the juvenile justice and family court systems also should be screened.

Screening for substance abuse should focus on the adolescent’s severity of use and core associated factors such as mental health status, family history of parental addiction, functioning in school, and any legal problems. Any adolescent whose screening reveals indicators (e.g., daily use of one or more substances) of serious substance abuse problems should be referred for a more comprehensive assessment.

Considerations for adolescent treatment
Treatment of substance abuse required special consideration of the adolescent’s individual experience and how it affects the nature and severity of his or her alcohol or drug use. Understanding the adolescent’s situation helps to explain why alcohol or drugs are used and how they became an integral part of his or her identity. The following factors should be considered when tailoring treatment for adolescents:
• Developmental Stages - Treatment for adolescents should address their unique developmental needs, which vary with the age of the client. Developmental features of younger adolescents are different from those of older adolescents. For example, older adolescents are more capable of abstract thinking and are more likely to openly rebel than younger adolescents.
• Ethnicity and Culture - Norms, values, and health beliefs differ across cultures and can affect substance abuse treatment. For example, some cultural groups may consider treatment invasive; others may wish to involve the extended family. Treatment services need to be culturally competent and use the preferred language of adolescent clients and their families.
• Gender and Sexual Orientation - Gender and sexual orientation play a role in adolescent substance abuse and involvement in treatment. For example, adolescent girls more often have internalizing coexisting disorders such as depression, whereas boys are more likely to have externalizing disorders such as conduct disorders. Effective treatment for gay, bisexual, and transgendered youth includes helping them to acknowledge and accept their sexual identity.
• Co-occurring Mental Disorders - Adolescents with substance abuse disorders are more likely than abstinent peers to have co-occurring mental health problems such as anxiety disorders, attention deficit-hyperactivity disorder, and depression. In these teens, substance abuse may disguise, exacerbate, or be used to “self medicate” psychiatric symptoms. Without tailored treatment, co-occurring mental disorders could interfere with the adolescent’s ability and motivation to participate in addiction treatment and could increase the potential for relapse.
• Family Factors – An adolescent’s family can play a role in the origin of the substance abuse problem, and/or can act as an agent of change in the adolescent’s environment. Family factors that increase risk for substance abuse problems in youth — including any history of parental or sibling substance abuse problems or addiction; domestic violence; physical, sexual, or emotional abuse; and neglect — all should be accounted for in treatment. Whenever possible, parents should be involved in all phases of their adolescent’s treatment.

Research indicates a strong correlation between parental pathology and mental health problems in children. A longitudinal study of mental health by Weissman and colleagues (1997) included parental psychiatric status of parents as a predictor of major depressive disorder and of alcohol abuse in adolescence. Studies found children of parents with substance use disorders are more likely to experience depression (Merikangas et al., 1985) and substance abuse problems (Hoffmann and Cerbone, 2002; Hoffmann and Su, 1998). Cited studies associate stressful events in the lives of adolescents with an increase in depressive symptoms, including parental psychopathology (Beardslee, 1990), divorce and discord between parents (Fendrich et al., 1990), and self blame for the parents’ problems (Beardslee, 1990). Hoffmann et al. (2003), cite Yoshikawa (1994), who states that adolescents without adequate family support suffer from poorer mental health and attenuated well being overall. Females, according to Nolen-Hoeksema and Girgus (1994), are more likely than males to experience depression during adolescence and, according to Klimes-Dougan and Bolger (1998), have a more difficult time coping with stressors, including parental psychopathology. It is imperative that family factors be addressed relative to diagnosis and treatment of adolescent girls with substance abuse and depression.

Cognitive-Behavioral Intervention
Family and Coping Skills (FACS) therapy is based in cognitive-behavioral family theory and research, and targets identified deficiencies in social cognitive processes (Curry et al., 2003). Curry et al. utilized both behavioral family therapy and cognitive behavioral therapy in their treatment program, based on their proven effectiveness in reducing adolescent depression (Curry, 2001) and in preventing or reducing teen substance abuse (Botvin et al., 1995; Kaminer et al., 1998). They utilized the Robin and Foster (1989) model of family therapy, focusing on parent-adolescent communication; conflict resolution; and problem-solving, augmented by behavioral interventions to improve monitoring of and consequences for teen substance use. Based on the treatment development process, which included two separate treatment programs, the current version of FACS therapy contains the following components:

• A clinical interview, including symptom review, with the adolescent and one or both parents, followed by adolescent-report scales for depression and substance abuse.
• A semi-structured research diagnostic interview and battery of adolescent and parent questionnaires.
• A feedback and treatment contract interview with the adolescent and parent(s) to review assessment results and to set individualized goals.(The treatment contract includes an agreement to: strive for abstinence during the program; help other group members attain abstinence; and a no-suicide contract.)
• Twice-weekly adolescent group therapy sessions; weekly family therapy sessions.
• Urine drug screens collected before randomly selected group sessions.
• Monthly parent psycho-educational group meetings.
• As-needed individual or crisis intervention sessions or telephone contacts.

A 2002 study by Paula D. Riggs, M.D. and Robert D. Davies, M.D. provides us with the basis for integrated treatment of adolescent girls with substance abuse and depression. The study published in the Journal of American Academy of Child and Adolescent Psychiatry, begins by engaging the patient in establishing her own goals regarding her substance use (with comorbid depression, clinicians should emphasize reducing or discontinuing substance use). Once the adolescent is engaged in substance treatment and abstinence is established, a carefully monitored pharmacological therapy for depression may be initiated, accompanied by close scrutiny of substance use, urine toxicology results, side effects, medication compliance, motivation, and symptom response, as well as behavior changes and psychosocial functioning. If depression and substance use do not significantly improve within the first two months, a more intensive level of treatment, with greater family involvement, should be considered. Family therapy is an important component of comprehensive, multi-modal treatment for adolescent substance abuse and depression. It is important to maintain a dialogue with the client about each step of the program and her progress. She may also derive benefit from participation in 12-step programs. The potential for relapse after achieving abstinence should be discussed with the adolescent, and a detailed plan should be developed to intensify treatment and family involvement to prevent lapses from becoming full-blown relapses.

Conclusion
According to Pipher (1994), girls have basic and unique needs — including love from family and friends; meaningful work; respect; challenges; physical and psychological safety; identities based on talents or interests rather than appearance; popularity or sexuality; good habits for coping with stress; self-nurturing skills; and a sense of purpose and perspective — for keeping true to themselves and growing into healthy adults. Girls who are challenged with the struggle against substance abuse and depression in their lives also face the basic question, “How do I, as an adolescent girl, bounce back or thrive and strive in spite of what has happened to me?”

An important issue for clinicians working with this population is resiliency. According to Apfel and Simon (1996), there are several factors that contribute to resiliency for adolescent girls, including: resourcefulness; ability to attract and use adult support; curiosity and intellectual mastery; compassion (with detachment); ability to conceptualize; conviction of one’s right to survive; ability to remember and invoke images of good and sustaining figures; ability to be in touch with a variety of effects; a goal to live for - a vision of the possibility and desirability of the restoration of a qualified moral order, and the need and ability to help others (This is important, because often when adolescents have challenges that prohibit them from seeing possibilities in their lives, they need an adult to see those possibilities for them.); an affective repertoire; and altruism toward others.

The interesting point is that an adolescent girl does not need to focus on developing all of the above components but, rather, just one — a goal to live for, such as a career goal. Perhaps her goals can serve as motivation to overcome the challenges presented by her depression and addiction. Finally, in working with adolescents, there is the principle that says, “If you take something away from a kid, you must be willing to replace it with something else.” It is this author’s hypothesis that rather than clinicians, parents, and teachers being so quick to say “no” to kids, we must give them some things to say “yes” to. Make them aware of the other positives in their lives — that they can recover from alcohol and drugs and depression and live normal lives; that their lives are worth living; that dreams do come true; and that they have value and worth. Adolescents, girls in particular, need to hear yes more often than no.

Fred Dyer, MA, CADC, is a nationally recognized trainer and consultant who services social service, juvenile justice, and mental health organizations and systems. He has 18 years of clinical experience working with children and adolescents and has published numerous articles and two workbooks for practitioners. Fred’s most recent publication is Razor’s Edge: Helping Adolescents Deal with Challenging Issues. Fred can be reached at (773) 944-9076, (773) 425-2512, or This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

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This article is published in Counselor,The Magazine for Addiction Professionals, August 2005, v.6, n.4, pp.12-20.

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