#8: Mental illness and substance abuse in children and teenagers

Substance abuse and mental health problems often seem to go together.

Which begs the question, which comes first, the chicken (mental illness) or the egg (substance use)? What we have seen, is that some mental illnesses such as anxiety, depression, bipolar disorder may contribute to substance use and addiction. Similarly, substance use and addiction can contribute to the development of a mental illness such as depression. When a child/teenager has a mental illness and a substance use disorder, it is called a dual diagnosis.

Treatment and management of a dual diagnosis is very specialized and intensive as both the substance use and mental illness must be treated. It is important to note, that if a child/teenager is diagnosed with bipolar disorder and substance use disorder, when the substance use stops and is managed appropriately, the mental illness will not suddenly disappear. What mental illness/disorder and substance use disorder have in common is a strong environmental connection (think back to Blog 1 and 2).

Some studies suggest that environmental factors interact with genetic vulnerability during the developmental stages and can increase the risk of mental illness and/or substance use disorder. Many environmental factors are associated with an increased likelihood of a child/teenager developing a mental illness/disorder and a substance use disorder e.g. traumatic events, chronic stress, ACEs (Adverse Childhood Experiences). For example, kids with PTSD (post traumatic stress disorder) may turn to drugs or alcohol to reduce anxiety, numb the pain and avoid dealing with the traumatic event. Furthermore, certain mental disorders increase the likelihood of a child/teenager developing a substance use disorder e.g. depression, bipolar disorder, schizophrenia.

Many areas of the brain are affected by substance use disorder. For example, the frontal lobe, which is involved in risk taking, impulse control, decision-making and emotional responses, can be affected by addictive substances such as alcohol and opioids.

Opioids are known to create an initial high, however, long-term, their continued use increase depressive symptoms and suicidal thoughts. When a child or teenager develops a mental illness, depending on where the changes occur in the brain pathways it may increase vulnerability for the use of substances by enhancing the effects of the frontal lobe e.g. reduces awareness, dulls feelings of sadness, negativity, alleviates unpleasant symptoms and/or the side effects of prescribed medication. For example, commonly prescribed antidepressants can result in feelings of agitation/restlessness, anxiety, worsening depression, insomnia, thoughts of suicide.

We know that early childhood trauma sets the stage for many mental and physical illnesses. Substance use can lead to changes in the brain similar to anxiety, depression, etc. and substance use that precedes the first signs/symptoms of a mental illness may produce changes in the brain function that kindle an underlying predisposition to developing a mental illness.*

It has been suggested that many kids with severe, mild or subclinical mental disorders may use drugs as a form of self medication. Some drugs such as opioids, benzodiazepines can reduce the signs and symptoms of a mental disorder; however, the effect is only temporary and over time, the drugs will exacerbate the signs and symptoms and create a vicious cycle. For example, a teenager with social anxiety disorder takes Xanax to help her relax, when the anxiety returns, she takes more but the anxiety keeps returning and is getting worse, so she increases the dose of Xanax and this cycle continues until the teenager is unable to function without taking dangerously high amounts of Xanax constantly.

Similarly, continued use of alcohol and drugs will inevitably result in depression and increased suicide risk. A child/teenager who has a mental illness and substance use disorder, the risk of suicide is five to six times higher. One third of teenagers who died by suicide were intoxicated.

As the brain continues to develop and grow through the teenage years, the circuits that control executive function (frontal lobe) are the last to mature (age 21 to 24 in females, age 24 to 27 in males). The poor impulse control, risk taking, and skewed judgement increases the risk of drug use and development of a substance use disorder.

Research shows that kids with ADHD, ODD, CD are more predisposed to use drugs, sniff glue or gasoline, whilst kids with depression, bulimia, anxiety, PTSD, schizophrenia tend to abuse drugs such as fentanyl, heroin and/or alcohol. There is also a strong association between cigarette smoking, depression and schizophrenia. Teenagers and young adults with schizophrenia have higher rates of alcohol, tobacco and drug use disorders compared to teenagers with other mental disorders.

Some shocking statistics
In the USA, more than 1 million children under the age of 6 years take psychiatric drugs. Yes, you read that correctly! Of these kids, 227,132 are less than a year old; 370,778 are ages 2 to 3. Nearly 248,000 of kids age 4 to 5 take antianxiety medications. From the ages of 6 to 12 years old, 4,130,340 take psychiatric drugs. Imagine what these medications are doing to a child’s growing and developing brain, the side effects he/she may be experiencing. Now, fast forward to when this child is a teenager and dealing with the pressures of school, home life, the need to belong and to be liked by his/her peers, to be accepted.

Add in some alcohol, marijuana, maybe an occasional pill and so begins the slippery slope to substance use disorder and addiction. Alcohol is the most common substance used followed by marijuana, vaping, cigarettes, speed, opioids. In 2016, more than 1.4 million teenagers in the USA required treatment for addiction.

In 2017, one in four high school seniors had used heroin or marijuana in the past 30 days, 33.2 percent of grade 12 students had drunk alcohol, 19.7 percent of grade 10 students and 8 percent of grade 8 student had drunk alcohol consistently in the past month. We also know that substance abuse in Native Alaskan and American Indian teenagers is increasing rapidly, as is the incidence of depression, suicide, and PTSD.

Other factors that can contribute to substance use and mental illness include:

  • Bullying: studies reveal that there is direct relationship between bullying, mental health and substance use
  • Stigma: shame, discrimination, social exclusion, isolation, blame, secrecy can all contribute to a child/teenager not complying with treatment for his/her mental illness, not seeking help, or self medicating with drugs/alcohol to numb his/her emotions
  • Treatment resistant depression: 40 percent of children/teenagers do not respond to antidepressants. (Recently, Ketamine has been introduced, with good results; however, it is important to point out that Ketamine is in fact a drug, called Special K on the street, and we still do not know the long-term effects of this drug on the growing child/teenager’s developing brain. One must also consider the possibility that kids who are struggling may choose to take the ‘street drug’ (without medical supervision) in an attempt to deal with his/her mental health problems
  • Side effects of psychiatric medications: Lithium, which is prescribed for major depressive disorder, bipolar disorder can cause weight gain, poor concentration, memory problems. A teenager may choose to forgo the lithium and try another drug, or may self medicate with alcohol/drugs to counteract the side effects
  • Numerous studies have documented an increased risk for substance abuse in teenagers with untreated ADHD
    -Frequent marijuana use as a teenager can increase the risk of psychosis
    -Misuse of prescription medications e.g. antidepressants, stimulants can result in manic or extremely irritable and angry moods

Some research studies have found that mental illness/disorder may precede a substance use disorder, suggesting that better diagnosis of mental illness in kids, may help reduce comorbidity*

What can you do?

Do not overreact, become angry, threatening or judgemental

  • Seek first to understand, why is your child/teenager using drugs/alcohol, what is the appeal
  • Ensure any medications, alcohol, guns are in locked cabinets or stored in a safe location
  • Talk with and listen to your child/teenager. Be understanding, objective and supportive, show love
  • Seek medical help e.g. physician, treatment centre, counselling
  • Work together as a team, a family

If you suspect your child/teenager is using substances

  • Check medications, alcohol in home, is any missing?
  • Observe body language and behaviour e.g. mood swings, isolation, declining grades, locking bedroom door
  • Check computer, phone and monitor on-line sites visited
  • Is money or items in home missing
  • Are there any new friends in life
  • Follow up with school, friends, family
  • Look for drug paraphernalia
  • Is there an increase in mail, parcels for child/teenager
  • Talk with a physician, counsellor, substance abuse specialist

It is important to monitor and follow up because the changes in behaviours etc. may also be indicative of a mood disorder and/or bullying and your child/teenager needs your support, help and guidance.

*Common Comorbidities with Substance Abuse Disorder. Feb 2018. National Institute on Drug Abuse. www.drugabuse.gov

In my next Blog #9
I will be discussing what happens if mental illness in children/teenagers is left untreated

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