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Assessing the Impact of Childhood Interventions on Subsequent Drug Use Home
Assessing the Impact of Childhood Interventions
on Subsequent Drug Use
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Commissioned Papers
Barbara J. Burns, Ph.D.
Scott N. Compton, Ph.D.
Helen L. Egger, M.D.
Elizabeth M.Z. Farmer, Ph.D.
E. Jane Costello
Tonya D. Armstrong
Alaattin Erkanli
Paul E. Greenbaum
Chi-Ming Kam
Linda M. Collins
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Service Use Among Adolescents With Comorbid Mental Health and Substance Use Disorders

Paul E. Greenbaum

Part 2: Service Use Among Adolescents with Comorbid Mental Health and Substance Use Disorders

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Service Use Among Adolescents with Comorbid Mental Health and Substance Use Disorders

Large numbers of adolescents with serious mental health (MH) disorders also have a co-occurring substance use (SU) disorder. Only recently, beginning with changes implemented in DSM-III that permitted multiple diagnoses and subsequent results from large-scale epidemiological field studies, has co-occurring MH and SU disorders been recognized as more the rule than the exception among those with either type of problem. For example, Greenbaum, Prange, Friedman, and Silver (1991) found that among 547 adolescents aged 12-18 years who were identified as having a DSM-III MH disorder, 22% had a co-occurring SU disorder. Other estimates have reported higher prevalence of co-occurrence; ranging from 45% to 71% (Groves, Batey, & Wright, 1986; Roehrich & Gold, 1986). Similar studies of adolescents, but among those initially identified with an SU disorder, have found even higher rates of co-occurrence, as high as 82-85% (Hovens, Cantwell, & Kiriakos, 1994; Stowell & Estroff, 1992). Unfortunately, as in all studies of prevalence based on clinical samples, completely unbiased estimates cannot be established from these samples, and currently there have been no detailed general population studies of co-occurrence among American adolescents.

Nevertheless, the few existing epidemiological studies of psychiatric disorders in the general population also have supported high co-occurrence of MH and SU, both among adults and adolescents. Kessler et al. (1996), in the National Comorbidity Study, found that co-occurring MH and SU disorders were widespread. For example, 52% of respondents with lifetime alcohol abuse or dependence diagnosis also had a lifetime mental disorder. Further, among those who had a history of both an MH and SU disorder, the first onset was preponderantly for the MH disorder. That is, 83.5% of those with co-occurrence had an initial MH disorder, 3.7% had simultaneous onset, and only 12.8% had the SU disorder occur first. When the course of these disorders was plotted by age of onset for those with a primary MH disorder, median onset for the MH disorder was 11 years of age, while median onset for the subsequent SU disorder was 21 years of age. The median difference between these onsets was 5-10 years. These results strongly support: (a) a clear temporal sequence among most individuals who experienced co-occurrence, (b) the characteristic start of the co-occurrence pattern was during adolescence, and (c) the initial diagnosis was typically a MH disorder. A strong implication of these findings has been that identification of children’s MH disorders may be useful for both prevention and effective delivery of services for treatment of SU disorders.

Current concepts of mental health treatment for children and adolescents have called for integrated services from all of the child-serving systems so as to maximize treatment impact on the multiple problems that these children have (e.g., Stroul & Friedman, 1986). Benefits to be derived from an integrated approach for children with co-occurrence include a systematic perspective that provides an improved ability to recognize, assess, and treat both types of disorders as they interrelate with each other (Petrila, Foster-Johnson, & Greenbaum, 1996). Nevertheless, a number of barriers to integrated services have existed. Historically, substance use treatment (i.e., drugs, alcohol) and mental health systems have been discrete entities with minimal coordination or collaboration between them. Little information exists as to the extent that nonintegrated MH and SU services remain a barrier to receive needed services for adolescents with co-occurring disorders.

The present study used an existing research database that sampled multiple residential mental health and special education sites (N = 121) to explore the extent that adolescents who had been identified as having co-occurring MH and SU disorders received appropriate services. During the 1985-1991 time period when the database was collected, no integrated service systems were in operation; therefore, the data reflect service delivery as provided by nonintegrated (i.e., either separate or parallel) systems delivery models. The primary research question addressed was: Do adolescents with a MH disorder who have been served in the mental health or special education system and have a SU disorder (i.e., alcohol, marijuana) receive differential rates of services from the various child-serving agencies compared to those who have only a MH disorder, particularly with regard to alcohol and drug counseling, mental health, educational, and health services, and contact with law enforcement? It was expected that those who were comorbid would have received, at a minimum, the same levels of mental health, medical, educational, and vocational services that their non-comorbid peers received. Any reduction in services for the comorbid presumably would reflect barriers that were experienced by children whose problems cross the traditional MH or special education service provider systems. Additionally, based on need, it was expected that the comorbid would receive higher rates of alcohol and drug counseling. Finally, the data on alcohol and drug counseling also would provide an objective measure of service penetration (i.e., the difference between service need and use) for children with co-occurring MH and SU disorders.

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