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Journal of Addictive Diseases Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjad20
Identifying Co-Occurring Disorders in Adolescent Populations a
b
Norman G. Hoffmann PhD , Brian E. Bride PhD , b
Samuel A. Macmaster PhD , Ana M. Abrantes PhD & Todd W. Estroff MD a
c
Community Health, Brown University , USA
b
College of Social Work , University of Tennessee , USA c
Center for Alcohol and Addiction Studies, Brown University , USA Published online: 12 Oct 2008.
To cite this article: Norman G. Hoffmann PhD , Brian E. Bride PhD , Samuel A. Macmaster PhD , Ana M. Abrantes PhD & Todd W. Estroff MD (2004) Identifying CoOccurring Disorders in Adolescent Populations, Journal of Addictive Diseases, 23:4, 41-53, DOI: 10.1300/J069v23n04_04 To link to this article: http://dx.doi.org/10.1300/J069v23n04_04
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Identifying Co-Occurring Disorders in Adolescent Populations Norman G. Hoffmann, PhD Brian E. Bride, PhD Samuel A. MacMaster, PhD Ana M. Abrantes, PhD Todd W. Estroff, MD
ABSTRACT. A structured diagnostic interview (Practical Adolescent Diagnostic Interview) designed to gather basic information about substance use disorders, other mental health conditions, and related experiences was used in a variety of clinical settings. Anonymous data from 279 adolescents interviewed as part of routine clinical assessments in a variety of clinical programs were analyzed to assess the ability of the questions to identify potential problem areas and to provide a preliminary exploration of interrelationships between those problems. Results demonstrated that the vast majority of individuals manifested indications of multiple problems. For a given diagnostic condition, the trend is for those meeting at least the minimal DSM-IV criteria to exhibit substantially more than the minimum number of symptoms. Internal consistencies for item groups defining the various conditions range from more than .700 to over .900 indicating adequate to excellent internal Norman G. Hoffmann is affiliated with the Evince Clinical Assessments and Department of Community Health, Brown University. Brian E. Bride and Samuel A. MacMaster are affiliated with the College of Social Work, University of Tennessee. Ana M. Abrantes is affiliated with the Center for Alcohol and Addiction Studies, Brown University. Todd W. Estroff has a Private Practice in Atlanta, GA. Address correspondence to: Norman G. Hoffmann, PhD, Evince Clinical Assessments, P.O. Box 17305, Smithfield, RI 02917 (E-mail: evinceassessment@aol.com). Journal of Addictive Diseases, Vol. 23(4) 2004 http://www.haworthpress.com/web/JAD ď›™ 2004 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J069v23n04_04
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consistency and reliability. Utility of the instrument for routine clinical use is also discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@ haworthpress.com> Website: <http://www.HaworthPress.com> ď&#x203A;&#x2122; 2004 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Co-occurring, adolescents, addictions, mental health
INTRODUCTION The co-occurrence of mental health and substance use disorders among adolescents has received increasingly greater empirical attention over the last decade. High rates of co-occurring disorders among adolescents have been demonstrated across a variety of settings.1 For example, a literature review of the prevalence rates for co-occurring mental health and substance use disorders among adolescents in community settings found that 60% of youths who were using, abusing, or dependent on a substance met criteria for a co-occurring psychiatric disorder.2 Another study of adolescents receiving substance abuse treatment reported that a majority (82%) also met criteria for a psychiatric Axis I disorder.3 Prevalence estimates for substance use disorders in psychiatric populations are lower, ranging from 33%4 to 50%.5 The differential between the substance treatment and psychiatric populations may reflect the observation that in adult populations substance induced mental health problems account for some of the observed co-occurrence.6 Thus, one would expect greater levels of co-occurrence in treatment populations for substance use disorders than in mental health treatment populations. Mental health disorders commonly co-occurring with substance use disorders among adolescents include both externalizing disorders [e.g., conduct disorder (CD) and oppositional defiant disorder (ODD)] and internalizing disorders (e.g., depression and anxiety).7-9 The co-occurrence of externalizing and substance use disorders in clinical adolescent populations have reported rates up to 90%.10-12 Studies of adolescents receiving treatment for substance abuse have shown that rates of depression range from 19% to 61%.12-14 Rates of anxiety disorders in the same samples of adolescents range from 15% to 43%. In addition to the high prevalence rates of co-occurring disorders among adolescent populations, concomitant psychopathology has been associated with significant negative consequences. Co-occurring mental
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health disorders among substance abusing adolescents have been associated with more severe substance involvement, greater suicidal ideation, academic problems, and family difficulties.15-20 While it has been well established that concomitant psychopathology is associated with poorer treatment outcomes among adult substance abusing populations, recent evidence points to similar findings among adolescent substance abusers as well. For example, findings from the Drug Abuse Treatment Outcome Study for Adolescents (DATOS-A) showed greater substance involvement and illegal acts among adolescents with a concomitant mental health disorder compared to those without a co-occurring disorder.21 In addition, conduct disorder among substance abusing adolescents has been associated with greater alcohol and drug involvement and poorer psychosocial functioning in young adulthood.22 Therefore, given the prevalence and clinical correlates of co-occurring disorders among adolescents, accurate identification and assessment of these disorders is crucial for the development of effective treatment interventions. While some structured interviews such as the Diagnostic Interview Schedule for Children (DISC)23 and semi-structured tools such as the Kiddie-Schedule for Affective Disorders and Schizophrenia for SchoolAge Children (K-SADS)24 have been developed for evaluating co-occurring conditions, they were initially developed for research and have limitations for routine clinical applications. For example, administrations of the DISC and KSADS are time consuming, averaging over one hour to complete. Given the limited resources available in most treatment programs, these measures, while well suited for research purposes, may not be the optimal choice for use by addiction treatment staff and mental health professionals. In order to accurately assess adolescents with co-occurring conditions, a practical instrument should be adolescent-specific, developmentally appropriate, and obtain a continuous measure of symptomatology to provide indications of severity. The instrument should also demonstrate strong psychometric properties across a wide range of mental health problems, including substance use disorders. In addition, the instrument should be able to be effectively utilized by treatment staff and providers in a clinical setting to provide a foundation for diagnostic documentation. To date, we are not aware of an assessment instrument that has demonstrated all of these characteristics. The Practical Adolescent Dual Diagnostic Interview25 (PADDI) was developed as a pragmatic clinical assessment tool to standardize diagnostic assessments. The structured questions are designed to collect in-
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formation about specific symptoms and behaviors in an objective and value neutral tone. It does not attempt to cover all possible diagnoses, nor does it attempt to probe every aspect of some of the covered conditions. Rather, it is designed to address the more common symptoms and indications of problems in the context of an interview limited to approximately 30 to 45 minutes. The two primary objectives of the current study are to evaluate the performance of the PADDI in terms of the statistical characteristics of its scales and to explore the apparent relationships among the disorders covered. METHODS The PADDI is a structured diagnostic interview that covers indications of prevalent mental health conditions and substance use disorders. It is designed explicitly for use with adolescents and is not an adaptation of an adult tool. The PADDI is structured for routine clinical administration facilitated by a detailed manual.26 Professionals who may not have expertise in both mental health and substance use disorders can gather pertinent information to aid in making a diagnosis within their areas of expertise and making focused and appropriate referrals to other professionals for those areas in which they might not practice. The interview includes questions related to depressive and manic episodes, mixed states, psychosis, PTSD, panic attacks, generalized anxiety and phobias, obsessive-compulsive disorder, conduct and oppositional defiant disorders, and possible paranoid and dependent personality disorders in addition to substance use disorders. Questions about dangerousness to self and others as well as victimization (physical, sexual, and emotional abuse) are also included. The design and branching allow the interview to be administered in approximately 30 to 45 minutes depending upon the extent of problems reported. Procedures The study obtained anonymous data consisting of the item responses to PADDI interviews conducted in routine practice from seven substance abuse treatment programs in five states. One of these programs serves juvenile justice incarcerated youth with substance use issues and the remainder consist of residential and outpatient programs in community settings. These programs use the PADDI as part of their standard clinical practice and supplied anonymous data for purposes of review
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and feedback on the administration of the instrument and for statistical analyses of problem prevalences. This aggregate sample should be considered a convenience sample rather than verified consecutive admissions to a specific program. The intent in this report is not to establish definitive prevalence estimates, but rather to consider the performance of the interview and to explore the relative prevalences and associations between various syndromes and problem areas. Sample Data from a total of 279 adolescents (141 males and 138 females) were analyzed. Ages ranged from 12 to 18, and the average age of the sample was 15.7 (S.D. = 1.18). Approximately 80% of the adolescents were between the ages of 15 and 17. The majority of the adolescents were Caucasian (66%), but African-Americans (16%) and Native Americans (8%) constituted the largest minority ethnic groups. The remainder of the sample were Hispanic/Latino or of mixed ethnicity. Most of the adolescents in the sample came from single parent homes with the majority living with their mothers. Fewer than 20% lived with both parents, and a similar proportion lived with their fathers. Educational achievement appears low for these adolescents. Although almost 60% were over the age of 15, almost half (48%) had passed no higher than the eighth grade in school. Of the 15 year olds, 20% had not passed the 8th grade; 42% of 16 year olds had not passed the 9th grade; and 37% of the 17 year olds had not passed the 10th grade. Although only 4% acknowledge not being able to read, 20% reported reading difficulties and more than 40% had been in special classes for academic or behavioral problems. A large number of these adolescents are or had been under some type of medication for either a medical or mental health condition. Almost two in five (37%) reported being on medications at the time of the interview and an additional 34% reported receiving medications within the past two weeks. Analyses Item responses from the PADDI forms were entered and verified into Excel spread sheets and converted into SPSS (Statistical Packages for the Social Science) system files for analyses. Items addressing a common condition or problem area were analyzed for internal consistency using the â&#x20AC;&#x153;Reliabilityâ&#x20AC;? procedure, which produces Cronbachâ&#x20AC;&#x2122;s alpha
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coefficients for each scale. Algorithms for scoring the scales related to conditions for which the PADDI captures sufficient information to suggest a specific diagnosis. Thus, the scales for symptoms of psychosis and generalized anxiety and phobias were not analyzed for placement into diagnostic groups because these scales serve more as screens than documenting diagnostic indications. The algorithms placed individuals into one of five a priori defined categories: no symptoms, sub-diagnostic, meeting minimal criteria, exceeding minimal criteria, and far exceeding minimal criteria. The subdiagnostic category includes individuals who reported at least one positive response, but not enough to meet the minimal indications for a diagnosis. Those in the “exceeds criteria” group report positive indications on at least one additional criterion beyond the minimum, and those in the last group typically endorsed 70% to 85% of the possible criteria items. RESULTS The Cronbach’s alpha coefficients for internal consistency are presented in Table 1. Internal consistency coefficients for all the scales are above the range considered acceptable for scales addressing relatively homogenous or consistent constructs. The scale for depression exhibits very high internal consistency and even the brief scales with relatively few items show coefficients as high as .88. In other words, the items on the various scales tend to correlate highly with each other. Syndromes, where the presentation may be highly variable such as anxiety disorders, conduct disorder, and oppositional defiant disorder, had lower coefficients irrespective of the number of items on the scale. TABLE 1. Internal Consistency Reliability Coefficients (N = 279) Major Depressive Episode Manic Episode Psychotic Symptoms Panic Attack Symptoms Anxiety/Phobia Symptoms Posttraumatic Stress Disorder Conduct Disorder Oppositional Defiant Disorder Substance Dependence Substance Abuse
8 items 10 items 6 items 5 items 7 items 7 items 11 items 7 items 18 items 9 items
.923 .892 .818 .886 .768 .872 .711 .755 .870 .790
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The diagnostic and severity of seven conditions presented in Table 2 suggest that for most conditions, the PADDI items make a relatively clear distinction for those who meet diagnostic criteria. Of those meeting minimal criteria, between 67% (for mania) to 96% (for substance dependence) exceed the minimal indications. Of those below the diagnostic threshold, the majority of cases typically are in the “no symptom” rather than the “sub-diagnostic” category. Several points need to be made concerning the categorizations in the table. The first is that oppositional defiant disorder is subsumed by conduct disorder. That is, if the individual meets both criteria, only the conduct disorder diagnosis is given. This is ignored in the present analyses to illustrate the profile of symptoms for both sets of items. The second point is that for substance dependence, those individuals denying any use in the previous 12 months were placed into the “no symptom” category and those meeting abuse criteria only were placed into the “sub-diagnostic” category. Finally, all conditions such as depression and mania that might be substance induced are placed in the “sub-diagnostic” category if the individual reports the symptoms to be associated only with use. Analysis of the relationships between the severity levels of the various conditions (Table 3) reveals that depression and mania are among the more highly correlated (r = .48, p < .001). Approximately 20% of the sample meets at least minimum criteria for both major depressive and manic episodes; 14% of the entire sample exceeds the minimal criteria for both TABLE 2. Symptom Profiles for Selected Conditions (N = 279)
Condition (Lifetime)
No SubSymptoms Diagnostic (%) (%)
Minimal Criteria (%)
Exceeds Criteria (%)
Far Exceeds Criteria (%)
Major Depressive Episode*
46
17
8
10
19
Manic Episode*
51
16
11
10
12
Panic Attacks**
62
20
4
8
6
Posttraumatic Stress Disorder
42
26
2
18
12
Conduct Disorder
5
13
23
28
31
Oppositional Defiant Disorder
9
36
15
11
29
14
4
3
8
71
Substance Dependence †
* Substance induced conditions are counted as sub-diagnostic. ** Only symptoms for attacks in the previous 12 months are considered. † Diagnosis considered only if use is reported in the past 12 months; abuse cases are counted in the sub-diagnostic category.
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TABLE 3. Correlations of Severity Levels Among Diagnostic Groups (N = 279) Depression
Mania
Mania
.483
--
Panic
.506
.408
Panic
PTSD
Conduct Oppositional Disorder Defiant
--
PTSD
.396
.373
.443
--
Conduct Disorder
.247
.180
.232
.187
--
Oppositional Defiant
.244
.266
.281
.183
.497
--
Substance Dependence
.248
.132
.222
.164
.147
.038
conditions. According to DSM-IV criteria, manic episodes with or without documented depressive episodes will qualify for a bipolar diagnosis. Using this criterion, almost a third might manifest a bipolar condition. Questions about possible mixed states suggest that about 16% have rapid alternations between depression and agitation or that the two seem to coexist. Panic and PTSD severity indications would be expected to correlate significantly, and they do (r = .44, p < .001). However, panic is actually more highly correlated with depression (r = .51, p < .001) and significantly correlated with mania (r = .41, p < .001). Whether possible bipolar episodes might trigger panic experiences cannot be determined from the present data. What is evident is that the mood and anxiety disorders show statistically significant intercorrelations. Conduct disorder and oppositional defiant symptoms also demonstrate some of the higher correlations (r = .50, p < .001). Examination of the diagnostic thresholds reveals that while 95% of those meeting oppositional defiant criteria also meet those for conduct disorder, only 64% of the conduct disorder cases also meet criteria for oppositional defiant. This means that according to the DSM-IV criteria, only 7 of the 154 individuals meeting oppositional defiant criteria would receive that diagnosis. Although conduct disorder and substance dependence are among the most pronounced disorders in the sample, they produce one of the lowest correlations (r = .15) second only to the correlation between the severity for substance dependence and oppositional defiant (r = .04). Still, 85% of those meeting criteria for either substance dependence or conduct disorder will meet criteria for the other condition. The very high prevalence rate for both of these conditions in this sample may account
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for the lack of apparent relationship. The present data also cannot account for how many individuals meet the criteria for conduct disorder due to behaviors related to the substance dependence. Rates of victimization are significantly different for the two genders. Emotional abuse, defined as being ridiculed and humiliated over time, is the most prevalent with 68% of the females and 43% of the males reporting such abuse. This is followed closely by physical abuse with 59% of females and 41% of males reporting such maltreatment. Sexual abuse defined as physical contact or coercion into sexual activity is reported by 63% of the females and 7% of the males. It should be pointed out that the victimization questions on the PADDI define these forms of abuse in relatively severe terms. Physical abuse is defined as being beaten so that marks were left, the victim was afraid of the perpetrator, or that the injuries required medical attention. The objective was to identify clear and unequivocal incidence of victimization. Interestingly, these questions are not reported to present distress or reticence in responding on the report of the adolescents interviewed. This may be because these questions are part of the normal flow of questions in the middle of the structured interview. For females, the largest correlation among the forms of victimization was between physical and sexual abuse (r = .42, p < .001), but for the males, the highest correlation was between emotional and physical abuse (r = .38). The highest correlations with diagnostic scales were between the severity indication of PTSD and all three forms of victimization (r = .33 to .40) for the females. However, for males, the highest correlations were between the severity of depression and physical abuse (r = .41) and emotional abuse (r = .37). DISCUSSION The results of the present study suggest a number of issues that merit specific discussion. Results of the reliability analysis indicate an acceptable range of coefficient alpha scores for the PADDI subscales when compared to the standard guidelines established for the interpretation of these scores.27,28 As a measure of internal consistency, high coefficient alpha scores are an indicator of how well the individual items of a subscale reflect a common, underlying construct.29 In addition, the obtained alpha values are comparable to those of other measures of adolescent psychopathology. While these findings support the reliability of
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the PADDI, additional investigation should be conducted to assess both test-retest and inter-rater reliability. A second finding is that the distribution of scores across the five diagnostic categories (no symptoms, sub-diagnostic, meeting minimal criteria, exceeding minimal criteria, and far exceeding minimal criteria) is such that, for most problem areas, a clear distinction exists between those individuals meeting diagnostic criteria from those that do not. This finding supports the utility of the PADDI as a screening instrument with the ability to discriminate between adolescents experiencing symptomatology and those not. It should be noted, however, that an alternative explanation is that these results are a function of the sample population, in that it was drawn from adolescents in treatment for substance abuse. Given the high rates of co-occurring mental disorders found among adolescents receiving substance abuse treatment,3,12,13 it may be expected that those individuals experiencing problems in the domains assessed by the PADDI would have relatively high severity levels. A third notable finding is that the pattern of correlations of severity levels among the diagnostic categories is generally consistent with the literature on co-morbidity. For example, the present study found that PTSD correlated highly with depression, panic, and mania, a finding that is supported by prior research demonstrating a high rate of co-morbidity between PTSD and other psychiatric disorders, particularly depressive and anxiety symptoms.30,31 It is also interesting to note that correlation analysis revealed that although identical proportions (82%) of the sample met at least minimal criteria for conduct disorder and substance dependence, severity indications for the two disorders were only weakly correlated (r = .147). Thus, severity of conduct disorder is not related to severity of substance dependence. Finally, there are apparent differences in the correlation of the severity of diagnostic categories and victimization by gender, with male victimization having the strongest correlation with severity of depression and female victimization having the strongest correlation with PTSD severity. Application of the findings of this paper may occur at both a research and practice level. First, these results may inform systematic empirical research on the characteristics of co-occurrence of disorders in adolescents, particularly as it relates to the severity of symptoms. From a research perspective, important next steps might include more rigorous investigation into the psychometric properties of the PADDI. In particular, an examination of construct, criterion, and discriminant validity is needed. Further examination of the interaction between victimization, substance dependence, and psychiatric symptomatology is also war-
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ranted. In addition, replication of these findings in other clinical samples as well as in juvenile justice populations is a logical next step. At a practice level, the study provides a description of a pragmatic clinical assessment tool to standardize diagnostic assessments that incorporates both empirically supported elements and a strong theoretical tie to symptoms described in the DSM-IV. The use of this instrument may be valuable in organizing and delivering assessment services. It is important to discuss some obvious limitations to the data presented here. First, as the PADDI is not designed to produce a definitive diagnosis, presentation of diagnostic categories in these analyses is limited as they are based solely on the results of this instrument. While a positive indication on the PADDI is a clear signal of a need for further evaluation, it is by itself not a diagnosis. Additionally, concurrent validity cannot be assumed, as no data exists to corroborate how often the PADDIâ&#x20AC;&#x2122;s impressions are confirmed with a firm clinical diagnosis. Second, the participants in this study may not be representative of all potential users of the instrument. The study is based on a sample that is both a convenience sample and is drawn solely from clinical populations. However, given the descriptive focus of the analyses presented and our focus upon description of the statistical characteristics of the PADDI scales, the sample is adequate for the purpose of the present study. Additionally, the reliability of self-report data from a clinical population of adolescents may be questioned, though the instruments upon which the present measures were based have been shown to have relatively high levels of reliability. Despite the above limitations, this article does provide basic statistical information on the PADDI and some descriptive information on the relationships between the severity of diagnostic conditions and forms of victimization. While previous research has clearly shown that substance dependence correlates with other mental health disorders, this article provides a description of the correlations of the severities of these disorders. Further research with other more representative samples and concurrent validity measures will be needed to provide more definitive answers to the questions raised here. REFERENCES 1. Aarons GA, Brown SA, Hough RL, Garland AF, Wood PA. Prevalence of adolescent substance use disorders across five sectors of care. Journal of the American Academy of Child and Adolescent Psychiatry. 2001;40:419-426. 2. Armstrong TD, Costello EJ. Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Journal of Consulting and Clinical Psychology. 2002;70:1224-1239.
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