How Substance Abuse and Behavioral Disorders Are Diagnosed
A substance use disorder, as defined by the DSM-5, is a pattern of problematic, disruptive, and physically damaging use of an intoxicating substance leading to impairment and/or distress. At least two of the following symptoms must manifest over a 12-month period:
- Larger amounts of a substance being taken over a longer period than intended
- Inability to stop taking the substance or reduce use
- A great deal of time is spent trying to obtain the substance, or worrying about where it will come from
- Intense cravings for the substance
- Recurrent use of the substance to the detriment or exclusion of social, family, work, or school obligations
- Understanding that there is an underlying problem leading to substance abuse, but being unable to stop
- Physical tolerance requiring higher doses to achieve the desired result
- Withdrawal symptoms when substance use is stopped
Behavioral disorders can exist in both children and adults, and if they remain untreated in children, they can become exacerbated in adulthood and lead to other problems. Behavioral disorders are classified under emotional disturbances, and they are typically defined as a long period (six months or more) of emotional or behavioral changes that detrimentally affect personal, educational, and social development. General diagnostic symptoms include:
- Inability to learn that cannot be explained by intellectual, sensory, or other health factors
- Inability to build or maintain emotional connections or social relationships to teachers, parents, or peers
- Inappropriate expression of feelings or inappropriate behaviors under normal, non-stressful circumstances
- General depression or moodiness that does not go away
- Physical symptoms like headaches or stomach aches associated with fears regarding interactions, school, or other normal circumstances
While addiction is a disease of the brain, behavioral disorders are not considered diseases, but disabilities of social and emotional functioning. Any genetic basis for behavioral disorders is complex and less understood than the genetic predisposition for drug or alcohol addiction. However, both substance use disorders and behavioral disorders can be caused by biochemical imbalances, genetics, or environmental triggers – or a combination of these situations.
The interaction of “nature” (genetics) and “nurture” (culture) on families is complex. Both have deep, lasting effects on family members starting at a young age, and, when untreated, can lead into a continuation of unhealthy patterns for generations.
Scientists are only beginning to understand the role of genetics in specific substance use disorders and behavioral disorders. Because genes are activated in some individuals and not others, there is the possibility that parents can pass genetic markers for mental health and substance use disorders to their children, without displaying problematic behaviors themselves. Investigations have shown that addiction tends to be heritable, depending on the individual’s relationship to the person with the substance addiction. First-degree relatives with substance use disorders, for example, put a person at a high risk of becoming addicted to alcohol or drugs.
Studies involving identical twins have helped researchers begin to find genetic markers that might contribute to problems involving substance abuse. For example, a group of medical researchers conducted a study through the National Institutes of Health that measured a spike in brain activity called P3 after study participants had experienced a sudden stimulus like sound or light. In people with alcohol dependence disorder, and their children, the amplitude of this brain activity was lower than in some other populations. Further studies showed that this P3 response appears to be associated with other disinhibitory disorders, including other forms of drug addiction, behavioral disorders, and adult antisocial personality disorder.
The link between parents with substance abuse issues and their children suggests a genetic component to the brain’s response. Further studies into genes involving neurotransmitters or the GABA receptors have also suggested that a genetic component could cause specific brain developments, which put the individual at a higher risk of mental health disorders, like behavioral disorders or substance abuse.
Mothers who abuse any drugs while pregnant can cause disruptions in fetal development. Beyond genetic or environmental factors, these changes can cause serious developmental problems, behavioral issues, and disability. While it is well understood in the medical community that substance abuse during pregnancy can cause serious defects in babies, 40 percent of women report some alcohol use while pregnant, and 10 percent of women in the US are alcoholics. In addition, about 20 percent smoke while pregnant. Many women who abuse substances while pregnant use more than one substance, and women who abuse substances while pregnant may also have co-occurring mental health issues.
A family’s cultural history can lead to behavioral disorders and substance abuse too. Patterns of interaction between parents and/or children struggling with substance abuse have several key characteristics that can negatively impact the psychology of those involved and lead to mental health issues like depression or behavioral disorders. According to a study conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, risk factors for mental health issues and substance abuse in children and adolescents were similar. Low self-esteem, academic problems, loneliness, depression, and the desire for social acceptance contributed to both sets of conditions. These can be influenced by family culture, which can be passed on by specific behaviors. Some of these include:
- Negative communication: Expressions of displeasure, complaints, criticism, or ignoring positive behaviors can be symptoms of behavioral disorders, mental health issues, or substance abuse in parents. They can also trigger children to develop behavioral disorders or substance abuse due to stress.
- Inconsistent parenting: Erratic rule-setting and enforcement, lack of regular boundaries that leads to confusion, and inadequate family structure can all be symptoms of a parent’s mental disturbance or substance use disorder. These issues can also lead to high levels of stress or trauma in a child, which can then lead the child to substance abuse or trigger a behavioral disorder.
- Unrealistic expectations: These unreasonable expectations may be particularly present if parents expect too much of their children, whether it is pressure to perform well in school or take care of a single parent who needs emotional support. Behavioral disorders and substance abuse can be expressions of a child’s rejection of parental needs. On the other hand, a parent’s mental health issues or substance abuse can lead a child to take too much personal responsibility for their family.
- Denial: Ignoring a drug or alcohol problem, and/or symptoms of mental illness like depression or anxiety, can enhance the underlying problem. Children whose parents suffer from these disorders often overcompensate for their parents’ poor behavior, but parents can struggle with denial regarding their child’s behavioral disorder or substance abuse symptoms.
- Misplaced anger: Inability to process negative emotions appropriately can lead to substance abuse as a way to express that displeasure or even as a form of self-harm. Parents with mental health or substance abuse problems will not be able to handle a child’s anger appropriately, and when children cannot express these emotions in a healthy way, they can develop similar problems.
- Self-medication: Mental health issues like behavioral disorders can lead to substance abuse as a form of medicating the symptoms. Similarly, substance abuse can change brain chemistry and lead to symptoms of a mental health issue or behavioral disorder.
Specific Types of Behavioral Disorders
Substance abuse among adolescents is potentially a problem of genetics influenced by easy access to addictive substances in the environment; however, it is also considered a symptom of underlying behavioral disorders, especially if the substance abuse is used to self-medicate or rebel against authority figures. According to SAMSHA, about 3.3 percent of adults in 2014 had a mental illness and a substance use disorder; about 340,000 children 12-17 years old had both a major depressive episode and substance use disorder.
There are many kinds of behavioral disorders, and these often manifest in childhood. Here are some of the groups of behavioral disorders, based on information from the Pacer Center for Children with Disabilities:
- Adjustment disorders: The most common sign of this type of disorder involves a child’s inappropriate or maladaptive emotional or behavioral response to changes or stress in their lives. For diagnostic purposes, symptoms must appear within three months of the life change, and last no more than six months after the end of the stressful event. Symptoms include extreme distress, disruptions of friendships or social bonds, and impairment at school. Other symptoms include truancy, fighting, or vandalism.
- Anxiety disorders: This classification covers a wide range of disorders, including phobias, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, and others. The primary feature is overwhelming anxiety beyond the average response to stress or disruption. Physical symptoms of anxiety can include headaches or stomach aches. Changes in conduct, such as refusing to do homework, and inappropriate emotional responses, such as giggling at a tragedy, can indicate an underlying anxiety disorder.
- Obsessive-compulsive disorder (OCD): This group of disorders is most often characterized by repeated and persistent obsessions (e.g., constant doubt or the need to have objects in a specific order) or compulsive behaviors (e.g., inability to stop washing one’s hands, requiring the door knob to be turned a certain number of turns, or silently repeating words). These are time-consuming and increase distress in the person suffering from the condition. Even when the person who suffers from OCD knows that their thoughts and behaviors are unnecessary or not reflective of reality, they are unable to stop.
- Post-traumatic stress disorder (PTDS): This condition develops when a person is exposed to a traumatic event or series of events. Consistent feelings of fear, helplessness, insomnia, nightmares, reliving the event, anhedonia or general unresponsiveness to emotional situations, or increased arousal are common symptoms of PTSD.
- Attention deficit hyperactivity disorder (ADHD): The most common symptom of this condition is the inability to concentrate, which is inconsistent with other mental development. Other symptoms are hyperactivity and impulsive behaviors. These symptoms are typically noticed in children early on, around elementary school.
- Oppositional defiant disorder (ODD): The main features of ODD are a negative attitude and defiance toward authority figures, such as parents and teachers. Although ODD involves refusal to acknowledge the person in charge, or acting against that person, it does not involve violence. Common behaviors more typically include arguing, refusing to follow directions, blaming others, deliberately annoying other people, or being vindictive.
- Conduct disorder (CD): This condition is defined as a repeated, persistent pattern of behavior that violates social norms and the rights of other individuals. Behaviors associated with this disorder include violent lashing out, running away from home, truancy from school, bullying, or physical cruelty to animals or other people. Children with CD tend to become involved in sexual behaviors, substance abuse, and reckless behaviors early in life.
- Major depressive disorder (MDD): People who struggle with MDD are diagnosed after they experience at least two major depressive episodes, with at least two months between the incidents. Symptoms of depression can appear as an inability to get along with others, including avoidance or aggression, along with general sadness, anhedonia, and malaise.
Children who grow up in an environment with parents or other relatives who have a substance use disorder, such as alcoholism or drug addiction are more likely to develop behavioral disorders. Substance abuse in the family can lead to a variety of stresses, including incarceration, divorce, or abuse, which all affect childhood development. However, there are many other ways that substance abuse can affect a child’s development and lead to behavioral disorders.
Additionally, struggling with a mental health issue such as a behavioral disorder can contribute to substance abuse later in life. A 2014 study conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that in adults with any mental illness, 18.2 percent also had a substance use disorder; in comparison, 6.3 percent of adults without mental health disorders struggled with substance abuse of some kind.
Treatment Requires the Whole Family
Early intervention is the best method for helping to prevent substance abuse and ease mental health issues. Identifying protective factors, like high self-esteem, self-control, competence, and positive relationships, and developing these factors can reduce the chance that a person will develop a substance abuse problem because of a behavioral disorder. These protective factors can also reduce the severity of behavior disorders.
Some risks and protections are outside of a person’s control, but many of them are within one’s control, and it is important to find ways to bolster these protective factors to minimize the risks. Both risks and protections are cumulative, as they have an ongoing influence on a person’s psychology and emotions.
Early intervention can also help a person to develop prevention strategies, which address the root causes of the behavioral disorder and/or substance abuse.
Education about drug use, parental involvement in social activities, and positive reinforcement are all examples of prevention strategies that are helpful. Cognitive Behavioral Therapy or other therapies to retrain thoughts and subsequent behaviors can help both behavioral disorders and substance use disorders. Educating parents on how to maintain solid boundaries with their children can also be helpful for long-term success.
Genetic factors and environment are both aspects of family history that can influence an individual’s development and life greatly. Both of these can contribute to substance use or mental health disorders, but with help, environmental factors can be changed. A family history of drug abuse or behavior disorders doesn’t doom a person to experience the same fate. When the family comes together to focus on protective factors, the negative impact of family history can be reduced, which improves everyone’s health.