Smoking & Struggling: Nicotine Dependence & Co-Morbid Psychiatric Illnesses

Addressing the Addiction

The 2021 National Survey on Drug Use and Health found that among individuals aged 12 and older in the United States, approximately 22.0% report using tobacco or nicotine vaping products in the last 30 days. Further, the 2022 Future Monitoring Survey found that among young people, approximately 8.7% of 8th graders, 15.1% of 10th graders, and 24.8% of 12th graders report using any form of nicotine in the past 30 days.[1] 

While the smoking rates among adults without chronic conditions are significantly reduced over years, the rates remain high among adults with psychiatric disorders.[2] Nicotine dependence especially affects individuals with underlying mental illnesses or cognitive impairments, at a rate of approximately 41% - twice the rate of which the CDC reports for the general population. Many nicotine-dependent individuals have comorbid psychiatric disorders, such as attention-deficit hyperactivity disorder (ADHD), anxiety disorders, and depression.[3]

Nicotine Dependence & Comorbid Psychiatric Disorders 

Smoking is the leading and most preventable cause of death in the United States, which is disproportionately affecting those with psychiatric disorders. By determining the prevalence of nicotine dependence and comorbid psychiatric disorders, smoking cessation efforts can be more focused upon those affected individuals.[4]

Miller (2005) conducted a representative sample study of U.S. adults, to investigate the connection between nicotine dependence and psychiatric disorders. A face-to-face interview conducted according to the DSM-IV interview schedule assessed the dependence on nicotine and the presence of a wide range of psychiatric disorders based on DSM-IV criteria. One of the criteria was whether they used nicotine to alleviate withdrawal symptoms of nicotine. This could be assessed based on four factors:[5]

1. Using nicotine upon waking

2. Using nicotine despite being restricted from its use (e.g., banned in certain locations, activities, events)

3. Using nicotine to avoid withdrawal symptoms

4. Waking up in the middle of the night to use nicotine

The study concluded that a significant correlation exists between individuals with a nicotine dependence and certain Axis I (e.g., alcohol and drug use disorders, major depression, dysthymia, mania, hypomania, panic disorder with and without agoraphobia, social phobia, specific phobia, and generalized anxiety disorder) and Axis II disorders (e.g., avoidant, dependent, obsessive-compulsive, histrionic, paranoid, schizoid, and antisocial PDs).[6] There was an especially strong association to disorders involving alcohol and other drug use, as well as mood disorders such as major depression, specific phobia, antisocial, and paranoid personality disorders.[7] 

Nicotine smoking has also been found that put individuals at an increased risk for suicide, biopolar disorder, and a dose-response relationship has been found between smoking and schizophrenia. In a two-sample Mendelian randomization study conducted by Yuan et. al (2020), the odds ratios of smoking initiation was higher for all seven psychiatric disorders included in the study than for no psychiatric disorder at all. The disorders and odds ratios include 1.96 for suicide attempts, 1.69 for post-traumatic stress disorder, 1.54 for schizophrenia, 1.41 for bipolar disorder, 1.38 for major depressive disorder, 1.20 for insomnia, and 1.17 for anxiety.[8]

The symptoms of ADHD are notably similar to withdrawal symptoms of nicotine. For example, such symptoms include deficits in sustained attention, response inhibition, and working memory. Pomerleau et. al (1995) found in their study that individuals with ADHD are at more risk for smoking due to the similarities in these symptoms, and the quit ratio for smokers with ADHD was 29%, while the quit ratio for smokers with no mental illness was a significantly higher percent of 48.5%. Other studies have also reached similar results, with Lambert and Hartsough (1998) finding tobacco dependence to be 40% in individuals with ADHD, compared to 19% for individuals without ADHD.[9] 

The reason why nicotine dependence affects patients with psychiatric disorders disproportionately higher is because people may attempt to self-medicate to alleviate symptoms of their mental disorders with nicotine. For some, nicotine abstinence may actually worsen symptoms of mental disorders.[10] Moreover, about 20 years ago, major tobacco US manufacturers recognized that a large proportion of their customer population was individuals with underlying psychiatric disorders. Knowing this, they began to craft advertisements and marketing of their nicotine products to target consumers with different psychological needs, such as using nicotine to manage mood, anxiety, stress, anger, social dependence, and insecurity.[11] 

Why is Quitting So Hard? 

Smoking cessation for individuals with psychiatric disorders is significantly more difficult than for healthy individuals for a variety of reasons. For one, smoking increases metabolism against antipsychotic medications. For example, smokers with schizophrenia would then have a lower ratio of serum concentration to dose of antipsychotics. Genetic differences influence which individuals will develop a nicotine addiction upon initial use of the drug. In particular, individuals with a fast metabolism may experience quicker nicotine withdrawal symptoms after being exposed to it, increasing the risk of nicotine dependency. The cessation process also involves addressing the fundamental deficit in cognitive processing that nicotine temporarily resolves. For example, in patients with schizophrenia, this deficit may be the psychotic symptoms.[12] 

Some individuals with a mental health illness may believe that the initial worsened feelings of anxiety and depression, withdrawal symptoms, upon cessation indicate that quitting nicotine will worsen their mental health. However, multiple researchers, such as Wu et. al (2023), have shown that long-term cessation of smoking among people with and without psychiatric disorders improved mental health outcomes. The incorrect psychological perception that smoking relieves stress prevents many people from trying to stop smoking. This distress is simply the cause of nicotine withdrawal, which would eventually end in long-term cessation.[13]

Smokers with a mental illness are also significantly more likely to develop nicotine withdrawal syndrome, where the symptoms of withdrawal are more severe and distressful. This heavy burden of withdrawal also makes it more difficult for a psychiatrically ill patient to quit. This makes nicotine withdrawal an important target for intervention for smokers with a mental illness.[14]

Starting the Journey to Stop Smoking 

Patients with a psychiatric illness and comorbid nicotine dependence are dying 25 years younger than the general population, from smoking-related illnesses such as heart and lung disease.[15] Understanding why these patients smoke, becoming dependent on nicotine, and what we can do to encourage smoking cessation would help prevent these premature mortalities.

Psychosocial support and medication are two types of treatment that have been published by the United States Public Health Service Guidelines in 2000 for general medical patients. However, these treatment types may not be completely suitable or applicable to psychiatric patients as well. Psychosocial support involves cognitive-behavior therapy (CBT) strategies to target identifying smoking cues, breaking the link between smoking and these cues, and learning alternative coping mechanisms. A formal program with other people trying to quit smoking may also contribute to the social aspect of support. Medications for nicotine replacement include bupropion, nortriptyline, clonidine, and varenicline. Identifying what a patient has already tried during their attempts to quit nicotine, as well as their mental and physical reactions to it, can help to determine what the next method of quitting can entail.[16]

If one is trying to quit, it is important to recognize that the cessation process will require constant effort. Overcoming withdrawal symptoms (e.g., feelings of irritability, anger, and depression) can be done by staying active, connected with people, and busy. Anxiety and depression levels are significantly reduced within the first few months of cessation, which means these withdrawal symptoms will decrease automatically, as well.[17] The Centers for Disease Control and Prevention (CDC) (2022) explains withdrawal symptoms that one may experience, and ways to manage them, including:[18] 

• Urges/Cravings

• Medications to quit 

• Avoiding triggers and cues to smoke (people one smokes with, places one smokes, activities one frequently does while smoking)

• Remind oneself why one is quitting

• Irritability/Anger

• Deep breaths

• Meditation

• Therapy

• Restlessness

• Physical activity

• Reducing caffeine intake

• Difficulty Concentrating

• Limiting activities with strong concentration for a short period of time

• Recognizing that this is an effect of nicotine withdrawal

• Trouble Sleeping

• Reducing caffeine, especially near bedtime

• Taking off nicotine patches at least an hour before sleeping

• Reducing electronic device usage

• Adding physical activity during the daytime

• Building a sleep schedule

• Excessive Hunger/Weight Gain

• Snacking smart

• Physical activity

• Mindfulness/focusing on eating while eating

• Anxiety or Depression Symptoms

• Physical activity

• Scheduling and organization

• Social interactions

• Rewarding yourself

• Speaking to a healthcare provider

If one is experiencing nicotine dependence and comorbid psychiatric illnesses, or having severe difficulty with quitting nicotine due to withdrawal symptoms, it is important to reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) or healthcare provider for guidance and support. 

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 U.S. Department of Health and Human Services. (2023, January 23). What is the scope of tobacco, nicotine, and e-cigarette use in the United States?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-scope-tobacco-use-its-cost-to-society  

2 U.S. Department of Health and Human Services. (2023b, February 24). Do people with mental illness and substance use disorders use tobacco more often?. National Institutes of Health. https://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/do-people-mental-illness-substance-use-disorders-use-tobacco-more-often 

3 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). Nicotine Addiction and Psychiatric Disorders. International review of neurobiology, 124, 171–208. https://doi.org/10.1016/bs.irn.2015.08.004 

4 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). Nicotine Dependence and Psychiatric Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(11):1107–1115. doi:10.1001/archpsyc.61.11.1107 

5 Ibid. 

6 Ibid. 

7 Ibid. 

8 Yuan, S., Yao, H. & Larsson, S.C. (2020). Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study. Sci Rep 10, 13807 https://doi.org/10.1038/s41598-020-70458-4 

9 Kutlu, M. G., Parikh, V., & Gould, T. J. (2015). 

10 Ibid. 

11 Grant B.F., Hasin D.S., Chou S.P., Stinson F.S., Dawson D.A. (2004). 

12 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). Smoking cessation in patients with psychiatric disorders. Primary care companion to the Journal of clinical psychiatry, 10(1), 52–58. https://doi.org/10.4088/pcc.v10n0109 

13 Wu A.D., Gao M., Aveyard P., Taylor G. (2023). Smoking Cessation and Changes in Anxiety and Depression in Adults With and Without Psychiatric Disorders. JAMA Network Open. 6(5):e2316111. doi:10.1001/jamanetworkopen.2023.16111

14 Smith, P. H., Homish, G. G., Giovino, G. A., & Kozlowski, L. T. (2014). Cigarette smoking and mental illness: a study of nicotine withdrawal. American journal of public health, 104(2), e127–e133. https://doi.org/10.2105/AJPH.2013.301502 

15 Gelenberg, A. J., de Leon, J., Evins, A. E., Parks, J. J., & Rigotti, N. A. (2008). 

16 Centers for Disease Control and Prevention. (2023, February 10). People with mental health conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/groups/people-with-mental-health-conditions.html   

17 Ibid.

18 Centers for Disease Control and Prevention. (2022, December 12). 7 common withdrawal symptoms. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/7-common-withdrawal-symptoms/index.html 

From Late Detection to Self-Discovery: Diagnosing Autism in Adulthood

Navigating New Horizons

Adulthood is often celebrated as a time of personal growth, independence, and achieving milestones (e.g., buying a home and career advancement). Each life experience involves responsibilities, unexpected life circumstances, and challenges that mold an individual. Amidst the whirlwind of adult life, how does one navigate an adulthood diagnosis of autism spectrum disorder (ASD)? Typically, ASD is diagnosed during childhood, where an individualized plan and support may more readily exist. While adults can achieve numerous feats, receiving an autism diagnosis in adulthood can be a validating and liberating experience.

Adulthood Autism Diagnosis Journey 

Autism is a neurodevelopmental condition categorized by challenges in two main areas: communication and interaction with others, and repeated certain behaviors or focus on particular interests.[1] Common indicators of autism include interpreting statements literally, struggling to grasp others' thoughts or words, experiencing heightened anxiety in social situations, and maintaining a strict daily routine - with anxiety arising from any alterations to it.[2] The most effective way to diagnose autism involves working with a team of licensed mental health and healthcare professionals (e.g., primary care doctor, neurologist, psychiatrist) with experience in autism. These trained professionals observe an individual's behavior and review their medical and developmental history.[3]

Behaviors consistent with autism must have manifested during childhood, making it crucial to recollect those exhibited during that period in an interview or questionnaire. The assessment can still be completed if an individual cannot recall developmental histories. Furthermore, an individual's family members can participate in the evaluation and provide developmental histories.[4] Throughout the assessment process, individuals should anticipate questions that pertain to difficulties in navigating social communication and interaction, sensory sensitivities, repetitive behaviors, and highly specific interests.[5] Following the assessment, an individual may receive a diagnosis of autism or not. If an autism diagnosis is confirmed, it is recommended to actively seek support and ongoing services, and access available resources to address any questions or concerns.

Self-Perception Before and After Diagnosis

The stigma that may accompany an autism diagnosis is often shaped by how the public interprets the observable traits of Autistic individuals. Turnock et al. (2022) notes that various factors can moderate or influence this stigma, including the extent and quality of interactions with autistic individuals, cultural influences, gender differences, personal variations, and how a diagnosis is revealed or disclosed.[6] Addressing and diminishing this stigma promotes greater awareness, simplifies the diagnosis process, and provides a more supportive environment for those with autism.[7]

A study by Leedham et al. (2019) examines the experience of 11 adult participants who received an autism diagnosis aged at, or over, 40 years.[8] The nine-question interview resulted in answers that can be categorized into themes, including: 

• a hidden condition

• the process of acceptance

• the impact of others post-diagnosis

• a new identity on the autism spectrum 

The 11 participants expressed their life experiences and self-perception before their diagnosis. Some participants stated that they internalized beliefs of being "wrong," "flawed," or "bad" because of connections that felt "failed".[9] Participants shared that they mimicked "normal" behaviors as a survival function, but that these behaviors resulted in feelings of exhaustion and unhappiness.[10]

A study by Stagg & Belcher (2019) examined 9 participants between the ages of 52 and 54 who received their autism diagnosis later in life.[11] This cohort shared similar life experiences to the Leedham et al. study, with some participants indicating they “never made friends”, social events were difficult, and they felt utterly isolated.[12] Additionally, two studies by Atherton et al. (2021) examined a total of 428 participant's life experiences to measure their quality of life relative to their diagnostic age. The correlation found that the diagnostic age later in life was associated with poorer quality of life. The participants stated painful experiences that affected their self-perception amidst sensory discomforts and recalling social miscommunications.[13]

Conversely, Leedham et al. note that after diagnosis, participants expressed feeling more free, better about themselves, less anxiety, and better self-awareness.[14] Participants indicated they had devised positive coping strategies to address anxiety and being overwhelmed. Lastly, there was a significant shift from self-judgment to self-empathy once they were aware of their diagnosis. Stagg & Belcher note that participants indicated post-diagnosis: feeling like it was a eureka moment, a complete relief, being stunned because it was not obvious to them before, and identifying that now they are viewing themselves in a different light.[15] Likewise, Atherton et al. (2021) found that their participants expressed that the diagnosis brought a sense of clarity.[16]

Value of Adulthood Autism Diagnosis

After interviewing participants diagnosed later in life, there were a few repeating challenges expressed throughout navigating the diagnostic process. These challenges included the obstacles of getting diagnosed, weighty emotional responses, and realizing the diagnosis explains the differences they recognized about themselves earlier in life.[17] The assessment's waitlist and wait times, lack of autism specialists, and the cost of care were specific obstacles highlighted in the studies. Throughout the interviews, participants noticed there was a lack of public awareness about autism, which contributed to their unmet needs. However, they could see that their autistic traits matched others with autism or the diagnosis criteria.[18] 

Participants explained that their late diagnosis was due to the lack of awareness about autism during their childhoods. Although family members had suspicions, they were unable to find explanations why their child did not appear neurotypical. Later in life, when participants received their diagnosis, they experienced relief and emotional validation. Additionally, the new diagnosis assisted participants in understanding their identity and challenges in a new light. One participant expressed that being able to articulate themselves and their diagnosis better was amazing and validating. Ghanouni & Seaker (2023) noted that although participants knew they were different from a young age, the new understanding allowed them to re-examine their previous life experiences.[19] The diagnosis allowed participants to explain their understanding of their needs and their relationships. For example, Leedham et al. (2019) explains that a participant’s partner can now take the lead in situations where they know the participant is uncomfortable, whereas in the past they might have thought their partner was simply acting awkwardly.[20] 

Understanding Co-Occurring Conditions: Autism & Comorbidities

Navigating the path to an adult autism diagnosis is a multi-faceted journey that extends well beyond receiving a single diagnosis and is rarely homogenous. Autism frequently intersects with other conditions, collectively known as co-occurring conditions or comorbidities. A recent study by Jadav and Bal (2022) delved into the correlation between the age of diagnosis and the emergence of co-occurring psychiatric conditions among adults on the autism spectrum.[21] They found that adults who received their autism diagnosis at the age of 21 or older reported significantly higher rates of anxiety disorders, depression, and dysthymia than those diagnosed before the age of 21.

These findings underscore the importance of comprehending the impact of various psychiatric conditions on the lives of adults with autism. In particular, life experiences (e.g., enduring societal exclusion, grappling with a diminished self-image, and enduring bullying) can significantly contribute to the prevalence of depression and anxiety disorders among this population.[22] Furthermore, the study highlights that generational mental health stigmas and a lack of awareness can influence the timing and willingness of adults to seek a diagnosis. According to Barlattani (2023), ADHD has the highest prevalence among psychiatric comorbidities in autism, followed by anxiety disorders. 70% of people with autism experience one comorbid psychiatric disorder, increasing the need to adapt and implement diagnostic tools for adults with autism.[23] Thus, acquiring a proper and valid diagnosis proves invaluable by offering autistic individuals of all ages significant benefits, especially for those experiencing comorbid conditions.

If you or someone you know has or suspects that they have Autism Spectrum Disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. Note: the University of Washington’s UW Autism Center offers many resources and provider options.

Contributed by: Kelly Valentin

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Ghanouni, P., & Seaker, L. (2023). What does receiving autism diagnosis in adulthood look like? Stakeholders’ experiences and inputs. International Journal of Mental Health Systems, 17(1). https://doi.org/10.1186/s13033-023-00587-6

2 Signs of autism in adults. (2023, March 8). nhs.uk. https://www.nhs.uk/conditions/autism/signs/adults/

3 Ghanouni & Seaker (2023)

4 Autism spectrum Disorder. (n.d.). National Institute of Mental Health (NIMH). https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

5 Ibid.

6 Turnock, A., Langley, K., & Jones, C. R. G. (2022). Understanding Stigma in Autism: A Narrative review and Theoretical model. Autism in Adulthood, 4(1), 76–91. https://doi.org/10.1089/aut.2021.0005

7 Ibid.

8 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

9 Ibid.

10 Ibid.

11 Stagg, S. D., & Belcher, H. (2019). Living with autism without knowing: receiving a diagnosis in later life. Health Psychology and Behavioral Medicine, 7(1), 348–361. https://doi.org/10.1080/21642850.2019.1684920

12 Leedham, A., Thompson, A. R., Smith, R., & Freeth, M. (2019). ‘I was exhausted trying to figure it out’: The experiences of females receiving an autism diagnosis in middle to late adulthood. Autism, 24(1), 135–146. https://doi.org/10.1177/1362361319853442

13 Atherton, G., Edisbury, E., & Piovesan, A. (2021). Autism Through the Ages: A Mixed methods approach to understanding how age and age of diagnosis affect quality of life. Journal of Autism and Developmental Disorders, 52(8), 3639–3654. https://doi.org/10.1007/s10803-021-05235-x

14 Leedham et al., (2019)

15 Stagg & Belcher (2019)

16 Atherton et al., (2021)

17 Ghanouni & Seaker (2023)

18 Ibid.

19 Ibid.

20 Leedham et al., (2019)

21 Jadav, N., & Bal, V. H. (2022). Associations between co‐occurring conditions and age of autism diagnosis: Implications for mental health training and adult autism research. Autism Research, 15(11), 2112–2125. https://doi.org/10.1002/aur.2808

22 Ibid.

23 Barlattani, T. (2023). Autism spectrum disorders and psychiatric comorbidities: a narrative review. Journal of Psychopathology. https://doi.org/10.36148/2284-0249-N281

Managing ADHD: Medication, Psychotherapy, and the Potential of Music Therapy

The ABCs of ADHD

ADHD is a prevalent neurodevelopmental disorder that primarily manifests in childhood and often continues into adulthood and is characterized by difficulties in maintaining attention, controlling impulsive behaviors (acting without considering the consequences), and excessive levels of activity.[1] It impacts approximately 11 percent of children attending school; in over 75 percent of cases, symptoms persist into adulthood. Although individuals with ADHD have the potential for success, it is crucial to identify and treat the condition appropriately and in a timely manner. Without proper intervention, ADHD can lead to significant consequences, including academic difficulties, strained family relationships, emotional distress, challenges in forming and maintaining social connections, substance misuse, involvement in delinquent behaviors, accidental injuries and difficulties in employment. Early identification and timely treatment play a vital role in mitigating these potential effects.[2] There are a number of intervention methods for people who experience symptoms of ADHD.

Common Treatments

Two common treatments for ADHD include medication and psychotherapy. 

Medication

ADHD medication is used to address the symptoms such as hyperactivity and impulsiveness.[3] 

Types of ADHD Medication Include:[4]

• Stimulants

• Non-stimulants

• Antidepressants 

Stimulants, such as medications containing methylphenidate or amphetamine, are the usual primary prescriptions for ADHD. These stimulants seem to enhance and stabilize the levels of neurotransmitters, which are brain chemicals responsible for various functions.[5] However, stimulants are classified as controlled substances, implying that they possess the risk of being misused or leading to substance use disorders.

Additional medications utilized in ADHD treatment consist of non-stimulant options (e.g., atomoxetine) and certain antidepressants (e.g., bupropion).[6] While non-stimulants are prescription medications, unlike stimulants, they are not classified as controlled substances. As a result, the risk of improper use or dependency is lower with non-stimulant medications. These medications function by elevating the levels of norepinephrine in the brain. Healthcare providers may prescribe non-stimulant medications either on their own or in conjunction with a stimulant for managing ADHD. 

Antidepressants are also used to treat symptoms of ADHD. The antidepressants commonly prescribed for ADHD primarily target the levels of dopamine and norepinephrine in the brain.[7] While atomoxetine and antidepressants have a slower onset of action compared to stimulants, they can still be viable choices when stimulants are not suitable due to health issues or when the side effects of stimulants are too severe for someone.[8] 

Psychotherapy

Psychotherapy is frequently utilized alongside medication to address mental health conditions. Depending on the situation, medication might be the more appropriate choice in some cases, while psychotherapy may be the preferred option in others.[9] 

Psychotherapy can assist people with ADHD in various ways:[10]

• Enhancing time management and organizational abilities 

• Teaching techniques to minimize impulsive behavior 

• Fostering improved problem-solving skills 

• Dealing with past academic, work, or social challenges 

• Boosting self-esteem

• Learning methods to strengthen relationships with family, co-workers, and friends

• Developing strategies to manage anger effectively

The typical forms of psychotherapy for ADHD treatment include cognitive behavioral therapy (CBT), marital counseling and family therapy. CBT involves a structured approach to teach skills for behavior management and transforming negative thought patterns into positive ones. It aids in handling life challenges like school, work, or relationship issues and also addresses other mental health conditions such as depression or substance misuse.[11] Marital counseling and family therapy aim to assist family members in coping with the challenges of living with someone who has ADHD. They provide tools and techniques to improve communication and problem-solving skills within the family dynamic.[12] 

Music Therapy

There is another form of psychotherapy that can be utilized for treatment of the symptoms of ADHD known as music therapy. Music therapy is a form of psychotherapy that follows a systematic process of intervention. The therapist employs musical experiences and the relationships that evolve from them as dynamic catalysts for promoting health in the client.[13]

During a music therapy session, a patient may:[14]

• Create music

• Sing music

• Listen to music

• Move to music

• Discuss lyrics

• Play an instrument

Music plays an inherent role in the human experience, eliciting responses related to pulse, rhythm, breathing, movement and a wide array of emotions. These deep connections with music can persist even in the face of disabilities and illnesses. As a result, music therapists and counselors can effectively use music to assist individuals, both children and adults, who have diverse needs arising from various causes such as learning disabilities, mental and physical illnesses, physical and sexual abuse, stress and terminal illnesses. Through interactive musical experiences, emotional, cognitive and developmental needs can be addressed.[15] The ADHD brain exhibits reduced levels of dopamine, a neurotransmitter that plays a crucial role in motivation, attention, working memory, and focus. Music has the unique ability to activate both hemispheres of the brain, facilitating comprehensive brain engagement, allowing the activated components to collaborate more effectively and potentially strengthen over time. Consequently, this process enhances motivation and improves the capacity to concentrate.[16]

A number of studies have highlighted the positive effects of music therapy on people with ADHD. One study conducted by Zhang et al. (2017) aimed to assess the effectiveness of music therapy in improving attention, behavior, and social skills in children and adolescents with ADHD. Music therapy was associated with a significant reduction in hyperactivity and impulsivity, and improvements in attention, social skills, and academic performance.[17] Another study by Park et al. (2023) investigated the effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability. The results showed that both music therapy and pharmacotherapy were effective in reducing depression symptoms.[18]

If you are interested in finding out if Music Therapy can benefit you, you can access the American Music Therapy Association’s provider link here. 

If you or someone you know has or suspects that they have ADHD, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Centers for Disease Control and Prevention. (2022). What is ADHD?. CDC.

https://www.cdc.gov/ncbddd/adhd/facts.html#:~:text=ADHD%20is%20one%20of%20the,)%2C%20or%20be%20overly%20active

2 Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2023). About ADHD - Overview. CHADD. https://chadd.org/about-adhd/overview/ 

3 Mayo Clinic. (2023). Adult attention-deficit/hyperactivity disorder (ADHD). https://www.mayoclinic.org/diseases-conditions/adult-adhd/diagnosis-treatment/drc-20350883#:~:text=and%20certain%20medications-,Treatment,they%20don%27t%20cure%20it

4 Cleveland Clinic. (2022). ADHD Medication. https://my.clevelandclinic.org/health/treatments/11766-adhd-medication

5 Mayo Clinic

6 Ibid.

7 Cleveland Clinic

8 Mayo Clinic

9 Bhatia, Richa. (2023). What is Psychotherapy?. American Psychiatric Association. https://www.psychiatry.org/patients-families/psychotherapy

10 Mayo Clinic

11 Ibid.

12 Ibid.

13 Zhang F, Liu K, An P, You C, Teng L, Liu Q. Music therapy for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database Syst Rev. 2017 May 2;2017(5):CD010032. doi: 10.1002/14651858.CD010032.pub2. PMCID: PMC6481398.

14 Music Therapy. (2020). Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/8817-music-therapy

15 Zhang (2017)

16 Attention Deficit Disorder Association. (2022). Can Music Therapy Help with ADHD?. ADDA. https://add.org/can-music-therapy-help-with-adhd/

17 Zhang (2017)

18 Park, J. I., Lee, I. H., Lee, S. J., Kwon, R. W., Choo, E. A., Nam, H. W., & Lee, J. B. (2023). Effects of music therapy as an alternative treatment on depression in children and adolescents with ADHD by activating serotonin and improving stress coping ability. BMC complementary medicine and therapies, 23(1), 73.

Examining Cross-Cultural Differences in Mental Health Diagnoses

Does Location Matter?   

Why do certain psychiatric conditions share universal diagnosis criteria and treatment while others vary widely, dependent on location and culture? These discrepancies can be attributed to the lack of a gold standard for validating these conditions as well as the lack of biological markers, leading to different clinical interpretations and inconsistency across studies.[1]

Consistency across cultural studies can allow a more general understanding of conditions and how culture affects symptoms’ manifestations and diagnoses differently. By creating a clearer understanding of mental health conditions worldwide, better/more effective treatments and patient outcomes can arise. 

Should Diagnosis be Universal or Relative?   

Within the debate of why these differences occur, two main arguments exist. The first focuses on universality across cultures. The “universalistic viewpoint” emphasizes that all conditions occur equally and have a core set of symptoms - what varies is the manifestations and determination of pathology versus normalcy. “Ethnotypic consistency” was coined by Weisz et al., in 1997 to describe the idea that psychopathology is the same across locations and cultures, but varies in how symptoms are displayed.[2]  

The opposing viewpoint of universality places a larger emphasis on culture. The “relativistic viewpoint” stresses that culture shapes a person’s development and psychopathology. Symptoms and conditions can be unique and particular to specific cultures, as well as affect the magnitude and intensity of the condition.[3] 

From these two viewpoints, a combined conclusion can be established: certain disorders are seen as “universally occurring” due to their neural pathology, while others are shaped by social contexts and cultural norms.[4] 

Examining Cross-Cultural Differences 

One of the most well-researched conditions cross-culturally is attention-deficit/hyperactivity disorder (ADHD). From 1997 to 2016, attention deficit disorders in the United States has fluctuated from 6.1% to 10.2%, with debate ensuing whether the fluctuation arose from over-diagnosis, under-diagnosis and/or diagnostic disparities.[5] When comparing global prevalence, vast differences were found between North America, Africa and the Middle East. However, those differences were not found between North America, Europe, Oceania, Asia or South America. Canino and Alegria (2008) note that these discrepancies were attributed to the differences in instruments, methods, and how these disorders are defined within the different cultural studies compared.[6] 

Professor Mashai Ikeda began to research Bipolar Disorder (BD) after finding most conclusions on major psychiatric disorders were made using European samples. In 2022, Ikeda specifically looked at the genes of patients with BD type I (manic and depressive states) and BD type II (mild mania and depression) between European populations and East Asian populations.[7] He found East Asian populations containing genes of BD I were more correlated with major depression while European populations with BD I were more correlated with schizophrenia, however, no differences were found between the samples when examining BD type II. These differences were attributed to how the disorder is diagnosed in each country; East Asian psychiatrists hold that bipolar disorder is a mood disorder while European psychiatrists tend to diagnose patients with delusion and other psychotic symptoms.[8] These vast differences in definitions can later lead to issues with clinical trials, especially for drug therapy. 

Even the threshold that needed to be met to be considered pathological differs culturally. For example, Hong Kong’s rates of reported hyperactivity are double those of the United States.[9] Additionally, Chinese and Thai cultures place a high value on hiding aggression and overt behaviors, which lowers the threshold of hyperactive behaviors and raises the likelihood that parents would report it. Chinese and Indonesian clinicians also gave higher scores for hyperactive behavior problems when compared to scores given by Japanese and American clinicians.[10] A study conducted by Bird (2002) examined Italy, New Zealand, China, Germany, Brazil and Puerto Rico and found that hyperactive disorders were found in all cultures, but the prevalence and threshold of what was considered pathological is what differed. Therefore, while these conditions happen universally, the way each culture views the symptoms varies widely.[11]

These cultural distinctions of appropriateness not only occur cross-continentally but also within different communities. According to Andrade (2017), African Americans are more likely than White Americans to keep personal distress private and seek spiritual support versus seeking professional mental health treatment.[12] Further, in the United States, most minority groups are less likely than White Americans to seek mental health treatments or delay seeking help until their symptoms are severe. Many of these issues are tied to the discrimination and mistreatment minorities face when seeking help; in fact, 43% of African Americans and 28% of Latinos have felt they were mistreated in clinical settings due to their background.[13] There is also a lack of resources for non-English speakers to gain access to mental health services. These cultural factors tied with affordability and insurance coverage also create a very difficult situation for many people in certain populations to get mental health assistance at all. 

Mental health resources vary widely across the globe, depending on location. Nielsen, et al., (2022) found major differences among countries in the Far East, Middle East, and Southeast Europe, as most countries reported the need for more child psychiatrists and mental health professionals. The researchers note that 10% to 20% of adolescents experience a mental health disorder before they turn 14 years old.[14] Thus, the lack of resources in these countries poses a great risk to the population, as early intervention is key to recovery and well-being.

Future Steps: Integrating Culture and Diagnosis 

These locational and cultural challenges pose a clear threat to the reliability and validity of cross-cultural research; as we discover more about how these factors affect diagnosis and symptoms, it is essential to create instruments keeping these differences in mind. Historically, research has been based on Western diagnosis systems and definitions, but when using those definitions with other populations, concepts can become unclear.[15] Conceptual equivalence ensures the concept is identified uniformly according to the populations being studied.[16] Therefore, these disparities must be emphasized when conducting research. If not, misclassifications and incorrect conclusions about populations can be made. 

Harris (2023) stresses that with the growing importance culture plays on manifestations and diagnosis, it is important clinicians and mental healthcare professionals assess how a person’s background affects their condition. As well, adjust their assessment based on the person’s attitude towards mental health and how they express and cope with their mental health. Different populations may also have stigmas on seeking help or undergoing certain treatments, professionals must be aware of and protect those preferences.[17] 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has also embraced these strategies and highlights the impact of race and culture on disorders. Clarifications and disclaimers have been added to provide further information when specific communities had higher rates of certain disorders.[18] These considerations are fundamental in improving the disparities in diagnosis found across cultures as it allows psychiatry residents and fellows to see the effects race and culture can have on mental health and diagnosis.  

If you or someone you know is struggling with their mental health, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology & Psychiatry, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Abdelnour, E. (2022, October 1). ADHD diagnostic trends: Increased recognition or overdiagnosis? PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/#:~:text=The%20past%20couple%20of%20decades,the%20causes%20for%20this%20trend 

6 Canino & Alegría (2008)

7 Saito, T., Ikeda, M., Terao, C., Ashizawa, T., Miyata, M., Tanaka, S., Kanazawa, T., Kato, T., Kishi, T., & Iwata, N. (2022). Differential genetic correlations across major psychiatric disorders between Eastern and Western countries. Psychiatry and Clinical Neurosciences, 77(2), 118–119. https://doi.org/10.1111/pcn.13498 

8 Ibid. 

9  Ho, T.P., Leung, P.W., Luk, E.S., Taylor, E., BaconShone, J., & Mak, F.L. (1996). Establishing the constructs of childhood behavioral disturbances in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, 417–4314

10 Canino & Alegría (2008)

11 Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of ADHD. In P.S. Jensen & J. Cooper (Eds.), Attention deficit hyperactivity disorder: State of the science; best practices (pp. 12-1–12-36). Kingston, NJ: Civic Research Institute. 

12 Andrade, S. (2017). Cultural Influences on Mental Health | The Public Health Advocate. The Public Health Advocate. 

https://pha.berkeley.edu/2017/04/16/cultural-influences-on-mental-health/

13 Ibid. 

14 Nielsen, M. S., Clausen, C. E., Hirota, T., Kumperscak, H., Guerrero, A., Kaneko, H., & Skokauskas, N. (2022). A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe. Asia-Pacific Psychiatry, 14(2), 1–9. 

https://doi.org/10.1111/appy.12490

15 Canino & Alegría (2008)

16 Ibid. 

17 Harris, J. (2023, January 9). Cultural competency in mental Health Care: Why it matters. NAMI - Dominate Amazing Capabilities. https://nami-dac.org/cultural-competency-in-mental-health-care-why-it-matters/

18 Moran, M. (2022). Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR. Psychiatric News, 57(3).  https://doi.org/10.1176/appi.pn.2022.03.3.20

Understanding the Mental Health of Children on the Autism Spectrum

Signs of ASD in Children 

Autism Spectrum Disorder (ASD) is a developmental condition affecting a person's ability to socialize and communicate with others. It can also present with restricted and/or repetitive behavior patterns, interests, or activities. ASD is considered a “spectrum” because some people diagnosed with this disorder are mildly affected while others are severely disabled.[1] 

Approximately 1-in-100 people are on the autism spectrum[2] and the CDC reports that roughly 1-in-36 children has been identified with ASD.[3] People with ASD typically get diagnosed in their early years since symptoms of ASD often begin to appear during the first three years of life.[4] Some symptoms of ASD in children may include:[5,6]

• Difficulty engaging in everyday human interactions

• Intense specific interests

• Different ways of interacting with others

• Failing to make eye contact

• Not responding to their name

• Playing with toys in unusual, repetitive ways

• Severe tantrums or non-compliance

• Destructiveness

• Self-injurious behavior

• They may sleep less or are awake frequently during the night

Co-Morbid Mental Health Conditions in Children with ASD

Autism Spectrum Disorder is one of the most common disabilities affecting children and has drawn many researchers to investigate the well-being of children affected by ASD’s well-being. Studies show children with ASD are at higher risk of developing a mental health condition; Melissa (2021) notes that it is reported that more than three-quarters of children with ASD have at least one co-morbid mental health condition. Based on the statistic, children with ASD are likely to develop a mental health condition which is more than children with an intellectual disability, special health care needs, or the general population.[7]

The most common mental health conditions children with ASD experience, in order, are behavioral/conduct problems, attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression.[8] Research has found certain factors have been tied to an increased likelihood of specific mental health conditions compared to others. For example: 

• Females with ASD are more likely to have anxiety; 

• Children with ASD and intellectual impairments are more likely to have behavioral problems;

• Children with ASD who experience multiple adverse childhood experiences have greater odds of anxiety and ADHD.[9] 

Age is yet another factor that affects how mental health conditions present in children, as emotional, behavioral, and social difficulties can influence the timing of an autism diagnosis. Early childhood diagnoses usually present with greater emotional, conduct, hyperactivity, and social difficulties. Meanwhile, late-diagnosed children often have mental health and social difficulties before diagnosis that become more severe as they enter adolescence.[10]

Multiple reasons contribute to children with ASD's high risk of developing mental health conditions. The Mental Health Foundation (2022) notes that children with ASD may struggle in trying to fit into or make sense of the world, which can lead them to have feelings of depression and anxiety.[11] The act of camouflaging or strategizing to hide autistic traits also contributes to higher levels of depression, anxiety, and stress in adolescents and adults with ASD.[12] Children with ASD are more likely to face stigma and discrimination because of their disorder,[13] and those with internalizing problems (e.g., feelings of guilt, fear, worry, depression or anxiety) are more likely to be victimized by bullying.[14] Lastly, children with ASD may face difficulties receiving the proper care for their mental health conditions, including delays in diagnosis and lack of appropriate support available (e.g., therapists trained to work with autistic children).[15]

Co-Morbid Condition Effects 

Categorized as an internalizing behavior of ASD, anxiety is an excessive feeling of worry about a variety of events and activities over a long period. Perihan, et al., (2021) and Shea et al., (2018) found that internalizing problems may predict externalizing problems (e.g., aggression, conduct issues, and hyperactivity) in children with ASD.[16,17] Children with ASD and ADHD have been found to express a more substantial severity of autistic symptoms than patients with ASD alone; this increase in symptoms may result from inattention, impulsivity and hyperactivity.[18] Greene & Sherrel (2022) report that obsessive-compulsive disorder (OCD) is also found comorbidity with ASD.[19] Repetitive behaviors and hoarding are common in mild forms of autism, and Bejerot (2007) has shown that a combination of ASD and OCD results in a more severe and treatment-resistant form of OCD.[20]

Example of visualized language cards.

Mental health treatment options 

Treatment for mental health conditions in autistic children often has to be tailored to accommodate how they individually communicate and make sense of the world around them. For example, existing clinical anxiety programs for neurotypical children use communication and the relationship between clients and therapists to treat the condition. However, since children with ASD experience social and communication difficulties, they may experience difficulty interacting with their therapists and understanding the therapeutic social and emotional contexts that foster successful treatment. Research has found visualization to be one of the most effective treatment strategies in promoting effective social interaction and communication in children with ASD and utilizing visualized language significantly improves the success of anxiety treatment in children with ASD.[21] 

Cognitive behavioral therapy (CBT) is another treatment option for children with autism spectrum disorder and mental health conditions (e.g., anxiety, depression and ADHD) and works by teaching children how to alter their beliefs or behaviors to avoid negative emotions.[22] The cognitive component of the therapy helps children change how they think about a situation, while the behavioral component helps change how they react.[23] Modifications to CBT techniques are often needed to provide a more successful treatment to children with ASD and therapists may include concrete, repetitive, and visual tactics and focus on the child's unique interests to hold their focus. Additionally, a therapist may have to incorporate frequent movement breaks or sensory activities for children with attention or sensory under- or over-reactivity.[24]

The role of community 

The mental health of children with ASD has been shown to improve as a result of community support. Caregivers of children with autism should be aware that feeling tired or hungry can increase the severity of the child’s mental health condition(s).[25] Additionally, families should be aware that accommodating anxiety by removing the source of anxiety in response to a child's outburst is not as beneficial as one would imagine it should be. Storch et al. (2015) studied the effects of family accommodation on anxiety levels of children with ASD and found that lower levels of family accommodation can actually lead to lower levels of anxiety.[26] It is also important that caregivers take care of their own physical and psychological needs since raising a child with ASD can be difficult to navigate; this will benefit the caregiver as well as the child as levels of parental psychological stress have also been positively correlated to anxiety symptoms in children and adolescents with ASD.[27]

Further, O'Connor et al., (2022) note that young people with ASD who have more positive friendship features present with fewer signs of depression.[28] Supporting children with ASD to have healthy, positive relationships can improve their overall mental health. Additionally, O’Connor et al. recommend teaching non-autistic children how to be supportive friends to their autistic peers in order to help more autistic children experience the positive effects of friendship.[29]

If you are the parent or caregiver of a child with ASD and are experiencing signs of significant stress, anxiety and/or depression, please reach out to a licensed mental health provider who can help you navigate through the nuances of this disorder as well as any stressors you may be experiencing.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Autism. NAMI. (n.d.). Retrieved February 27, 2023, from https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Autism#:~:text=Children%20with%20autism%20can%20also,conditions%20than%20children%20without%20autism.  

2 Autism and mental health. Mental Health Foundation. (2022, February). Retrieved February 27, 2023, from https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health  

3 Data & Statistics on Autism Spectrum Disorder. Centers for Disease Control and Prevention. (2023, April). Retrieved August 23, 2023, from https://www.cdc.gov/ncbddd/autism/data.html

4 NAMI

5 Ibid. 

6 Payakachat, N., Tilford, J. M., Kovacs, E., & Kuhlthau, K. (2012, August). Autism spectrum disorders: A review of measures for clinical, health services and cost-effectiveness applications. Expert review of pharmacoeconomics & outcomes research. Retrieved February 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502071/  

7 Melissa J. (2021, March). Mental health conditions seen in 78% of children with autism. Retrieved February 27, 2023, from https://publications.aap.org/aapnews/news/11976?autologincheck=redirected  

8 Ibid. 

9 Ibid.

10 Mandy, W., Midouhas, E., Hosozawa, M., Cable, N., Sacker, A., & Flouri, E. (2022). Mental health and social difficulties of late-diagnosed autistic children, across childhood and adolescence. Journal of child psychology and psychiatry, and allied disciplines, 63(11), 1405–1414. https://doi.org/10.1111/jcpp.13587

11 Mental Health Foundation (2022)

12 Bernardin, C. J., Lewis, T., Bell, D., & Kanne, S. (2021). Associations between social camouflaging and internalizing symptoms in autistic and non-autistic adolescents. Autism : the international journal of research and practice, 25(6), 1580–1591. https://doi.org/10.1177/1362361321997284

13 Mental Health Foundation (2022)

14 Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experiences among children and youth with autism spectrum disorders. Journal of autism and developmental disorders, 42(2), 266–277. https://doi.org/10.1007/s10803-011-1241-x

15 Mental Health Foundation (2022)

16 Perihan, C., Bicer, A., & Bocanegra, J. (2022). Assessment and Treatment of Anxiety in Children with Autism Spectrum Disorder in School Settings: A Systematic Review and Meta-Analysis. School mental health, 14(1), 153–164. https://doi.org/10.1007/s12310-021-09461-7

17 Shea, N., Payne, E., & Russo, N. (2018). Brief Report: Social Functioning Predicts Externalizing Problem Behaviors in Autism Spectrum Disorder. Journal of autism and developmental disorders, 48(6), 2237–2242. https://doi.org/10.1007/s10803-017-3459-8

18 Banaschewski, T., Poustka, L., & Holtmann, M. (2011). Autismus und ADHS über die Lebensspanne. Differenzialdiagnosen oder Komorbidität? [Autism and ADHD across the life span. Differential diagnoses or comorbidity?]. Der Nervenarzt, 82(5), 573–580. https://doi.org/10.1007/s00115-010-3239-6

19 Greene N, Sherrell Z.(2022, March). ADHD vs. OCD: Differences, symptoms, treatment, and more. Medical News Today. Retrieved February 27, 2023, from https://www.medicalnewstoday.com/articles/adhd-vs-ocd  

20 Bejerot S. (2007). An autistic dimension: a proposed subtype of obsessive-compulsive disorder. Autism : the international journal of research and practice, 11(2), 101–110. https://doi.org/10.1177/1362361307075699

21 Perihan et al., (2022)

22 Cognitive behavioral therapy for autism spectrum disorder in children. Patient Care at NYU Langone Health. (n.d.). Retrieved February 27, 2023, from https://nyulangone.org/conditions/autism-spectrum-disorder-in-children/treatments/cognitive-behavioral-therapy-for-autism-spectrum-disorder-in-children#:~:text=Cognitive%20behavioral%20therapy%20may%20be,behaviors%20to%20avoid%20negative%20emotions  

23 Ibid. 

24 Schorr, B. (2021, April 28). Cognitive behavioral therapy for autism. Hidden Talents ABA. Retrieved February 27, 2023, from https://hiddentalentsaba.com/cognitive-behavioral-therapy-for-autism/  

25 Behavioral Innovations. (2023, January 5). Autism and impact on mental health. Behavioral Innovations - ABA Therapy for Kids with Autism. Retrieved February 27, 2023, from https://behavioral-innovations.com/blog/autism-and-impact-on-mental-health/

26 Storch, E. A., Zavrou, S., Collier, A. B., Ung, D., Arnold, E. B., Mutch, P. J., Lewin, A. B., & Murphy, T. K. (2015). Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response. Journal of anxiety disorders, 34, 94–99. https://doi.org/10.1016/j.janxdis.2015.06.007

27 Guerrera, S., Pontillo, M., Tata, M. C., Di Vincenzo, C., Bellantoni, D., Napoli, E., Valeri, G., & Vicari, S. (2022). Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family. Brain sciences, 12(12), 1597. https://doi.org/10.3390/brainsci12121597

28 O'Connor, R. A. G., van den Bedem, N., Blijd-Hoogewys, E. M. A., Stockmann, L., & Rieffe, C. (2022). Friendship quality among autistic and non-autistic (pre-) adolescents: Protective or risk factor for mental health?. Autism : the international journal of research and practice, 26(8), 2041–2051. https://doi.org/10.1177/13623613211073448

29 Ibid.

Imprisioned Youth: Mental Health Impacts of the Juvenile Justice System

The Goal & The Current Reality

Established in 1899, the U.S. Juvenile Justice System was created with the goal of deterring youth offenders from the damaging punishments of criminal courts while encouraging rehabilitation based on the individual juvenile’s needs.[1,2] Although the number of arrests of minors has been decreasing since 1997, nearly 60,000 minors are incarcerated daily in the United States. While roughly two-thirds of youth in juvenile facilities are 16 or older, more than 500 confined children are no more than 12 years old.[3-5] Youth who are incarcerated may be exposed to negative circumstances such as overcrowding, physical and sexual violence, risk of suicide and death.[6] 

Violence and abuse

Youth are exceptionally susceptible to many types of abuse during incarceration.[7] Many types of violence may occur in youth prisons, including:[8]

• physical violence amid detainees

• excessive violence committed by prison staff towards detainees amounting to torture or ill-treatment

• sexual assaults of inmates by other inmates or by prison staff

• psychological violence (e.g., verbal aggression, intimidation, etc.)

• suicides, attempts and other self-harm.

In “Victims Behind Bars: A Preliminary Study on Abuse During Juvenile Incarceration and Post-Release Social and Emotional Functioning,” researchers Dierkhising, Lane and Natsuaki (2014) examined the consequences of abuse while incarcerated. Of the youth surveyed, 96.8 percent had experienced at least one type of abuse during their incarceration (e.g., neglect or witnessing of abuse); 77.4 percent experienced a direct form of abuse, including physical injury.[9] The most common forms of direct abuse were the excessive use of solitary confinement, peer-to-peer physical assault between youth and psychological abuse of youth by staff.[10,11] Although violence is difficult to assess and address due to it being underreported, roughly approximately 25% of incarcerated youth are victimized by violence each year; 4-5% of whom experience sexual violence, with 1-2% subject to rape.[12] Psychological and physical effects of abuse may persist after the release of inmates.[13]

The abuse endured and exposure to violence in prisons and jails are associated with long term problems. These long term issues include post-traumatic stress symptoms, such as anxiety, depression, avoidance, hypersensitivity, hypervigilance, suicidality, flashbacks, difficulty with emotional regulation, and increased risk of criminal involvement.[14,15] Quandt & Jones (2021) note that the lasting effects of the trauma experienced while incarcerated can lead to Post-Incarceration Syndrome.[16] Similar to Post-Traumatic Stress Disorder (PTSD), Post-Incarceration Syndrome is a set of symptoms present in many currently incarcerated and recently released prisoners; it is caused by being subjected to prolonged incarceration in environments of punishment with few opportunities for education, job training, or rehabilitation.[17] In addition, a study conducted by Piper & Berle (2019) examined the relationship between trauma experienced during incarceration and PTSD outcomes. They found that incarcerated people experience high rates of potentially traumatic events, and that there was a relationship between experiencing these events behind bars and the rate of PTSD upon release.[18] The National Child Traumatic Stress Network (2007) found an average of 30% of previously incarcerated youth develop some form of PTSD.[19]

 

Mental Health in the Juvenile Justice System

The National Conference of State Legislatures found that the juvenile justice system is ill-equipped to handle minors with mental health needs.[20] Approximately 1-in-4 children and adolescents arrested each year suffer from a mental illness so severe it impairs his or her ability to function as a young person and grow into a responsible adult.[21] The lack of treating a minor’s mental illness can increase the chances of delinquency transforming into adult criminality.[22] It is estimated that 60 to 70 percent of the 2 million children and adolescents that enter the juvenile justice system have one or more diagnosable disabilities (e.g., learning disabilities, emotional and behavioral disorders and developmental disabilities).[23] The most common diagnoses found in incarcerated youth include: Attention-Deficit Hyperactivity Disorder (ADHD), learning disabilities (LD), depression, developmental disabilities (DD), conduct disorder, anxiety disorders, Post-Traumatic Stress Disorder (PTSD), and substance abuse.[24] 

Many youth experience conduct, mood, anxiety and substance disorders that frequently put them at risk for troublesome behavior and delinquent acts.[25] Symptoms of mental health disorders often start in childhood; behavior disorders such as ADHD impact about 9-10 percent of children in America and emotional disorders (e.g., depression) impact 1 in every 33 children.[26] Mental health disorders in youth can be difficult to treat; however, assessing and treating issues early can create positive outcomes.[27] 

Many youth with mental health disorders also engage in substance abuse and there is an overrepresentation of this co-occurrence within the juvenile justice system.[28] Two-thirds of juveniles within the system with a mental health diagnosis also had dual disorders; this most often involves substance abuse in addition to another diagnosis.[29] 

Methods of Reform

In order to reform the juvenile justice system, the subsystems within it need to be addressed. While reform is a long process that can take many years, Sander (2021) notes that many states have already made such reforms over the last 15 years to reduce youth incarceration.[30]

Eliminating violence and abuse while incarcerated poses a difficult task, however there are many policies currently in place that can accomplish this. Jocelyn Fontaine, Director of Criminal Justice Research at Arnold Ventures believes that, “The pathway to reform is in opening them, making the invisible more visible so by revealing what’s happening, then we hope that people would be motivated to change them.”[31] Fontaine considers transparency and accountability of  reform as shedding light on a situation due to the public and policymakers wanting to change it because they didn’t know about it before.[32] Other suggested reforms include increasing programs in order to keep juveniles focused to avoid violence. This notion, Social Bond Theory, was founded by Travis Hirschi and is based on the basic assumption that humans naturally tend towards delinquency.[33] Hirschi states that the stronger amount of social control and the denser the network of social bonds are, the more likely people are to behave in accordance with standards.[34]

The Healthy Returns Initiative is another way to combat the juvenile mental health crisis. This initiative was created to strengthen the capacity of county juvenile justice systems to improve health and mental health services, and ensure continuity of care as youth transition back to the community.[35] The Healthy Returns Initiative, created by The California Endowment, follows practices considered critical to any systems reform effort.[36,37] Life-changing reform practices have been implemented by the Initiative, such as: screening using validated mental health screening tools; connecting youth and families to benefits and resources (e.g., health care, housing assistance, and food stamps); collaboration and integration across services; and providing funding and resources to sustain multi-disciplinary, collaborative, holistic approaches.[38]

In addition to HRI, the Comprehensive Systems Change Initiative (CSCI) is a model that brings together juvenile justice and mental health systems to identify youth with mental health needs at their earliest point of contact with the juvenile justice system to develop an effective service delivery system to meet their needs.[39] This includes collaborating among all relevant youth-serving agencies and families, identifying youth with mental health needs through use of standardized screening and assessment tools, diverting youth from the justice system to community programs where possible and treating youth who remain in the system using a continuum of evidence-based mental health services.[40,41] 

By applying and executing reform in the juvenile justice system, society as a whole can better understand, assess and treat mental health disorders in children and adolescents. This implementation will allow youth in America to remain on-track to do better academically and subsequently have better odds at leading healthier and more fulfilling lives. 

Contributed by: Ariana McGeary

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Juvenile Justice History. (n.d.). Retrieved from Center on Juvenile and Criminal Justice: http://www.cjcj.org/education1/juvenile-justice-history.html

2 McCord, Joan; Spatz Widom, Cathy; Crowell, Nancy A.; National Research Council. (2001). Juvenile Crime, Juvenile Justice. Washington: National Academy Press.

3 ACLU. (n.d.). America’s Addiction to Juvenile Incarceration: State by State. Retrieved from ACLU: https://www.aclu.org/issues/juvenile-justice/youth-incarceration/americas-addiction-juvenile-incarceration-state-state#:~:text=On%20any%20given%20day%2C%20nearly,prisons%20in%20the%20United%20States.

4 Youth Involved with the Juvenile Justice System. (n.d.). Retrieved from Youth.gov: https://youth.gov/youth-topics/juvenile-justice/youth-involved-juvenile-justice-system

5 Ibid.

6 Stephens, R. (2021, May 28). Trauma and Abuse of Incarcerated Juveniles in American Prisons. Retrieved from Interrogating Justice: https://interrogatingjustice.org/prisons/trauma-and-abuse-of-incarcerated-juveniles-in-american-prisons/

7 Modvig, J. (n.d.). 4. Violence, sexual abuse and torture in prisons - WHO/Europe. Retrieved from WHO/Europe: https://www.euro.who.int/__data/assets/pdf_file/0010/249193/Prisons-and-Health,-4-Violence,-sexual-abuse-and-torture-in-prisons.pdf

8 Dierkhising, C. B., Lane, A., & Natsuaki, M. N. (2014). Victims Behind Bars: A Preliminary Study on Abuse During Juvenile Incarceration and Post-Release Social and Emotional Functioning. Psychology, Public Policy, and Law, 20(2), 181-190.

9 Repka, M. (2014, March 26). Confronting an Unseen Problem: Abuse and Its Long-Term Effects on Incarcerated Juveniles . Retrieved from Chicago Policy Review: https://chicagopolicyreview.org/2014/03/26/confronting-an-unseen-problem-abuse-and-its-long-term-effects-on-incarcerated-juveniles/#:~:text=The%20most%20common%20forms%20of,staff%20was%20also%20widely%20reported.

10 Dierkhising, C. B., Lane, A., & Natsuaki, M. N. (2014)

11 Modvig, J. (n.d.). 

12 Dierkhising, C. B., Lane, A., & Natsuaki, M. N. (2014)

13 Repka, M. (2014)

14 Quandt, K. R., & Jones, A. (2021, May 13). Research Roundup: Incarceration can cause lasting damage to mental health . Retrieved from Prison Policy Initiative: https://www.prisonpolicy.org/blog/2021/05/13/mentalhealthimpacts/#:~:text=Exposure%20to%20violence%20in%20prisons,and%20difficulty%20with%20emotional%20regulation.

15 Ibid.

16 Post Incarceration Syndrome (PICS). (2021, October 16). Retrieved from BarNone, Inc.: https://barnoneidaho.org/resources/post-incarceration-syndrome/#:~:text=Post%20Incarceration%20Syndrome%20(PICS)%20is,%2C%20job%20training%2C%20or%20rehabilitation.

17 Piper, A., & Berle, D. (2019). The association between trauma experienced during incarceration and PTSD outcomes: a systematic review and meta-analysis. The Journal of Forensic Psychiatry & Psychology, 30(5), 854-875.

18 Bierkhising, C. B., Ko, S. J., Woods-Jaeger, B., Briggs, E. C., Lee, R., & Pynoos, R. S. (2013). Trauma histories among justice-involved youth: findings from the National Child Traumatic Stress Network. European Journal of Psychotraumatology, 4.

19 National Conference of State Legislatures. (2012, May 25). Mental Health Needs of Juvenile Offenders. Retrieved from NCSL: https://www.ncsl.org/documents/cj/jjguidebook-mental.pdf

20 Ibid.

21 Sawyer, W. (2019, December 19). Youth Confinement: The Whole Pie 2019. Retrieved from Prison Policy Initiative: https://www.prisonpolicy.org/reports/youth2019.html

22 Juvenile Justice Issues. (n.d.). Retrieved from Pacer Center: https://www.pacer.org/jj/issues/

23 Ibid.

24 National Conference of State Legislatures. (2012)

25 Ibid.

26 Ibid.

27 Substance Abuse and Mental Health Services Administration. (2022, March 22). Criminal and Juvenile Justice . Retrieved from SAMHSA: https://www.samhsa.gov/criminal-juvenile-justice

28 National Conference of State Legislatures. (2012)

29 Sanders, C. (2021, July 27). State Juvenile Justice Reforms Can Boost Opportunity, Particularly for Communities of Color. Retrieved from Center on Budget and Policy Priorities: https://www.cbpp.org/research/state-budget-and-tax/state-juvenile-justice-reforms-can-boost-opportunity-particularly-for#:~:text=Though%20much%20work%20remains%2C%20several,shifting%20to%20community%2Dbased%20approaches.

30 D'Abruzzo, D. (2020, August 24). How Can Prisons Eliminate Violence? One Researcher Is Determined to Find Out. Retrieved from Arnold Ventures: https://www.arnoldventures.org/stories/how-can-prisons-eliminate-violence-one-researcher-is-determined-to-find-out

31 Ibid.

32 Wickert, C. (2022, April 18). Social bonds theory (Hirschi). Retrieved from SozTheo: https://soztheo.de/theories-of-crime/control/social-bonds-theory-hirschi/?lang=en

33 Ibid.

34 Healthy Returns Initiative. (n.d.). Retrieved from i.e. communications, llc: https://www.iecomm.org/healthy-returns-initiative/

35 Reform Trends: Mental Health & Substance Use. (2022)

36 Healthy Returns Initiative.

37 Reform Trends: Mental Health & Substance Use. (2022)

38 Ibid.

39 Chayt, B. (2012, December). Juvenile Justice and Mental Health: A Collaborative Approach. Retrieved from ModelsforChange: https://www.modelsforchange.net/publications/350/Innovation_Brief_Juvenile_Justice_and_Mental_Health_A_Collaborative_Approach.pdf

40 Reform Trends: Mental Health & Substance Use. (2022)