Ideally, maturing young adults should be able to make independent decisions as they become more self-reliant and self-confident, possessing the ability to set goals and follow through on tasks until goal attainment has been achieved. Young adults strive to become productive citizens who can navigate complex demands revolving around advancing their education, seeking independence, and experimenting with intimate relationships (Clark & Unruh, 2009). They articulate their dreams for the future and are able to plan and follow through with career goals. Having an income and at least the appearance of being self-sufficient is important to them (Fetzer, Garner, Shepler, Thom, & Firesheets, 2008).
When individuals are faced with complicating factors, such as mental or emotional disorders and substance abuse, their chances of realizing their full potential become jeopardized as they pass through transition (Clark & Unruh, 2009). Transition-aged youths with a diagnosed mental illness are often left with impaired functioning in three basic functional domains: (a) family, (b) school, and (c) community (American Psychiatric Association, 2013). A chasm in any one of the three domains significantly disrupts the ability to gain an education, secure employment, attain housing, receive comprehensive health care, and achieve overall desirable quality of life (Fetzer et al., 2008). Developing and maintaining interpersonal relationships is particularly troublesome (Clark & Unruh, 2009). Transition-aged youths with dual diagnoses are presented with greater challenges the further they venture into the adult phase of their lives. Unfortunately, the realities of life and meeting societal expectations are not always forthcoming.
There are varying opinions and guidelines as to what constitutes the transitional years. According to the Individuals with Disabilities Education Act (IDEA), transition services are to begin when a youth reaches age 16. Therefore, planning for transition services may begin at approximately age 14 or earlier. Although some programs (e.g., foster care) consider an individual to be an adult at age 18, others (e.g., those that provide services under IDEA) continue through age 21. Young individuals with dual diagnoses may need extra time to find secure footing in the adult world; therefore, some programs advocate that transition supports and services be available through age 29 (Dresser, Clark, & Deschênes, 2015). For the purposes of the current discussion, statistics and studies are included pertaining to individuals ages 13 to 29.
In 2006, more than 2.4 million youths (ages 18 to 26) experienced serious mental illnesses, such as depression, schizophrenia, and mood disorders (U.S. Government Accountability Office, 2008). Those who experience mental illness are twice as likely as those without mental illness to abuse drugs; the converse is also true—those who abuse drugs are twice as likely as non-abusers to experience mental illness (National Institute on Drug Abuse, 2011). In fact, youths in this age range have higher rates of substance abuse than any other age group with mental disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). In 2014, >29% of youths ages 18 to 25 with any type of mental illness also had a substance use disorder—a figure that climbs to >35% among those whose mental illness is classified as serious in accordance with guidelines from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Center for Behavioral Health Statistics and Quality, 2015).
Causes of Vulnerability to Drug Abuse
Drug abuse is a major concern, especially because the human brain (particularly the prefrontal cortex, which is involved in evaluation of situations, decision making, and impulse control) is still developing well into young adulthood. Interruption and impairment of this critical development induced by substance use can have lifelong consequences (Lebel & Beaulieu, 2011; National Institute on Drug Abuse, 2010).
Vulnerability to drug abuse can have a variety of causes. Drug abuse may be the result of genetic predisposition, family dynamics, peer pressure, or socioeconomic pressures. It may provide a method of self-medication, particularly among youths who are insecure or depressed, experience anxiety, or feel overwhelmed by stress (e.g., trauma of sexual abuse, homelessness, poverty) (Pahl, Brook, & Lee, 2014). Early exposure to addictive substances can be particularly problematic, as drug abuse can disrupt the brain's normal response to stress and rewards. In some cases, it may be that substance abuse triggers the onset of symptoms of latent mental illness (Lebel & Beaulieu, 2011).
Perceptions and Consequences
Woolsey and Katz-Leavy (2008) reported a multitude of challenges individuals with mental illnesses face as they transition to adulthood; high in significance was the stigma of being labeled mentally ill or intellectually challenged. Of equal importance were fears associated with receiving mental health treatment, the necessity of coping with feelings of low self-esteem and self-worth, and the lack of ownership over personal life plans and activities of daily living (Woolsey & Katz-Leavy, 2008).
In a study of mental health issues among 400 urban youths, Schwinn, Schinke, and Trent (2010) found that those who were anxious or depressed were more likely to be hostile. Such findings have implications for interference of a youth's goal attainments and potential for independence. Among the same sample, when substance use and abuse were added to the mix, youths manifested increased levels of depressive and anxiety symptoms and hostility (Schwinn et al., 2010). Consequently, the co-occurring conditions of substance abuse and mental disorders can create troublesome complexities for young individuals, health care providers, and health care delivery systems—complexities that may then affect families and communities.
To make a paradigm shift in the way health care is delivered, the patient, provider, and mental health system must be involved in planning and implementing transitional programs that will provide those supports and guidance, which are necessary for this vulnerable population to succeed as adults.
Prevention and Interventions
Baillie et al. (2010) concluded their extensive review of psychological interventions for mental illness and substance use disorders with the observation that there have been few well-designed studies conducted on this subject. O'Connell, Boat, and Warner (2009) also stressed the lack of comprehensive research on the effectiveness of interventions addressing mental, emotional, and behavioral disorders among youths. Taking into account increased costs related to health care; juvenile and criminal justice; education; and lost income that affects young individuals, their families, and communities, it is estimated that the cost–benefit ratios for efforts to prevent or treat mental illness and substance abuse before serious problems manifest are at least $2 for every $1 invested, with some estimates being as high as $10 for every $1 invested (National Academies, 2009; O'Connell et al., 2009). Based on a survey of 10,123 youths ages 13 to 18 in the United States, in which it was observed that 20% to 25% met DSM-IV criteria for a mental disorder with severe impairment, Merikangas et al. (2010) urged the nation to renew efforts aimed at the prevention and early treatment of mental illness.
Youths with dual diagnoses deserve the opportunity to maximize their potential. Because the stigma of mental illness and substance abuse continues to be profound and riveting throughout society, federal financial support and community awareness about mental illness and substance abuse should continue to be a major focus in all program-related activities. Key community players and stakeholders should have an investment in improving the quality of life for individuals in the community, including transition-aged youths with mental health and substance abuse disorders.
Dependency on drugs often begins with cigarette smoking (with nicotine often referred to as the gateway drug), as it appears to be an antecedent to other maladaptive social and health behaviors (National Institutes of Health, 2011). Individuals who used drugs or alcohol during their earlier years were more likely to develop dependencies on drugs and alcohol during their later years (SAMHSA, 2008). Preventing or delaying cigarette and substance use among this population is of utmost importance, and has been an ongoing goal of the SAMHSA initiative (SAMHSA, 2008).
In a study of 838 urban youths, Pahl et al. (2014) observed that the more self-control youths exhibited at age 14, the more likely they were to have resisted the use of marijuana and the less likely they were to have experienced depression over the course of the next 15 years. This finding suggests the importance of expanding programs that facilitate continuity of services and support throughout the entire duration of the transition period for young adults, as youths with dual diagnoses face enough serious threats to well-being without the stark reality of aging out of programs and supports. Young adults with dual diagnoses oftentimes do not know where to turn or how to access resources in what is perceived to be a hostile labyrinth of adult services.
An excellent program confronting this dilemma is the Transition to Independence Process (TIP) model, an evidence-supported program that improves outcomes for transition-aged individuals with mental illness (Clark & Unruh, 2009; Dresser et al., 2015). The TIP model is designed to begin services at age 14, when planning for transition services is normally initiated. For some, particularly those who have complicating issues (e.g., dual diagnoses), it may take longer to achieve a solid footing in the world of adulthood; therefore, the TIP model provides continuity of services through age 29. The guiding principles of TIP pivot upon connecting young individuals with individualized services and supports appropriate for age, mental health status, and personal goals. Because the young adult is involved in the identification of his/her own needs and goals, there is increased motivation toward success. A safety net, formed by family members and other formal and informal key players, ensures success in making beneficial personal choices. Thus, the TIP model is able to facilitate the achievement of optimal physical and mental health, self-confidence, fulfillment, and self-sufficiency in young adults (Dresser et al., 2015).
The current study provides an overview of problems encountered by transition-aged youths with dual diagnoses. Transition-aged youths find themselves confronted with multiple stressors, owing to the fact that they are in the midst of change on all fronts (i.e., physiological, social, emotional, and environmental). Individuals with dual diagnoses of mental health disorders and substance abuse often find themselves in a quagmire of supports and services poorly suited to their specific needs. One of the most difficult dilemmas stems from the lack of continuity and consistency of services and supports that embrace the entirety of the transition period. All too often the struggle through this difficult period in their lives has dire outcomes for youths with dual diagnoses, indicating the urgent need for changes in the ways services and supports are offered to this vulnerable population. The future well-being of youths with dual diagnoses can benefit from interventions that increase self-control (e.g., cognitive-behavioral therapy, mindfulness techniques) (Pahl et al., 2014) and programs (e.g., TIP) that empower young adults to find sure footing along the journey to adulthood. The investment of time and money to support programs that provide intensive guidance throughout the transition years promises to return generous dividends.
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