An excerpt from The Addicted Child: A Parent’s Guide to Adolescent Substance Abuse.

How do you know if your teen has a substance problem? The inability to control substance use despite negative consequences is a classic definition of a severe substance use disorder. But substances aren’t the only thing afflicting adolescents. Another dangerous behavior is invading the adolescent population: process disorders. These are compulsive behaviors often accompanying alcohol and drug disorders, though not always. Examples include sex, shopping and spending, gambling, gaming, eating disorders, self-harm, and cell phone use.

The process disorders I frequently saw among adolescents were eating disorders, self-injury and, to a lesser extent, gaming. Patients with eating disorders were mostly females, while males presented with gaming disorders.

These behaviors can evolve without your child using alcohol or drugs, but it’s not uncommon to have both a substance use disorder combined with a process disorder. For example, teens might be smoking marijuana and engaging in self-harm by cutting or burning themselves. When both disorders are present, treatment becomes more complicated.

Self-harm refers to injuring yourself on purpose and can be a symptom of extreme emotional distress. Unfortunately, this act is becoming increasingly common in teens.

Research from the Centers for Disease Control shows that up to 30 percent of teenage girls say they have intentionally injured themselves. About one in ten boys engaged in self-inflicted injury. Combined, nearly 18 percent of teens have used methods of self-harm, the most prevalent method being cutting. As a result, this trend has become an ongoing danger.

Beth was admitted to the psychiatric unit with a history of cutting beginning at age 10. She smoked marijuana multiple times a day and showed traits of borderline personality disorder (BPD). BPD involves difficulties regulating emotion, which means that people who experience BPD feel emotions intensely and for extended periods of time.

Like most self-harming teens, Beth concealed her cutting for years. She cut in areas unnoticed by her parents, such as her thighs, upper legs, and arms. This coping skill helped relieve intense feelings of anxiety and guilt, though it left physical and emotional scarring. Without access to marijuana, Beth’s self-harm increased while she was hospitalized as she found staples or pens and made superficial scratches on her arms.

If your child is self-harming, you may not understand it, or you might ask, “Why would anyone, especially my child, intentionally harm themselves?”

Self-harm is a coping skill to manage intolerable feelings like anger, shame, grief, guilt or self-loathing. It’s a desperate attempt to gain control over these emotions. Also, some teens self-harm because they want to punish themselves for what they perceive as their faults or flaws.

While some teens cut with a knife or other sharp object, other methods of self-harm include the following:

• scratching or biting the skin
• burning the skin with matches, cigarettes or hot, sharp objects
• hitting or punching themselves or the walls
• piercing their skin with sharp objects
• banging their head or body against walls and hard objects.

Teens will go to great lengths to hide their wounds and self-harming instruments. Here are some warning signs:

• scars or scabs
• unexplained cuts, scratches, bruises, or other wounds often found on wrists, arms, and thighs
• keeping sharp objects on hand
• wearing clothes that cover up the skin, such as long sleeves or pants in hot weather
• impulsive and unstable behavior
• expressing feelings of hopelessness or worthlessness
• difficulties with relationships
• bloodstains on bedding, clothing, towels, or tissues
• having sharp objects in their possession, including razors, scissors, and needles
• spending long periods of time alone, often in the bathroom or bedroom
• avoiding situations where they need to reveal skin, such as swimming

Therapies for self-harm include cognitive-behavioral therapy (CBT) and dialectical behavioral therapy (DBT). Your child can learn to practice safe, effective coping skills in DBT groups. The success of such treatment, however, depends on a willingness to practice these coping skills. Beth attended numerous DBP training classes. She knew all the DBT acronyms and skills but never practiced them or committed to using them when needed. As a result, she was setting herself up for failure.

It’s fairly easy to keep patients away from alcohol and drugs in an acute hospital setting. It’s more challenging in residential and outpatient programs. For example, if there is a history of marijuana use and self-harm like cutting, controlling the cutting becomes a challenge.

Another patient named Julie, much like Beth, smoked marijuana multiple times a day and self-harmed to manage anxiety. Because she was in a psychiatric hospital, her access to marijuana was denied. When her anxiety spiked, her self-harm increased because she didn’t access her other coping skill of smoking marijuana. That’s the challenge with adolescents diagnosed with a substance use disorder and a process disorder like self-harm or an eating disorder. Both disorders are coping skills, and when one skill is curtailed, the other may increase.

The Self Abuse Finally Ends (S.A.F.E) website offers information and resources you may find helpful. There is information for family members and intervention tips.

Eating disorders

The American Academy of Child and Adolescent Psychiatry believes that the two primary psychiatric eating disorders, anorexia nervosa and bulimia, are on the rise among teenage girls. While these two eating disorders also occur in boys, it’s less often.

A teenager with anorexia nervosa is typically female, a perfectionist, and a high achiever in school. At the same time, she suffers from low self-esteem, irrationally believing she is fat regardless of how thin she becomes. Desperately searching for a feeling of mastery over her life, a teenager with anorexia nervosa experiences a sense of control only when she says no to the normal food demands of her body. In a relentless pursuit to be thin, the girl starves herself.

Symptoms of bulimia are different as the patient binges on large quantities of high-calorie food followed by purging the body of dreaded calories by self-induced vomiting, extreme exercise, or laxatives. The binges may alternate with severe diets, resulting in dramatic weight fluctuations. Teenagers may try to hide the signs of throwing up by running water while spending long periods of time in the bathroom.

Treatment for eating disorders usually requires a team approach, including individual therapy, family therapy, working with a primary care physician, seeking out a nutritionist, and medication. Parents who notice symptoms in their teenagers should ask their family physician or pediatrician for a referral to a child and adolescent psychiatrist.

Eating disorders often go unnoticed, and “most parents do not realize how common teen eating disorders are. In most cases, the onset of eating disorders occurs in adolescence or early adulthood.” What’s worse is that these disorders can be deadly. Every 62 minutes, a person dies from an eating disorder.

How can you detect if your child has an eating disorder? You’ll notice that your adolescent tends to be moody, anxious, and/or depressed. Most adolescents suffering from eating disorders will deny that they have a problem. In many cases, they’ll blame everything but their relationship with food.

Here are the behavioral signs and physical symptoms to look for:

Behavioral signs

• making excuses to avoid eating
• always being on a diet, even when not needed
• over-exercising, and obsessed with exercise to lose weight
• secretly storing food or eating alone, particularly at night
• a distorted body image
• compulsive use of laxatives, diet pills, and weight-loss aids
• an intense, obsessive focus on calories and caloric intake
• an unwillingness to discuss weight gains or weight loss
• resistance to joining social situations where eating is expected
• extended bathroom use during or right after meals

Similar behavioral signs can appear in adolescent girls and boys going through normal childhood development. Still, when teens repeatedly exhibit a number of these behaviors, the parents should investigate further.

Physical symptoms

• unhealthy loss or gain of weight
• repeated weight cycling, going up and down
• constipation or vomiting
• skin rash or dry skin
• erosion of tooth enamel, dental cavities
• loss of hair and/or nail quality
• obvious signs of exhaustion or insomnia
• irregular menstruation or absence of menstruation
• easily bruised or more prone to physical injury
• cold sensitivity

One referral site for eating disorders is ED Referral. It offers search programs and the ability to identify specific co-occurring issues like addiction. Also, you can search for programs by insurance. Under the Find Help tab, selecting “Only for Treatment Centers” brings a list of programs where you can select a program and view the program’s site.

Richard Capriola is a counselor and author of The Addicted Child: A Parent’s Guide to Adolescent Substance Abuse.

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