CONDUCT DISORDER AND DRUG USE

A behavior pattern characterized by such behaviors as stealing, violence, running away from home, and truancy occurs in about 10 percent of children under 16 years of age. Within the framework of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV), this serious and persistent pattern of antisocial behavior is diagnostically labeled conduct disorder (CD). CD is the most common psychiatric disorder in emotionally disturbed youth, present in about 75 percent of cases. Boys outnumber girls in ratios of 4:1, but 8:1 for property and violent crimes. Emerging evidence suggests, however, that the gender gap is narrowing; and by adolescence, commonly associated problems include alcoholism, drug addiction, criminality, incarceration, sexually transmitted diseases (STDs), pregnancies, prostitution, traumatic injuries, dropping out of school, and comorbid psychiatric disorders.

DIAGNOSIS

In the American Psychiatric Association classification system for diagnosing mental disorder (DSM-IV), conduct disorder is defined as "a repetitive and persistent pattern of conduct in which the basic rights of others or major age-appropriate societal norms or rules are violated" (American Psychiatric Association, 1994). Conduct disorder has become one of the most valid and reliably diagnosed psychiatric disturbances. The problem behavior is transsituational—it is manifested in the home, at school, and in daily social functioning. Often, CD youth are suspicious of others and, consequently, they misinterpret the intentions and actions of others. By adolescence, aggression may become so severe that violent assault, rape, and homicide are committed. Precocious sexual behavior and sexual misbehavior, especially among females, are also common. Denial and minimization generally occur when the youngsters are confronted about their behavior. Typically, feelings of guilt are not experienced.

Other, less severe, types of behavior disorders are also known. The most common that resemble CD are

1. adjustment disorder with disturbances of conduct;
2. childhood (or adolescent) antisocial behavior; and
3. oppositional defiant disorder.

Substantial differences in the behavioral manifestations of CD have prompted efforts to develop subtypes. The most well-known subtyping criteria are

1. socialized versus unsocialized;
2. aggressive versus nonaggressive; and
3. overt versus covert.

Just one variant of CD, the solitary aggressive type, characterizes approximately 50 percent of incarcerated youth; they are usually socioeconomically disadvantaged and typically derive from dysfunctional families. Moral development is arrested, cognitive abilities are low, and behavior is often dangerous both to self and others. This CD variant should not be confused with adaptive delinquency, in which the behavior is an attempt to adjust to the manifold disadvantages of inner-city living.

NATURAL HISTORY

Other psychiatric disorders frequently occur in conjunction with conduct disorder. The most prevalent comorbid (coexisting) psychiatric disorder is attention deficit disorder. By adolescence, the comorbid conditions of psychoactive substance use disorder with depressive disorders often emerge; however, virtually any type of psychiatric disorder can be present concurrently with CD (Rutter, 1984). By adulthood, an Antisocial Personality disorder is the most common outcome of CD; this disorder may also be accompanied by any other psychiatric disorder.

Among those who have CD with attention deficit disorder, the onset age of behavior problems tends to be earlier and more severe than in cases with either disorder alone. In the situation where both are present, children are also at greater risk for developing criminal behavior and substance abuse by adolescence or young adulthood.

The coexistence of CD and substance abuse has been frequently observed. It is estimated that as many as 50 percent of serious offenders are substance abusers. In these cases, CD usually preceded the onset of substance abuse. Some evidence has been marshaled to suggest that, for many individuals, substance abuse and CD are the overt expressions of a common underlying predisposition. Only in some cases, does the onset of CD follow the onset of substance abuse. Drug use during adolescence, by virtue of its pattern of illegal behavior plus association with nonnormative peers, increases the risk for violent assault as well as getting arrested and convicted for drug possession or distribution. In effect, the use of drugs in this circumstance socializes a person to a deviant lifestyle by early to mid-adolescence.

Approximately 30 percent of boys with CD also qualify for a diagnosis of Depression. In this comorbid condition, there appears to be a lower risk of depression in adulthood compared to cases of depression in childhood without CD. Since the outcome of depressed children with comorbid CD is similar to nondepressed CD children, this suggests that the affective disturbance is a secondary condition.

CD in childhood is associated with an increased risk for antisocial personality disorder in adulthood. Compared to other psychiatric disorders of childhood, CD is the most likely to remain stable. Persistence of conduct problems into adulthood is most likely if the behavior problems are serious, are generalized across multiple environments or situations, have an early age onset, and lead the person into the criminal-justice system (Loeber, 1991).

ETIOLOGY

Adoption and family studies implicate a genetic predisposition for the development of antisocial behavior in many. A genetic propensity does not, however, appear to invariably ensure this adverse outcome. Other complicating factors include being a child in a dysfunctional family where the parents are abusive, neglectful, or absent or where there are poor parenting skills. Alcoholic and physically abusive parents have been frequently linked to CD in their own childhoods. Neurologic injuries (e.g., trauma) and neurodevelopmental disability (e.g., dyslexia) can exacerbate the expression of CD. Socioeconomic and ethnic factors (e.g., Poverty, street Gangs) also influence the development of CD.

TREATMENT

The following are generally inadequate for the treatment of youth with CD: individual psychotherapy, behavior modification, group counseling, family therapy, milieu therapy, and immersion in a long-term therapeutic community. The most promising approaches emphasize training parents in the skills necessary to promote normal socialization in their children, accompanied by training children in the use of problem-solving strategies (Kazdin et al., 1987). The complexity and severity of CD-associated problems dictate the need for multimodal treatment. Primary consideration should be given to containment and limit setting—which create the conditions for treatment, to provide safety, and to delineate a comprehensive program of intervention encompassing behavioral and social-skill building, family therapy, and educational assistance.

(See also: Adolescents and Drug Use ; Crime and Drugs ; Families and Drug Use ; Family Violence and Substance Abuse ; Vulnerability As Cause of Substance Abuse )

BIBLIOGRAPHY

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders-4th ed. (DSM-IV). Washington, DC: Author.

Kazdin, A. E., et al. (1987). Effects of parent management training and problem-solving skills combined in the treatment of antisocial child behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 416-424.

Loeber, R. (1991). Antisocial behavior: More enduring than changeable? Journal of the American Academy of Child and Adolescent Psychiatry, 30, 393-397.

Rutter, M. (1984). Psychopathology and development. I. Childhood antecedents of adult psychiatric disorder. Australian and New Zealand Journal of Psychiatry, 18, 225-234.

Ada C. Mezzich

Ralph E. Tarter

Revised by Mary Carvlin