The complexities of conduct disorder

More and more substance abuse counselors, mental health professionals, juvenile justice workers, and school personnel are examining the interrelationships between conduct disorder and substance abuse in adolescents. Conduct disorder is one of the most common forms of psychopathology and also one of the most costly in terms of personal loss to patients, families, and society.1 It also is one of the most difficult conditions to treat, because the disorder is complex and pervasive. This complexity is exacerbated by the lack of resources in the families and communities in which conduct disorder develops.^2-5

Treatment also is complicated by the tendency of juvenile justice and school systems to delay bringing children with conduct disorder to the attention of behavioral health professionals. Instead, these youths often are hardened by the probation and parole systems, delaying treatment and making intervention more difficult as the disorder becomes chronic.

Conduct disorder is a repetitive and persistent disorder in which the basic rights of others or other major age-appropriate societal norms or rules are violated. Symptoms do not occur spontaneously but endure over time, until there is a consistent pattern of aggression toward people and animals, destruction of property, deceitfulness, and violation of rules. Many of these youths fail to develop social attachments and tend to have poor peer relationships. This may lead to further withdrawal and self-isolation.

The development of conduct disorder also has been associated with negative parental attitudes and a chaotic home environment. Parental psychopathology and criminality, as well as child abuse and neglect, have been shown to be associated with the development of symptoms.

Look for comorbidity

Research supports that one of the most consistent findings in child and adolescent psychopathology is the high rate of co-occurrence of disorders. As reported by Anderson and colleagues, 55% of children with a diagnosable condition have two or more additional disorders.6 With respect to conduct disorders, comorbidity constitutes the rule rather than the exception. Substance use disorders frequently co-occur with conduct disorder/oppositional defiant disorder.7,8

The association between substance use disorders and conduct disorder often has been explained using a framework in which different problem behaviors are viewed as part of a broader deviance pattern reflecting a single underlying syndrome.9 Hawkins and colleagues provide an excellent listing and description of the risk factors for adolescent substance abuse (these also apply to delinquency, teenage pregnancy, and a variety of other problems).10 The risk factors are:

• Laws and norms favorable toward behavior;

• Availability of drugs;

• Extreme economic deprivation;

• Neighborhood disorganization;

• Physiologic factors;

• Family alcohol and drug behavior and attitudes;

• Poor and inconsistent family management practices;

• Family conflict;

• Low bonding to family;

• Early and persistent problem behaviors;

• Academic failure;

• Low degree of school commitment;

• Peer rejection in elementary grades;

• Association with drug-using peers;

• Alienation and rebelliousness;

• Attitudes favorable to drug use; and

• Early onset of drug use.

Although not all youths who use substances have a history of conduct disorder, it is apparent from research, clinical practice, and general observation that preexisting conduct disorder constitutes a significant risk factor for substance use, particularly in girls.11 In addition, concurrent substance use may increase the risk of more serious delinquent behavior.

Integrated treatment for adolescents

Historically there has been a divide between treatment systems for substance abuse and mental health disorders. Some substance abuse counselors often have little or no training in mental health issues, and programs often ignore co-occurring problems or refer patients to other systems either during or after substance abuse treatment. A consensus exists that lack of integration leads to poor coordination of services, miscommunication, and funding conflicts, all of which contribute to attrition and poor outcomes for patients.12 According to Paula D. Riggs, MD, and colleagues,13 the following psychopharmacological principles are important in treating adolescents with substance abuse and conduct disorders:

• Medication is not a first-line treatment for oppositional defiant disorder and conduct disorder, the most common comorbid diagnoses with substance use disorders.

• Behavioral and family-based interventions are used most effectively with these disorders.

• Practitioners should avoid treating conduct disorder with medication, although there may be social, educational, and family pressures to employ pharmacological practices first.

• Behavioral approaches linked with urine testing should show some promise for monitoring youths with conduct disorder and substance use disorders.

• Cognitive-behavioral therapy gives the adolescent skills to mediate impulsivity, aggression, and anxiety, all of which are symptomatic of conduct disorder.

Bukstein, in one of the first useful books targeted to the spectrum of issues related to adolescent substance use disorders, provided seven specific social skills for adolescents who present with substance abuse and conduct disorder.14 Counselors should work toward helping youths develop drug and alcohol refusal skills; relapse prevention skills; communication skills; problem-solving skills; anger control; relaxation techniques; and leisure time management.

Haggerty and colleagues target four skill areas for working with adolescents with substance abuse and conduct disorder.15 These are consequential thinking to identify the antecedent and consequences of behaviors; self-control in resisting impulses to use and peer pressure; avoidance of trouble by identifying high-risk situations for use and associated problem behaviors; and development of social networks by identifying pro-social activities and new non-using friends.

Many youths with substance abuse and conduct disorders also experience challenges in social problem solving. The social problem model of Van Hasselt and colleagues has demonstrated effectiveness in both individual and group settings.16 It is a staged process that helps youths stop and identify a problem and then identify goals. The youth then generates possible solutions and determines the consequences of each, and then chooses the most effective solution, later evaluating its actual effectiveness and self-reinforcing for appropriate adaptive behaviors.

Professional challenges

Adolescents with substance abuse and conduct disorders offer numerous challenges for those working with them. Impulsive, aggressive, retaliatory, and intimidating behaviors have the potential to cause staff burnout and, in some instances, unprofessional actions (yelling at youths, adopting a parental role, being punitive with youths). For the purpose of supplying the most effective treatment, therapists who work with these youths in various settings might follow a team approach. This appears to reduce problems such as staff sick days and staff acting out with youths.

Adolescents with these co-occurring problems need to know that they can recover, improve interpersonal relationships, learn new and appropriate ways to have their needs met, complete school, and lead meaningful lives. They need to see that if others can do this, so can they.

References

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2. Adam BS, Kashani JH, Schulte EJ. The classification of conduct disorders. Child Psychiatry Hum Dev 1991 Fall; 22:3–16.
3. Blaske DM, Bourduin CM, Henggeler SW, et al. Individual, family, and peer characteristics of adolescent sex offenders and assaultive offenders. Develop Psychol 1989; 25:846–55.
4. Chiland C, Young J (eds.). Children and Violence. Northvale, N.J.:Jason Aronson, Inc.; 1994.
5. Christ MA, Lahey BB, Frick PJ, et al. Serious conduct problems in the children of adolescent mothers: disentangling confounded correlations. J Consult Clin Psychol 1990 Dec; 58:840–4.
6. Anderson JC, Williams S, McGee R, et al. DSM-III disorders in preadolescent children: prevalence in a large sample from the general population. Arch Gen Psychiatry 1987; 44:69–76.
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9. Jessor R, Jessor SL. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York:Academic Press; 1977.
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11. Loeber R, Keenan K. The interaction between conduct disorder and its comorbid conditions: effects of age and gender. Clin Psychol Rev 1994; 14:497–523.
12. Osher FC, Drake R. Treating substance abuse in patients with severe mental illness.In Henggeler SW and Santos AB (eds.). Innovative Approaches for Difficult-to-Treat Populations. Washington, D.C.:American Psychiatric Press; 1997.
13. Riggs PD, Thompson LL, Mikulich SK, et al. An open trial of pemoline in drug-dependent delinquents with attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1996 Aug; 35:1018–24.
14. Bukstein OG. Adolescent Substance Abuse: Assessment, Prevention, and Treatment. New York:Wiley Interscience; 1995.
15. Haggerty KP, Wells EA, Jenson JM, et al. Delinquents and drug use: a model program for community reintegration. Adolescence 1989 Summer; 24:439–56.
16. Van Hasselt VB, Null JA, Kempton T, et al. Social skills and depression in adolescent substance abusers. Addictive Behaviors 1993; 18:9–18.