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The complexities of conduct disorder

November 1, 2007
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Counselors must be vigilant on co-occurring issues in adolescents

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.