Childhood Antisocial Behavior and Adolescent Alcohol Use Disorders

Duncan B. Clark, M.D., Ph.D., Michael Vanyukov, Ph.D., and Jack Cornelius, M.D., M.P.H.

Antisocial behaviors (e.g., aggression toward people and animals, destruction of property, deceitfulness, theft, and serious rule violations) and related mental disorders (i.e., conduct disorder and oppositional defiant disorder) during childhood predict alcohol use disorders (AUDs) during adolescence. This sequence of disorders may reflect developmentally specific forms of deficits in the ability to control behavior. Therefore, childhood antisocial behaviors and adolescent AUDs may share common genetic and environmental influences. A comprehensive conceptual model may clarify the relationship between childhood antisocial behaviors and adolescent AUDs. A better understanding of this relationship is essential for advancing research into the causes of both behaviors and for developing prevention programs and treatment for adolescents with these problems. Prevention programs targeting childhood antisocial behaviors have met with some success. Clinical interventions for adolescents with AUDs may be improved by focusing evaluation and treatment planning on antisocial behavior. KEY WORDS: comorbidity; childhood behavioral problem; antisocial behavior; adolescent; AODD (alcohol and other drug dependence); alcoholic beverage; conduct disorder; disinhibition; genetic linkage; risk factors; prevention; patient assessment; psychosocial treatment method; literature review

hildhood antisocial behaviors “childhood” will refer to age 12 and implications of the relationship between are a central element in the younger, and “adolescence” will refer antisocial behaviors and AUDs for Cdevelopmental pathway leading to ages 13 through 18.) Understanding understanding the etiology of AUDs, to adolescent alcohol abuse or depen­ the nature of the relationship between for developing effective methods to pre- dence. Theories and empirical observa­ antisocial behaviors and AUDs is essen­ vent alcohol problems, and for evaluat­ tions indicate that childhood antisocial tial in planning interventions designed ing and treating adolescents with AUDs. behaviors increase the risk for alcohol use to prevent or ameliorate both types of disorders (AUDs). In its most severe behaviors or disorders. Definitions of Antisocial forms, childhood antisocial behavior This article reviews antisocial behav­ Behavior and Related can lead to diagnoses of conduct disorder iors and related mental disorders com­ Disorders (CD) or oppositional defiant disorder monly found in children and adolescents (ODD). Particularly for children meet­ and describes the relationship between ing the criteria for CD, childhood anti- antisocial behaviors and alcohol problems. Behaviors and Diagnoses social behaviors predict early initiation The article then presents a conceptual of alcohol use, adolescent alcohol-related model for explaining this relationship, Antisocial behaviors are any acts that problems, and the onset of AUDs (Cadoret including genetic and environmental violate social rules and the basic rights et al. 1995; Clark et al. 1998a, 1999). factors that may play a role in the pro­ of others. They include conduct intended (Throughout this review, the term cess. Finally, the article summarizes the to injure people or damage property,

Vol. 26, No. 2, 2002 109 illegal behavior, and defiance of generally rules, deliberately annoying others, CD, such as aggression and deceitful­ accepted rules and authority, such as blaming others for one’s behavior, and ness. One can also distinguish between truancy from school. These antisocial displaying anger or vindictiveness (see overt antisocial behaviors, such as fight­ behaviors exist along a severity continuum. textbox, p. 111). In addition, a diagno­ ing, and covert antisocial behaviors, When childhood antisocial behaviors sis of ODD according to the DSM–IV such as theft without confronting the exceed certain defined thresholds— criteria requires a pattern of behavior victim (Loeber et al. 2000). The extent the diagnostic criteria specified in the lasting at least 6 months in which 4 or to which such dimensions correspond Diagnostic and Statistical Manual of more of a total of 8 behaviors are exhib­ to the diagnostic classifications specified Mental Disorders, Fourth Edition ited. A diagnosis of CD supercedes in DSM–IV is a matter of some debate. (DSM–IV) (American Psychiatric ODD—that is, if a child meets the cri­ On the one hand, the available empirical Association 1994)—the child is consid­ teria for both CD and ODD, he or she literature indicates that the DSM–IV ered to have CD or ODD. Together will be diagnosed with CD. distinction between ODD and CD is with attention deficit hyperactivity dis­ clinically useful for children in general order (ADHD), these two disorders are Dimensions of Antisocial Behavior (Loeber et al. 2000) and for adolescents classified as “disruptive behavior disor­ with AUDs in particular (Moss and ders” in the DSM–IV. Diagnoses summarize a constellation of Lynch 2001). On the other hand, these characteristics as the presence or absence syndromes are multidimensional, and Conduct Disorder (CD). Antisocial of a disorder. Although diagnostic clas­ some features overlap between CD and behaviors represented in the DSM–IV sifications of such antisocial behaviors ODD (i.e., are diagnostically ambiguous) diagnostic criteria for CD include as CD and ODD have both practical (Hartman et al. 2001). For CD, overt aggression toward people and animals, and scientific utility, one can also con­ antisocial behaviors may be meaning- destruction of property, deceitfulness, ceptualize these behaviors as occurring fully distinguished from covert antiso­ theft, and other serious social rule vio­ along multiple dimensions. Relevant cial behaviors (Loeber et al. 2000). lations (see textbox, below). A diagnosis dimensions include the categories of Developmental considerations are of CD also requires a persistent behav­ behaviors required for a diagnosis of also important for understanding the ior pattern in which 3 or more of a total of 15 behaviors occur over a 12- month period. The DSM–IV specifies Diagnostic Criteria for Conduct Disorder childhood-onset and adolescent-onset types of CD and different degrees of Conduct disorder is diagnosed if a persistent pattern of behavior involving severity of the disorder. three or more of the following behaviors is present over a 12-month period.

Oppositional Defiant Disorder (ODD). Aggression toward people and animals ODD is characterized by negativistic, • Often bullies, threatens, or intimidates others hostile, and defiant behaviors, such as • Often initiates physical fights losing one’s temper, arguing, defying • Has used a weapon that can cause serious physical harm to others • Has been physically cruel to people • Has been physically cruel to animals DUNCAN B. CLARK, M.D., PH.D., and • Has stolen while confronting a victim JACK CORNELIUS, M.D., M.P.H., are both • Has forced someone into sexual activity associate professors of psychiatry and phar­ Destruction of property maceutical sciences at the University of • Has deliberately set fires with the intention of causing serious damage Pittsburgh School of Medicine and School • Has deliberately destroyed the property of others of Pharmacy, Pittsburgh, Pennsylvania. Deceitfulness or theft MICHAEL M. VANYUKOV, PH.D., is assis­ • Has broken into someone else’s house, building, or car tant professor of pharmaceutical sciences, • Often lies to obtain goods or favors or to avoid obligations psychiatry, and human genetics at the • Has stolen items of nontrivial value without confronting a victim University of Pittsburgh School of Medicine Serious violations of rules and School of Pharmacy, Pittsburgh, • Often stays out at night despite parental prohibitions, beginning Pennsylvania. before age 13 • Has run away from home overnight at least twice while living in parental Support for this work was provided by or parental surrogate home National Institute on Alcohol Abuse and • Often truant from school, beginning before age 13 Alcoholism grant K02–AA–00291 and SOURCE: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American National Institute on Drug Abuse grants Psychiatric Association 1994). P50–DA–05605, R01–DA–14635, and R01–DA–12845.

110 Alcohol Research & Health Childhood Antisocial Behavior and Adolescent Alcohol Use

alcohol involvement and AUDs. Thus, Diagnostic Criteria for Oppositional Defiant Disorder childhood manifestations of deficits in the ability to control behavior (i.e., Oppositional defiant disorder is diagnosed if a pattern of behavior involving behavioral undercontrol), including four or more of these criteria is present for at least 6 months. CD and ODD, predict the initiation of regular alcohol use in early adoles­ • Often loses temper cence (Clark et al. 1998a) and the • Often argues with adults onset of alcohol-related problems • Often actively defies or refuses to comply with adults’ requests or rules (Clark et al. 1999) and AUDs (Caspi et • Often deliberately annoys people al. 1996; Rydelius 1981) during adoles­ • Often blames others for his or her mistakes or behavior cence. ADHD may be less relevant • Is often touchy or easily annoyed by others because it did not predict AUDs in • Is often angry or resentful some studies (Mannuzza et al. 1998). • Is often spiteful or vindictive In other studies, ADHD did predict adolescent alcohol and drug problems; SOURCE: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association 1994). however, that association may have been attributable to CD co-occurring in the children with ADHD (Clark et al. 1999). Finally, children of parents with implications of particular antisocial behaviors that develop early can predict alcohol and other drug use disorders behaviors for predicting outcomes. For early onset CD. An earlier age of onset (i.e., high-risk children) have increased example, the early emergence of aggres­ of CD has been hypothesized to indicate rates of antisocial behaviors. Childhood sive behaviors tends to be accompanied more severe antisocial characteristics, antisocial behavior, such as noncompli­ by ODD (Loeber et al. 2000) and to although to date empirical support for ance with parental directives in the tod­ predict later CD (Côté et al. 2001). this hypothesis exists only for boys dler years (Eiden et al. 2001), and CD (Loeber et al. 2000). and ODD in the school-age years (Clark Developmental Continuity The extent to which antisocial behav­ et al. 1997a) are more common in chil­ and Specificity iors persist across multiple developmen­ dren at high risk for alcohol and other tal periods also may be an important drug use disorders. Serious antisocial behaviors, including distinguishing feature (Moffitt 1993). Based on these observations, it is severe forms of ODD and CD, have For example, in some people such clear that childhood antisocial behavior remarkable developmental stability in behaviors occur during childhood, ado­ precedes and predicts adolescent AUDs. boys and girls—that is, these behaviors lescence, and adulthood (i.e., are “life- Consequently, a conceptual model is persist throughout various stages of course persistent”), whereas in other needed to guide further investigation childhood and adolescence. Mild or people they are evident only in one into the causal relationships between moderate forms of the disorders, how- developmental stage. This developmental both types of behaviors. Such a model ever, are considerably less stable (Loeber distinction may be useful in understand­ is presented in the following section. et al. 2000). Antisocial behaviors also ing the relationship between antisocial tend to be consistent across social settings, behavior and AUDs. Correlations among such as school and home (Dishion et various antisocial behaviors over time A Conceptual Model al. 1995). Although the propensity for have led to the theory that a general Conceptual approaches from several serious antisocial behaviors is quite sta­ tendency toward psychological dysreg­ traditions have proven useful for devel­ ble across the lifespan, the manifesta­ ulation may underlie many forms of oping theories about the relationship tions of this propensity vary according childhood and adolescent psychopathol­ between childhood antisocial behaviors to developmental stages. This concept ogy, including alcohol and other drug and adolescent AUDs. The model pre­ has been termed “heterotypic continuity” use disorders (Tarter et al. 1999). sented here, and described in more (Moffitt 1993). For example, antisocial detail in Clark and Winters (in press), behavior that manifests as irritability represents an integrated conceptual and impulsivity in young children may Antisocial Behaviors model and measurement approach that manifest as criminal behavior once Predict Alcohol Problems allows researchers to consider the mul­ these children reach adulthood. tiple causes and effects shaping this The significance of specific childhood Prospective, longitudinal studies (i.e., relationship. This model is informed antisocial behaviors also depends, in studies that followed participants over by prior theories (Zucker et al. 1995; part, on the timing of their appearance. several years) of children who initially Tarter et al. 1999), assessment method­ For example, CD that develops early in did not exhibit behavior problems have ologies (Clark et al. 2001), and research life is often preceded by ODD (Loeber provided clear evidence that childhood (Clark et al. 1999) in this area. The et al. 2000), suggesting that ODD antisocial behaviors predict adolescent model combines two approaches:

Vol. 26, No. 2, 2002 111 • The multifactorial model of complex traits. control also has been hypothesized to in the biological parent to CD in the This model assumes that individual underlie the observed associations among offspring and, subsequently, drug use differences in observable characteristics— childhood CD, alcohol and other drug disorders and antisocial personality dis­ in this case, antisocial behaviors and use disorders, and adult antisocial per­ order in the offspring. AUDs—are determined by variations sonality disorders. Other studies found that the corre­ in the combined influences of multi­ During a person’s development, the lation between childhood antisocial ple genes and environmental factors ability to regulate and control behaviors behavior and adult drug use disorders (Lander and Schork 1994; Vanyukov and emotions emerges at the same time is more strongly influenced by genetic and Tarter 2000). that a brain region called the prefrontal factors than is the correlation between cortex matures. Accordingly, researchers adult antisocial behaviors and drug use • The theoretical framework of developmen­ have hypothesized that the neurobio­ disorders (Grove et al. 1990). This tal psychopathology. This framework logical functions that modulate thoughts observation reinforces the notion that emphasizes specific methodological (i.e., cognition), the emotions associated childhood characteristics are of funda­ approaches and conceptual issues by with those thoughts (i.e., affect), and mental importance for the development contrasting normal and atypical devel­ behavior are located in the prefrontal of adult behaviors. The relationship opment. It also takes into consideration cortex (Spear 2000). Consistent with between childhood antisocial behavior that the effects of risk factors may vary this hypothesis, neuroimaging findings and the later development of AUDs across developmental stages (Cicchetti indicate that abnormalities in the struc­ may be the result of common genetic and Cohen 1995). ture of the prefrontal cortex are associated influences (Waldman and Slutske 2000). with severe antisocial behavior (Raine This model, as well as conceptual­ et al. 2000). The rate with which certain Molecular Genetics. In general, varia­ izations from several other traditions, brain circuits involving the prefrontal tions in the structure of certain genes hypothesizes that childhood antisocial cortex mature may be an important (i.e., genetic polymorphisms) account behaviors and adolescent AUD have mechanism through which genetic for the inheritance of individual differ­ common causes. Several mechanisms factors influence psychopathological ences in behavior. Although extensive may underlie these common causes. manifestations (Todd et al. 1995). evidence has established that heritable First, both antisocial behaviors and factors are a major influence in the devel­ AUDs may be manifestations of a Genetic Influences opment of AUDs, researchers have not fundamental deficiency in the person’s yet been able to identify the mechanisms ability to control or regulate his or her Behavior Genetics. Researchers have behavior (Tarter et al. 1999). Second, begun to investigate the extent to which leading to the development of AUDs the observed relationship between anti- similarities in antisocial behavior and and the specific genes involved. One social behaviors and AUDs may reflect AUDs among relatives result from genetic candidate that has been implicated in the presence of common genetic factors inheritance (i.e., shared genes) or envi­ AUDs is a brain signaling system called and/or environmental influences. These ronmental factors. Studies in this area the dopamine neurotransmitter system. mechanisms, which are not mutually have provided convincing evidence that Individual differences in this system are exclusive and can both be included genetic factors contribute substantially likely to influence the extent to which within the proposed comprehensive to individual variations in both antiso­ a person experiences alcohol’s effects as model, are discussed in more detail in cial behavior and AUDs (Tarter et al. pleasant and therefore wants to consume the following sections. 1999). Some studies have also suggested more alcohol (i.e., the extent to which that the high correlations between ODD a person experiences drinking as posi­ tively reinforcing). Variations in the The Dysregulation Hypothesis and CD symptoms can be attributed to genetic similarity (Eaves et al. 2000). level of reinforcement obviously can A common underlying factor—namely, The characteristic features of behavioral influence a person’s risk for alcohol and a tendency toward poor behavioral reg­ undercontrol are highly susceptible to other drug use disorders. Accordingly, ulation—may predispose some people genetic influence, and common genetic researchers have begun to study associ­ to both childhood antisocial behaviors factors may account for the associations ations between genetic polymorphisms and AUDs (Cadoret et al. 1995). between antisocial behaviors and drug influencing dopamine and other brain Behavioral undercontrol (also referred use (Young et al. 2000). To explore the signaling systems on the one hand, and to as “behavioral dysregulation” and role of genetic factors in the intergener­ the risk for AUDs on the other hand “disinhibition”) is characterized by deficits ational transmission of antisocial behav­ (Vanyukov and Tarter 2000). These in the planning and execution of goal- ior, Cadoret and colleagues (1995) associations may provide insights into directed behavior, and is manifested by studied adopted children and their biolog­ the genetic, biochemical, and neurobi­ aggressive, antisocial, and impulsive ical and adoptive parents. They found ological mechanisms underlying AUDs behavior (Martin et al. 2000), all of evidence for a genetically transmitted and may also reveal the nature of the which predict problematic alcohol use pathway leading from antisocial per­ relationship between AUDs and antiso­ (Caspi et al. 1996). Behavioral under- sonality disorder and drug use disorders cial behaviors (Vanyukov et al. 2000).

112 Alcohol Research & Health Childhood Antisocial Behavior and Adolescent Alcohol Use

Environmental Influences group. When combined with a genetic tive interventions for childhood CD predisposition to alcohol dependence, (Sheldrick et al. 2001), which may Several environmental factors have the adolescent’s selection of deviant reduce the risk for adolescent AUDs. been found to increase the risk for anti- peers and consequent high exposure to social behavior as well as AUDs in alcohol may result in the development Evaluation adolescents. These influences include of AUDs. Such interactions are ideally problematic family functioning, such taken into consideration when study­ A comprehensive assessment, including as low levels of parental monitoring ing the relationship between childhood a systematic evaluation of the patient’s and inconsistent disciplinary practices antisocial behaviors and AUDs. history of antisocial behaviors and drug (Clark et al. 1998b), as well as childhood use disorders, is the foundation for maltreatment (Clark et al. 1997b). The effective treatment planning for adoles­ developmental psychopathology frame- Implications for cents with these problems. Too often, work described earlier suggests that Prevention, Evaluation, clinical assessments lack this foundation. specific environmental factors may be and Treatment For example, clinical assessment strate­ particularly influential during critical gies are typically unstructured and may developmental periods. For example, A causal model explaining the association lead to inaccurate diagnoses (Clark et paternal drug use disorders may have between childhood antisocial behaviors al. 1995). Systematic diagnostic interviews differential effects depending on a child’s and the development of AUDs during provide for a more thorough assessment stage of development. In a study exam­ adolescence, if it can be validated, has with greater reliability and validity and ining psychopathology in a sample of implications for the prevention, evalua­ have been advocated for both clinical high-risk boys (Moss et al. 1997), boys tion, and treatment of those behaviors. evaluations and research (Clark et al. whose fathers overcame drug use disorders For example, early intervention for 1999). Moreover, additional domains prior to the child’s school-age period antisocial behaviors might reduce the risk should be included in such comprehensive were similar to a control group of boys of developing an AUD, and treatment assessments, including parent-adolescent whose fathers had no drug use disorders. for AUDs might be more effective if it relationships, peer characteristics, school Conversely, boys whose fathers had also addressed behavioral undercontrol. functioning, and health. Clark and continuing drug use disorders exhibited These possible implications are reviewed Winters (in press) have proposed assess­ significant psychopathology. in the following sections. ment strategies that are designed to Parents’ drug use and other pathology provide the comprehensive and devel­ may affect the development of their Prevention opmentally appropriate information offspring through several mechanisms. that is necessary for clinical interventions, For example, parental drug use and other A potentially effective strategy to prevent prevention, and related research. pathology may directly influence parent­ the development of AUDs involves It is also important to recognize that ing behaviors. In addition, the effects using interventions designed to reduce AUDs have risk factors and consequences of parental pathology may be indirect. childhood characteristics that predict that manifest differently at various Thus, parental mental disorders may adolescent AUDs, such as childhood developmental stages. Assessment of act as barriers impeding their children’s antisocial behavior. Several research relationships among various behaviors access to adequate mental health treat­ programs have been investigating this over time requires specialized measure­ ment, which in turn may increase the approach, and early reports have shown ment approaches called “diachronic children’s likelihood of developing AUDs promising results. For example, Linking assessment” strategies (Clark et al. 2001). in adolescence (Cornelius et al. 2001). the Interests of Family and Teachers Recently developed statistical techniques Environmental influences invariably (LIFT) is an elementary-school preven­ that can provide more realistic summaries interact with genetic factors to determine tion program that uses behavior modifica­ of growth and development (e.g., Muthén a person’s risk for certain disorders. tion with children on the playground, and Muthén 2000) allow optimal sta­ The dynamic interaction of genetic and provides social and problem-solving tistical modeling of data obtained with environmental influences with certain skills training to children in the class- such assessment approaches. The use behaviors over the course of development room, and offers parenting skills train­ of diachronic assessment strategies in is particularly complex and therefore ing to their parents (Eddy et al. 2000). combination with such innovative sta­ difficult to analyze (Tarter et al. 1999). When the children receiving the LIFT tistical modeling techniques can allow For example, for AUDs to develop, intervention and a group of control insights into the relationships among alcohol availability in the environment children were reevaluated 3 years after problem behaviors such as antisocial (e.g., from family or friends) is a neces­ the intervention, the LIFT program was behavior and AUDs. sary but not sufficient condition. An found to delay the time to first regular adolescent who chooses peers who use alcohol use, first marijuana use, and Treatment alcohol and other drugs may be more first police arrest. Other similar projects frequently exposed to alcohol than is are in progress (e.g., Ialongo et al. 2001). Although achieving abstinence from an adolescent with a different peer Researchers also have identified effec­ alcohol is the optimal treatment goal

Vol. 26, No. 2, 2002 113 for patients with AUDs, adolescents clinical studies) can be transferred to these highly problematic adolescents is participating in conventional alcoholism real-life settings (e.g., home and school). even greater (Scott et al. 2001). treatments have high relapse rates Moreover, the potential benefits of Substantial challenges remain in (Cornelius et al. in press). Several clinical simultaneously treating antisocial behav­ understanding the relationship between studies have indicated that co-occurring ior and AUDs must be elucidated fur­ childhood antisocial behavior and ado­ CD predicts particularly poor outcomes ther. Future studies also must consider lescent AUDs. Both antisocial behav­ among adolescents receiving treatment gender differences more thoroughly, iors and AUDs are complex problems for alcohol and other drug problems because although antisocial behaviors with multiple contributing factors. (Brown et al. 1996; Crowley et al. 1998; and AUDs are more common in males, Consequently, genetic, family, epidemi­ Kaminer et al. 1992). Accordingly, pro- ological, and clinical studies are needed grams for adolescents with AUDs may to define clinically meaningful patient need to include interventions designed Although achieving subgroups, identify children at highest to reduce antisocial behaviors. risk for AUDs, and inform more effective Several treatment approaches specif­ abstinence from alcohol prevention and treatment efforts. ically target CD. Psychosocial interven­ tions with standardized methods and is the optimal treatment documented effectiveness include train­ References ing parents in child management tech­ goal for patients with niques and teaching children prosocial AUDs, adolescents American Psychiatric Association (APA). Diagnostic responses to interpersonal conflicts and Statistical Manual of Mental Disorders, Fourth (Sheldrick et al. 2001). 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