Elsevier

Drug and Alcohol Dependence

Volume 49, Issue 3, 1 February 1998, Pages 225-237
Drug and Alcohol Dependence

Substance-dependent, conduct-disordered adolescent males: severity of diagnosis predicts 2-year outcome1

https://doi.org/10.1016/S0376-8716(98)00016-7Get rights and content

Abstract

Most delinquent youths have conduct disorder (CD), often with comorbid substance use disorder (SUD), attention-deficit/hyperactivity disorder (ADHD) and depression. Some youths' conduct problems later abate, while those of others persist into adult antisocial personality disorder. Earlier CD onset and ADHD reportedly predict persisting antisocial problems, but predictors of persisting SUD are poorly understood. Males aged 13–19 years (n=89), most referred by criminal justice and social service agencies, received residential treatment for comorbid CD and SUD. They had diagnostic assessments for SUD at intake and for CD, ADHD, and depression (as well as drug-use assessments) at intake and 6, 12 and 24 months later. At intake nearly all had DSM-III-R substance dependence (usually on alcohol and marijuana) and CD with considerable violence and criminality. The 2-year follow-ups revealed improvements in criminality, CD, depression and ADHD, but substance use remained largely unchanged. Various aspects of conduct, crime and substance outcomes at 2 years were predicted by intake measures of intensity of substance involvement, and by CD severity and onset age, but not by severity of either ADHD or depression, nor by treatment duration. Earlier CD onset, more severe CD and more drug dependence predicted worse outcomes, supporting the validity of these diagnoses in adolescents.

Introduction

Does diagnostic severity predict prognosis in substance-involved, delinquent adolescents? Adolescent substance use disorder (SUD) often is comorbid with and worsened by CD, mood disorder and attention-deficit/hyperactivity disorder (ADHD) (Bukstein et al., 1989, Crowley and Riggs, 1995, Grilo et al., 1995, Riggs et al., 1995, Young et al., 1995, Thompson et al., 1996). CD or SUD in adolescence may impair performance later in life (Kessler et al., 1995), but the impact of the severity of comorbid CD, SUD, ADHD and mood disorders is poorly understood.

Many children with CD later develop persisting antisocial personality disorder (ASPD) (Robins, 1978). Earlier CD onset (Moffitt, 1990), more CD symptoms (Feehan et al., 1993), or associated ADHD (Moffitt, 1990) may predict such persistence. Childhood CD also predicts substance problems in adolescence and adulthood (Robins and McEvoy, 1990, Lynskey and Fergusson, 1995). Among adults, antisocial behavior and fully developed ASPD are highly associated with substance problems (Kandel and Raveis, 1989, Regier et al., 1990).

Despite those associations, in adolescents CD and SUD may follow different temporal courses. The prevalence of CD and delinquent behavior peaks in mid-adolescence, declining in later adolescence (Elliott and Huizinga, 1984, Feehan et al., 1993). Meanwhile, drug-use prevalence rises throughout that time (Elliott and Huizinga, 1984).

Controlled evidence for treatment efficacy in either CD or SUD among adolescents is very limited (Offord and Bennett, 1994). Among both hospitalized and community-treated adolescents, the prevalence of CD, SUD, ADHD and mood disorders did decline significantly from intake to follow-up 18–24 months later (Moretti et al., 1994, Mattanah et al., 1995), although SUD persisted more often than the other diagnoses (Mattanah et al., 1995). Those investigators did not report whether diagnostic severity predicted persistence.

The relationship between diagnosis and prognosis remains uncertain in CD and SUD. Diagnoses either were not reported, or were not examined as predictors, in numerous studies of adolescent substance outcome (Myers and Brown, 1994, Greiner, 1985, Friedman and Glickman, 1987, Brown et al., 1989, Alford et al., 1991, Myers et al., 1993, Blood and Cornwall, 1994, Brown et al., 1994). Two large studies, the Drug Abuse Reporting Program (DARP; Sells and Simpson, 1979) and the Treatment Outcome Prospective Study (TOPS; Hubbard et al., 1985) made no formal diagnoses. Despite somewhat inconsistent results (Catalano et al., 1990–1991), they generally found weak to modest improvements in marijuana and alcohol use. In those studies better prognoses were predicted by later drug-use onset, less criminality, fewer arrests and fewer psychiatric complaints.

Our treatment-demonstration project assessed adolescents with severe CD and SUD at treatment admission and 2 years later. The evaluations had the rigor of clinical research, although demonstration projects lack control groups. This paper reports on males’ 2-year outcomes for SUD, CD, ADHD and mood disorders, and it examines whether intake diagnostic characteristics predict persistence of antisocial problems and SUD. Follow-ups of female patients will be reported separately.

Section snippets

Source

Subjects were males aged 13–19 years at Synergy, a treatment program for delinquent, substance-involved youths. Synergy patients were described earlier (Riggs et al., 1995, Young et al., 1995, Thompson et al., 1996); this sample overlaps those samples. Juvenile justice or social service agencies referred most patients. Treatment admissions had: (a) serious antisocial problems (usually including arrest) and substance problems (usually including substance-related treatment, arrests, or

Intake status: followed and non-followed subjects

The followed and non-followed groups did not differ significantly in demographics, although racial/ethnic distributions approached significance (Table 1). Mean social class scores corresponded to class IV (V is lowest).

Alcohol and cannabis dependence each occurred in over 80% of followed and non-followed groups, nicotine dependence in over half, with the boys being dependent on a mean of nearly 3.5 different drugs. A greater prevalence of opioid-dependence in the non-followed group is the only

Discussion

We studied the course of delinquent, substance-dependent boys during 2 years following admission to a residential treatment program. This report is unique for examining presence and severity of intake psychiatric diagnoses as predictors of later antisocial behavior and substance use, and for validating self-reports of substance use with urine and breath tests. Five important observations emerge:

Acknowledgements

The work was supported by grants DA06941 and DA09842 from the National Institute on Drug Abuse. The following persons assisted: L. Coffman, A. Crowl, K. Ehlers, S. Hall, D. Hernandez, B. Johnson, C. Martin, J. Silverthorne, J. Stout and E. Williams.

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    1

    Presented in part to the Research Society on Alcoholism, Steamboat Springs, CO, 19 June 1995.

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