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Am Fam Physician. 1998;58(6):1418-1420

Antisocial behavior is predictive of adolescent and adult involvement in substance abuse. In addition, conduct disorder during adolescence is a strong prognostic indicator for antisocial personality disorder and psychoactive substance abuse in adulthood. Myers and associates prospectively studied a group of adolescents who met the criteria for conduct disorder to evaluate factors associated with progression to adult antisocial personality disorder in the context of models of antisocial behavior.

A total of 146 adolescents who were recruited from inpatient substance abuse treatment programs completed interviews during the course of treatment and four years after treatment ended. Eighty-four of the participants, of whom 71 percent were males, met the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) for antisocial personality disorder. The subjects with antisocial personality disorder had significantly greater rates of drug use but not alcohol use during the three months before treatment.

Onset of conduct disorder behavior at 10 years of age or earlier, a greater diversity of conduct disorder behavior and heavier drug use before admission were the most reliable predictors of antisocial behavior diagnosis. The group with antisocial personality disorder reported more frequent problems in school or work related to alcohol and drug use. The subjects in the antisocial personality disorder group had significantly higher rates of alcohol use at the four-year interview than those without antisocial disorder. The antisocial personality disorder group had an incidence of problems with a spouse or partner related to alcohol or drug use that was five times higher than that of the group without antisocial disorder.

Those in the antisocial personality disorder group were four times more likely to report needing professional help for emotional problems overall but not for problems unrelated to alcohol or drug use. This group also experienced more serious depression and anxiety when substance abuse was concurrent. The adolescents with antisocial personality disorder were significantly more likely to have legal problems, to have been arrested or to have spent time in jail, especially when the antisocial behavior was associated with substance abuse.

These results are consistent with theoretic models of the persistence of antisocial behavior and emphasize the importance of early, severe deviant behavior as a predictor of adult antisocial behavior. In addition, abuse of alcohol and drugs appears to support progression of antisocial pathology in adolescents. Heavier involvement with substance abuse may limit options for engaging in more socially acceptable activities. Among the subjects with anti-social personality disorder and substance abuse, overall functioning was poorer, suggesting that alcohol and drug abuse may be closely involved in the progression of antisocial pathology among adolescents with a history of substance abuse. The results would also indicate that difficulties continue because of lack of remediation or improvement in daily functioning.

The authors conclude that antisocial behavior has little likelihood of regressing after the critical period during which many cognitive and interpersonal skills are typically acquired and refined. This study has important clinical implications. Careful assessment of the extent of conduct disorder behavior and identification of behavior that occurs before and independent of substance abuse may serve to identify persons who may be at risk of persisting in antisocial behavior. These persons should receive more targeted interventions to reduce violent and criminal offenses among serious juvenile offenders. Although the functioning achieved through treatment may be less than optimal, it may be adequate to prevent serious deviant behavior.

editor's note: The increase in published reports of violence committed by adolescents shows that clinicians must pay special attention to antisocial pathology among their adolescent patients. The combination of drugs and alcohol may cause these adolescents to engage in more violent acts as adults. Careful assessment of conduct disorder should be a part of every adolescent health maintenance examination.—b.a.

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