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CORK Bibliography: Relapse

59 citations. October 2006 to present

Prepared: September 2007

Abrantes AM; Strong DR; Ramsey SE; Lewinsohn PM; Brown RA. Substance use disorder characteristics and externalizing problems among inpatient adolescent smokers. Journal of Psychoactive Drugs 37(4): 391-399, 2005. (44 refs.)

Attention deficit hyperactivity disorder (ADHD) and/or conduct disorder (CD) have been found to be associated with substance use disorders and cigarette smoking among adolescents. However, studies have often failed to explore these relationships among females from a dimensional perspective, taking into account comorbidity between ADHD and CD symptomatology, and examining ADHD symptom subtypes (i.e., inattention and hyperactivity/impulsivity) separately as they relate to substance involvement and smoking characteristics. This study takes each of the above into consideration when examining the relationship between externalizing symptomatology and substance involvement characteristics in a sample of 191 (62.3% female, mean age = 15.4 years) inpatient adolescent smokers. The results of this study suggest that ADHD and CD symptoms may be related to different types of substance use characteristics. CD symptoms were associated with early onset of substance involvement and ADHD symptoms were related to alcohol and marijuana frequency. ADHD inattention symptoms, but not hyperactivity/impulsivity symptoms, were associated with marijuana and nicotine dependence. Lastly, significant interactions suggested that ADHD symptoms among boys and CD symptoms among girls were related to frequency of any type of substance use prior to inpatient hospitalization. The results of this study point to potentially important clinical implications such as tailoring prevention and intervention efforts according to type of externalizing symptomatology and gender.

Arendt M; Rosenberg R; Foldager L; Perto G; Munk-Jorgensen P. Psychopathology among cannabis-dependent treatment seekers and association with later substance abuse treatment. Journal of Substance Abuse Treatment 32(2): 113-119, 2007. (28 refs.)

We determined the proportion of psychiatric treatments for disorders not due to substance use among a cohort of subjects (n = 3,114) seeking treatment for cannabis dependence. Data were retrieved from Danish treatment registers. Cases were compared with a representative sample, which was randomly selected from the general population according to age and gender (it =: 15,570). Cannabis users were followed, and reentry into substance abuse treatment was used as an outcome deploying Cox regression analysis. The proportion of treatment for all psychiatric disorders was much higher among cases than among controls: schizophrenia (odds ratio [OR] 7.9; 95% confidence interval [95% CI] - 6.1-10.2), bipolar disorders (OR = 4.9; 95% CI - 2.8-8.5), other affective disorders (OR 7.6; 95% CI - 6.1-9.5), and personality disorders (OR = 17.3; 95% CI 14.5-20.5). All in all, 40.7% of cases, compared with 5.2% of controls, had received psychiatric treatment (OR - 12.5; 95% CI = 11.3-13.8). A history of psychiatric treatment was associated with increased rates of reentry into substance abuse treatment, in general (OR 1.35-1 95% CI 1.20-1.53), specifically for cannabis (OR - 1.26 95% CI 1.07-1.48) and opioid (OR 1.56; 95% CI 1.23-1.99) dependence. This is the first study to show that the proportion of psychiatric treatment is much elevated among, subjects seeking treatment for cannabis dependence, and that a history of psychiatric problems is associated with higher rates of reentry into substance abuse treatment.

Askenazy FL; Sorci K; Benoit M; Lestideau K; Myquel M; Lecrubier Y. Anxiety and impulsivity levels identify relevant subtypes in adolescents with at-risk behavior. Journal of Affective Disorders 74(3): 219-227, 2003. (41 refs.)

Background: Impulsivity (I) and anxiety (A) were hypothesized to be crucial clinical features in adolescents with at-risk behavior. We therefore classified them into sub-groups according to these two major dimensions. The study examined the relevance of these groups by describing their major diagnoses and behavioral characteristics. Methods: During a 1-year period, all in-patients consecutively admitted for at-risk behavior, except those with a previous psychotropic treatment and/or schizophrenic disorders, were rated for anxiety and impulsivity, and categorized into four groups: impulsive and anxious (IA), impulsive and non-anxious (Ia), non-impulsive and anxious (iA), non-impulsive and non-anxious (ia). We assessed the main behavioral disturbances (suicide attempt, carving, violence, delinquency, substance abuse, and eating disorder) and the main current axis I disorder in each sub-group. Results: A total of 69 patients were included. In the IA group 62% exhibited hypomanic episodes and 87% recurrent suicide attempts. In the la group all exhibited conduct disorders, 93% were males, 80% delinquents, and 100% violent with others. Both groups reported a high percentage of cannabis use (67%). The iA group exhibited anorexia nervosa (73%) with a major depressive episode. The ia patients were mainly non-violent, first suicide attempts with low risk. Limitations: Long-term data are needed to assess the stability of these groups. Conclusions: We found that sub-typing adolescents with at-risk behavior into four groups according to their level of anxiety and impulsivity was highly predictive of being suicidal with mood disorders (AI), delinquent with conduct disorder (Ia), anorectic or depressed (Ai), and with substance abuse associated only to impulsivity. It is likely that this sub-typing of patients may be useful for prevention and therapeutics. The impulsive-anxious group (IA) appears closely related to the soft bipolar spectrum. A replication and follow-up data are now needed.

Brody GH; Ge XJ; Kim SY; Murry VM; Simons RL; Gibbons FX et al. Neighborhood disadvantage moderates associations of parenting and older sibling problem attitudes and behavior with conduct disorders in African American children. Journal of Consulting and Clinical Psychology 71(2): 211-222, 2003. (87 refs.)

Data from 296 sibling pairs (mean ages 10 and 13 years), their primary caregivers, and census records were used to test the hypothesis that African American children's likelihood of developing conduct problems associated with harsh parenting, a lack of nurturant-involved parenting, and exposure to an older sibling's deviance-prone attitudes and behavior would be amplified among families residing in disadvantaged neighborhoods. A latent construct representing harsh-inconsistent parenting and low levels of nurturant-involved parenting was positively associated with younger siblings' conduct disorder symptoms, as were older siblings' problematic attitudes and behavior. These associations were strongest among families residing in the most disadvantaged neighborhoods. Future research and prevention programs should focus on the specific neighborhood processes associated with increased vulnerability for behavior problems.

Bucholz KK; Nurnberger JI; Kramer JR; Hesselbrock VM; Schuckit MA; Bierut LJ. Comparison of psychiatric diagnoses from interview reports with those from best-estimate procedures. Journal of Studies on Alcohol 67(1): 157-168, 2006. (37 refs.)

Objective: The aim of this study was to compare psychiatric diagnoses based on interview information with those based on best-estimate procedures, to evaluate information used in such procedures, and to use 5-year follow-up data to determine whether the best-estimate diagnosis is an improvement over the interview-based diagnosis. Method: Psychiatric diagnoses were based on interview reports from 373 probands and 2,615 relatives participating in a high-risk family study of alcoholism. The diagnosis also included clinician ratings in a best-estimate procedure of this study. Results: For most diagnoses, both sensitivity and specificity, using the best-estimate diagnosis (BED) as the gold standard, were excellent, in both relatives and probands. Substance abuse was an exception, with very low sensitivity, although specificity rates were excellent. For nonsubstance diagnoses, specificity was high, but sensitivity ranged from 59% to 84% across relatives and probands. In general, BED procedures led to higher prevalence estimates than those from the interview only. In the BED process, family history data were especially useful for conduct and antisocial personality disorders. Follow-up interview data supported the fact that BED procedures led to both enhancements of, as well as errors in, diagnosis. Conclusions: Our data attest to the utility of family history information, particularly for antisocial personality disorder and conduct disorder, and indicate that, for the phenotype of substance-dependence disorder, an interview-based diagnosis alone is adequate in classifying individuals with a minimum of error. These results should be reassuring for research studies in which costs and resources required for best-estimate procedures are not affordable.

Bukstein OG; Cornelius J; Trunzo AC; Kelly TM; Wood DS. Clinical predictors of treatment in a population of adolescents with alcohol use disorders. Addictive Behaviors 30(9): 1663-1673, 2005. (35 refs.)

The purpose of this paper is to identify potential predictors of treatment utilization, among both psychiatric and drug and alcohol variables. The subjects were 393 adolescents and young adults, age 12.9 to 18.11 years, who met DSM-IV criteria for a lifetime history of either alcohol abuse or alcohol dependence at baseline assessment. DSM-IV psychiatric and AUD diagnoses were obtained by semi-structure interviews (K-SADS and SC1D). Other alcohol and drug variables were obtained by the Alcohol Consumption Questionnaire and other self-reports. The results of these analyses suggest that there are few potential predictors associated with substance use disorder (SUD) treatment. For mental health (MH) treatment, depression in the form of Major Depressive Disorder was relatively strong associated at baseline and follow-up, while Attention Deficit Hyperactivity Disorder and Conduct Disorder appear to be associated with MH treatment at follow-up. For SUD treatments, there are essentially no variables strongly associated with treatment. The best potential predictors of who enters treatment and how long they stay may not be related to comorbidity or other dimensional variables of clinical severity. Rather, treatment utilization appears to be related to environmental factors, which may include family factors, adolescent and parental motivation, access to treatment, or to the use of appropriate treatment modalities.

Burleson JA; Kaminer Y; Dennis ML. Absence of iatrogenic or contagion effects in adolescent group therapy: Findings from the Cannabis Youth Treatment (CYT) study. American Journal on Addictions 15(Supplement 1): 4-15, 2006. (50 refs.)

Though widely used and presumed effective in practice, some scholars (Dishion et al., 1999) have raised the concern that group therapy for adolescents with substance use disorder and a range of deviancy has the potential for causing iatrogenic effects (e.g., increased substance use, behavior and legal problems) for those with low deviancy. Using data from 400 youth in the largest adolescent treatment experiment conducted to date (Dennis et al., 2004), this study shows that group composition in terms of conduct disorder symptoms is not associated with worse substance use, psychological, environmental or legal treatment outcomes. The results actually indicated that there was a slight advantage for youth with high conduct disorder to be included in the groups with less symptoms. The results appear consistent with recent meta-analyses of delinquency studies (Lipsey, 2006) which have found no evidence of iatrogenic effects. These results support the common clinical belief that group therapy for youths with substance use disorders is a safe and effective treatment modality.

Clark DB; Cornelius J; Wood DS; Vanyukov M. Psychopathology risk transmission in children of parents with substance use disorders. American Journal of Psychiatry 161(4): 685-691, 2004. (39 refs.)

Objective: Children of fathers with substance use disorders are at increased risk for psychopathology, including conduct disorder, attention deficit hyperactivity disorder (ADHD), major depressive disorder, and anxiety disorders. This study examined the distinct influences of parent substance use disorder and other psychopathology in the transmission of the risk for psychopathology to their children. Method: The subjects were 1,167 children (ages 6-14 years; 62% were male, 38% were female) from 613 families recruited according to a high-risk paradigm. Of these families, 294 had fathers with a substance use disorder (high-risk group), and 319 had fathers without a substance use disorder or other mental disorder (low-risk group). In all families, father, mother, and children were directly assessed. Mixed-effects ordinal regression analyses controlled for the nested data structure. Results: For conduct disorder, ADHD, major depression, and anxiety disorders, the results indicated that the predominant predictor of specific mental disorders in offspring was a history of the corresponding disorders in both parents. Conclusions: These results support specific parent-child transmission for childhood psychopathology.

Compton WM; Conway KP; Stinson FS; Colliver JD; Grant BF. Prevalence, correlates, and comorbidity of DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Journal of Clinical Psychiatry 66(6): 677-685, 2005. (57 refs.)

Objective: The purpose of this study was to provide nationally representative data on the prevalence, sociodemographic correlates, and comorbidity of antisocial syndromes across alcohol and 8 specific drug use disorders, including sedative, tranquilizer, opiate, stimulant, hallucinogen, cannabis, cocaine, and inhalant/solvent abuse and dependence. Method: This study is based on a nationally representative sample of adults. Lifetime prevalences of antisocial syndromes were estimated and logistic regression analyses were used to examine associations between antisocial syndromes and sociodemographic characteristics and substance use disorders. Diagnoses were made according to the criteria of the DSM-IV using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. Results: The lifetime prevalences of antisocial personality disorder (APD), conduct disorder, and adult antisocial behavior were 3.6%, 1.1 %, and 12.3%, respectively. Prevalences of alcohol use disorders and drug use disorders were 30.3% and 10.3%, respectively. In general, men and individuals who were younger, widowed/separated/divorced, of lower socioeconomic status, and living in urban areas or in the West were more likely to have antisocial syndromes. Native Americans were more likely and Asians and Hispanics were less likely to have APD and adult antisocial behavior. Virtually all of the associations between APD and adult antisocial behavior and specific substance use disorders were positive and statistically significant (p <.05). Significant associations between conduct disorder and substance use disorders were concentrated among women. Conclusion: Comorbidity of specific substance disorders with antisocial syndromes is very common in the U.S. population. Further work in many directions is indicated by the results of this study, including the factors that give rise to the associations and the treatment and prevention implications of these conditions when comorbid.

Copur M; Turkcan A; Erdogmus M. Substance abuse, conduct disorder and crime: Assessment in a juvenile detention house in Istanbul, Turkey. Psychiatry and Clinical Neurosciences 59(2): 151-154, 2005. (20 refs.)

The purpose of the present study was to determine the rate of substance abuse in the juvenile detention house and to determine the relationship between crime and substance abuse and conduct disorder. Two hundred and thirty cases in the biggest juvenile detention house in Istanbul, Turkey were assessed according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria. Law files and data of crime were examined. A total of 80 out of 230 juvenile detainees (34.8%) were found to have substance abuse excluding nicotine and alcohol. The substances abused in preferential order were cannabis (72.5%), volatile substances (21.3% bally and 3.7% thinner; 25%) and sedative hypnotic drugs and biperidents (2.5%). The rate of conduct disorder was 46.3% in substance abusers and 25.3% in the others (odds ratio: 2.536). The rate of substance abuse was 48.5% in the juveniles who had committed multiple crimes and 14.1% in the others (odds ratio: 5.735). The study shows that conduct disorder was very high in juvenile detainees. Conduct disorder was higher in substance-abusing than in non-abusing juvenile detainees. Substance-abusing juvenile detainees were found to have a higher detention rate than non-abusing juvenile detainees. There was a close relation between conduct disorder and substance abuse and multiple crimes. In the light of these results, diagnosis and treatment for conduct disorder in juvenile detainees are of great importance.

Costello EJ; Sung M; Worthman C; Angold A. Pubertal maturation and the development of alcohol use and abuse. Drug and Alcohol Dependence 88(Supplement 1): S50-S59, 2007. (71 refs.)

Objective: To examine the impact of various aspects of puberty on risk of using alcohol and developing alcohol use disorder (ADD). Methods: Data come from the Great Smoky Mountains Study, a longitudinal study of a representative sample of 1420 youth aged 9-13 at recruitment. Participants were interviewed annually to age 16. A parent was also interviewed. Information was obtained about use of a range of drugs including alcohol, drug abuse and dependence, other psychiatric disorders, life events, and a wide range of family characteristics. Pubertal hormones were assayed annually from blood samples, and morphological development was assessed using a pictorial measure of Tanner stage. Results: Controlling for age, Tanner stage predicted alcohol use and AUD in both boys (OR 1.58, 95% CI 1.18-2.22) and girls (OR 1.62, 95% CI 1.17-2.23). The effect of morphological development was strongest in those who matured early. Early pubertal maturation predicted alcohol use in both sexes, and AUD in girls. The highest level of excess risk for alcohol use was seen in early maturing youth with conduct disorder and deviant peers. Lax supervision predicted alcohol use in early maturing girls, while poverty and family problems were predictive in early maturing boys. Conclusions: Among the many biological, morphological, and social markers of increasing maturation, the visible signs of maturity are important triggers of alcohol use and AUD, especially when they occur early and in young people with conduct problems, deviant peers, problem families and inadequate parental supervision.

Darke S; Ross J; Lynskey M. The relationship of conduct disorder to attempted suicide and drug use history among methadone maintenance patients. Drug and Alcohol Review 22(1): 21-25, 2003. (29 refs.)

In order to examine the effects of a diagnosis of childhood conduct disorder (CD) on history of attempted suicide and drug use, unconfounded by early onset heroin use, 181 methadone maintenance patients who commenced heroin use after the age of 15 were interviewed. CD was diagnosed in 54% of patients. Compared to other patients, CD patients were younger and less educated. The onset of drug use, injecting drug use and heroin use occurred, on average, 2 years earlier than in other patients, and they had broader histories of injecting polydrug use. CD patients were more likely to have attempted suicide and to have been hospitalized after an attempt, and to have attempted suicide while enrolled in their current treatment. The current study indicates that a history of CD increases the risk of attempted suicide over and above the higher risks associated with injecting drug use per se.

Delligatti N; Akin-Little A; Little SG. Conduct Disorder in girls: Diagnostic and intervention issues. Psychology in the Schools 40(2): 183-192, 2003. (27 refs.)

Current prevalence rates of Conduct Disorder (CD) in girls may be an underestimate due to inappropriate diagnostic criteria, biased perceptions by those responsible for reporting problematic behavior, and differential social constraints for each gender. Relatively few published studies of CD and related behaviors in girls exist. Available evidence suggests adolescent girls with CD have a poor outcome including early and violent death, arrest, substance abuse and dependence, antisocial personality disorder, failure to finish high school, pregnancy, sexual promiscuity, and contraction of sexually transmitted disease. Even with its relatively low, possibly underestimated prevalence rate in comparison with that of boys, CD has been found to be the second most common psychiatric disorder in adolescent girls. In addition to examining possible reasons for the lack of research on CD in girls, this article reviews possible risk factors and suggested assessment and intervention strategies for this population. Particular attention is paid to implications for practitioners in the school setting.

Dick D. Covariation between conduct/antisocial problems and alcohol dependence in the COGA sample: Genetic links? (meeting abstract). Alcoholism: Clinical and Experimental Research 28(5 Supplement): 174A-174A, 2004. (0 refs.)

Fergusson DM; Horwood LJ; Ridder EM. Conduct and attentional problems in childhood and adolescence and later substance use, abuse and dependence: Results of a 25-year longitudinal study. Drug and Alcohol Dependence 88(Supplement 1): S14-S26, 2007. (57 refs.)

Background: This paper examines the linkages between conduct problems and attentional problems in middle childhood and adolescence and later substance use, abuse and dependence in young adulthood. Methods: Data were gathered over the course of a 25-year longitudinal study of a birth cohort of 1265 New Zealand born children. These data included: (a) measures of conduct and attentional problems in middle childhood (7-9 years) and adolescence (14-16 years); (b) measures of substance use, abuse and dependence from 18-25 years; and (c) confounding social, family and related factors. Results: Statistical modelling produced a consistent set of results showing: (i) conduct problems in childhood and adolescence were generally related to later substance use, abuse and dependence even after control for attentional problems and confounders; (ii) attentional problems were largely unrelated to later substance use, abuse and dependence after control for conduct problems and confounders. Conclusions: Conduct problems in both middle childhood and adolescence are related to increased risks of longer-term substance use, abuse and dependence. Any association between early attentional problems and later substance use abuse and dependence is largely mediated via the association between conduct and attentional problems.

Finn PR; Bobova L; Wehner E; Fargo S; Rickert ME. Alcohol expectancies, conduct disorder and early-onset alcoholism: Megative alcohol expectancies are associated with less drinking in non-impulsive versus impulsive subjects. Addiction 100(7): 953-962, 2005. (41 refs.)

Aims: Research suggests that positive alcohol expectancies promote excessive alcohol use while negative alcohol expectancies discourage excessive alcohol use. Evidence suggests that disinhibitory characteristics, such as conduct disorder and impulsivity, are associated with a general neglect of long-term negative outcomes. This study assessed whether negative expectancies would be associated more strongly with lower levels of alcohol use for low-compared with high-impulsive individuals. Design: Positive and negative alcohol expectancies, alcohol use and impulsivity were assessed in a sample of 99 young adults with alcohol dependence (AD) and conduct disorder (CD), 77 with AD and no CD and 124 controls. Findings AD/CD subjects had higher proximal (same day) and distal (next day) negative alcohol expectancies, even though they drank more alcohol, compared with AD-alone and control subjects. Distal negative expectancies were associated more strongly with lower levels of drinking for low-impulsive compared with high-impulsive subjects. Proximal negative expectancies were associated more strongly with higher alcohol consumption for high-versus low-impulsive subjects. Conclusions: Impulsivity and conduct disorder may be important factors in determining how much distal negative alcohol expectancies may discourage excessive alcohol consumption.

Fisckenscher A; Novins D. Gender differences and conduct disorder among American Indian adolescents in substance abuse treatment. Journal of Psychoactive Drugs 35(1): 79-84, 2003. (25 refs.)

Studies have found high prevalences of conduct disorder among youth in residential substance abuse treatment programs, but no studies have examined this issue among American Indian adolescents while taking into account gender differences. The Diagnostic Interview Schedule for Children, Youth Version and the Composite International Diagnostic Interview, Substance Abuse Module were used to determine the diagnostic status of 89 American Indian adolescents aged between 13 and 18 years who were admitted to a residential treatment program. Seventy-four percent of the adolescents met full DSM-IV criteria for conduct disorder. More than 85% of the participants met at least one criterion for conduct disorder. Conduct disorder was common among both boys and girls in this sample of American Indian adolescents, but the specific antisocial behaviors displayed and their relationships to other psychiatric disorders varied by gender.

Flory K; Lynam DR. The relation between attention deficit hyperactivity disorder and substance abuse: What role does conduct disorder play? Clinical Child and Family Psychology Review 6(1): 1-16, 2003. (74 refs.)

This paper presents a comprehensive review of the literature examining the relation between childhood attention deficit hyperactivity disorder (ADHD) and substance abuse. A number of researchers have statistically controlled for conduct disorder (CD) when examining the ADHD-substance-abuse relation. These studies have generally found that the ADHD-substance-abuse relation disappears when the high overlap between ADHD and CD is taken into account. On this basis, one may conclude that ADHD is unimportant to substance abuse. However, there is some evidence from both empirical studies and related fields that ADHD and CD may interact to afford a higher risk for substance abuse than may either disorder alone. Thus, ADHD appears to be important to substance abuse in that it interacts with CD to increase the risk. This paper calls for more research that directly examines the joint effects of ADHD and CD on risk for substance abuse. There is also a need for more research that examines gender differences, and mechanisms of the relations among ADHD, CD, and substance abuse.

Flory K; Milich R; Lynam DR; Leukefeld C; Clayton R. Relation between childhood disruptive behavior disorders and substance use and dependence symptoms in young adulthood: Individuals with symptoms of attention-deficit/hyperactivity disorder are uniquely at risk. Psychology of Addictive Behaviors 17(2): 151-158, 2003. (31 refs.)

Most prior literature examining the relations among attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and substance use and abuse suggests that CD fully accounts for the ADHD-substance abuse relation. This study sought to test an alternate theory that individuals with symptoms of both ADHD and CD are at a special risk for substance abuse. Relations between childhood ADHD and CD symptoms, and young adult tobacco, alcohol, marijuana, and hard drug use and dependence symptoms, were examined in a sample of 481 young adults. ADHD and CD symptoms interacted to predict marijuana dependence symptoms and hard drug use and dependence symptoms, such that individuals with high levels of both ADHD and CD had the highest levels of these outcomes.

Haber JR; Jacob T; Heath AC. Paternal alcoholism and offspring conduct disorder: Evidence for the 'common genes' hypothesis. Twin Research and Genetics 8(2): 120-131, 2005. (43 refs.)

Not only are alcoholism and externalizing disorders frequently comorbid, they often co-occur in families across generations; for example, paternal alcoholism predicts offspring conduct disorder just as it does offspring alcoholism. To clarify this relationship, the current study examined the 'common genes' hypothesis utilizing a children-of-twins research design. Participants were male monozygotic NZ) and dizygotic (DZ) twins from the Vietnam Era Twin Registry who were concordant or discordant for alcohol dependence together with their offspring and the mothers of those offspring. All participants were conducted through a structured psychiatric interview. Offspring risk of conduct disorder was examined as a function of alcoholism genetic risk (due to paternal and co-twin alcohol dependence) and alcoholism environmental risk (due to being reared by a father with an alcohol dependence diagnosis). After controlling for potentially confounding variables, the offspring of alcohol-dependent fathers were significantly more likely to exhibit conduct disorder diagnoses than were offspring of nonalcohol-dependent fathers, thus indicating diagnostic crossover in generational family transmission. Comparing offspring at high genetic and high environmental risk with offspring at high genetic and low environmental risk indicated that genetic factors were most likely responsible for the alcoholism-conduct disorder association. The observed diagnostic crossover (from paternal alcoholism to offspring conduct disorder) across generations in the context of both high and low environmental risk (while genetic risk remained high) supported the common genes hypothesis.

Hodgins S; Tiihonen J; Ross D. The consequences of Conduct Disorder for males who develop schizophrenia: Associations with criminality, aggressive behavior, substance use, and psychiatric services. Schizophrenia Research 78(2-3): 323-335, 2005. (56 refs.)

Men with schizophrenia are at increased risk, as compared to the general population, for criminal offending and to have displayed Conduct Disorder (CD) before age 15. The present study examined the consequences of CD among a sample of 248 men with schizophrenia or schizo-affective disorder, aged, on average, 39 years old. Participants were intensively assessed at discharge from the hospital and four times during the subsequent two-year period. CD was associated with criminality and substance misuse among first-degree male relatives and substance misuse among female relatives. In childhood and adolescence, CD was associated with poor academic performance, substance abuse, and physical abuse. In adulthood, the diagnosis of CD and each CD symptom were associated with increased non-violent and violent criminal offending, after adjusting for lifetime diagnoses of substance misuse disorders. CD was not associated with homicide. CD was associated with life-time diagnoses of alcohol and drug abuse and/or dependence. During the 24 month follow-up period, CD and the number of CD symptoms were associated with aggressive behavior, controlling for life-time diagnoses of substance use disorders, substance misuse measured objectively and subjectively, medication compliance, and obligatory care. CD was associated with an earlier age at onset of schizophrenia and at first admission to hospital, and with length of time spent in hospital. During the two-year follow-up period, neither the diagnosis of CD nor the number of CD symptoms was associated with levels of positive and negative symptoms assessed five times, compliance with medication, substance use, or readmission. The results are interpreted to suggest that CD is a distinct co-morbid disorder that runs parallel to the course of schizophrenia.

Hser YI; Grella CE; Collins C; Teruya C. Drug-use initiation and conduct disorder among adolescents in drug treatment. Journal of Adolescence 26(3): 331-345, 2003. (27 refs.)

This study investigated effects of drug-use initiation and conduct disorder (CD) among 1031 adolescents who participated in the Drug Abuse Treatment Outcomes Studies for Adolescents (DATOS-A) sponsored by the National Institute on Drug Abuse (NIDA). The mean age of first drug use was 12.7 (S.D.=2.2), 57% met DSM-III-R criteria for CD, and earlier initiators were more likely to have CD. About 78% of the adolescents with CD reported that their first CD symptom occurred prior to drug-use initiation. The proportions of adolescents who had prior treatment were similar (about 28%) across all groups, but earlier initiators reported a greater number of treatment episodes and younger ages at their first treatment. Conduct disordered adolescents revealed greater problems prior to DATOS-A treatment, but they appeared to be more motivated and ready for treatment. Although adolescents with CD still showed worse outcomes after treatment, the impact of CD appeared to lessen when pretreatment differences were controlled. To a lesser extent, adolescents who began using drugs at earlier ages had greater alcohol and drug use and other problems at intake, but their treatment outcomes appeared to be similar to later initiators. There were few significant interaction effects of initiation and CD. Findings from this study highlight the importance of better understanding the progression of drug use, treatment utilization, and psychiatric comorbidity among adolescents with substance abuse problems.

Kendler KS; Kuo PH; Webb BT; Kalsi G; Neale MC; Sullivan PF et al. A joint genomewide linkage analysis of symptoms of alcohol dependence and conduct disorder. Alcoholism: Clinical and Experimental Research 30(12): 1972-1977, 2006. (19 refs.)

Background: A large linkage peak for alcohol dependence (AD) was detected on chromosome 4q in the Irish Affected Sib Pair Study of Alcohol Dependence (IASPSAD). Are the susceptibility genes underlying this peak specific for AD or do they increase risk for externalizing disorders more generally? Can we, in the IASPSAD, replicate prior evidence for linkage to conduct disorder (CD)? Methods: The 733 all possible sibling pairs in IASPSAD were typed for 1,020 short-tandem-repeat genetic markers. Univariate and bivariate linkage analyses were conducted by the program sequential oligogenic linkage analysis routines (SOLAR), for both the raw and the transformed number of symptoms of AD (ADsx) and number of symptoms of CD (CDsx). In the bivariate analyses, specificity was assessed by the ratio of the variance accounted for in ADsx and CDsx by the quantitative trait locus. Results: In the univariate linkage analyses, no evidence for linkage to CDsx was found under the 4q peak for ADsx and the largest peaks for CDsx were seen on chromosomes 1q (LOD=3.16) and 14p (LOD=2.36). In the bivariate linkage analysis, the 4q peak had high specificity for AD (AD/CD ratio of 39.9). Several smaller peaks, on chromosomes 1, 7, and 10, had moderate specificity for CD but also impacted on risk for AD, with AD/CD ratios of 0.18 to 0.32. Conclusions: Genes under the 4q linkage peak for AD in the IASPSAD impact specifically on risk for AD rather than more broadly on risk for externalizing syndromes. Suggestive linkages were found in several locations for CD, 2 of which broadly replicate prior findings. The bivariate analyses identified genomic locations containing susceptibility loci that impacted on risk for both CDsx and ADsx.

King SM; Iacono WG; McGue M. Childhood externalizing and internalizing psychopathology in the prediction of early substance use. Addiction 99(12): 1548 -1559, 2004. (40 refs.)

Aims: To examine the prospective relationships between childhood externalizing and internalizing disorders and substance use in early adolescence. Design:Longitudinal, community-based study of twins (aged 11 at intake; aged 14 at follow-up). Setting and participants:The sample was composed of twins participating in the Minnesota Twin Family Study, an epidemiological sample of twins and their families representative of the state population of Minnesota. A total of 699 twin girls and 665 twin boys participated at both time-points. MeasurementsTwins participated in in-person, life-time diagnostic assessments of the following childhood DSM III-R externalizing and internalizing disorders at age 11: conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder, major depressive disorder and in addition, for girls only, overanxious disorder and separation anxiety disorder. At ages 11 and 14, substance use and abuse were assessed. Findings: Externalizing psychopathology predicted having tried alcohol, nicotine and cannabis by age 14 as well as regular and advanced experience with these substances. Internalizing disorders showed weak effects, with only major depression at age 11 showing a significant relationship with substance use at age 14. Conclusion:The results suggest that externalizing psychopathology is a robust prospective predictor of a variety of early onset substance use behaviors and is systematically related to degree of substance use involvement. The results also suggest that depression may predict initiation of licit substance use in early adolescence.

Kodl MM; Wakschlag LS. Does a childhood history of externalizing problems predict smoking during pregnancy? Addictive Behaviors 29(2): 273-279, 2004. (15 refs.)

While the demographic characteristics of women who smoke during pregnancy are well established, less is known about psychiatric characteristics that may differentiate among persistent smokers, spontaneous quitters, and nonsmokers. The purpose of the present study was to test the hypothesis that a history of externalizing problems is related to persistent smoking during pregnancy. Participants included 93 pregnant women (mean AGE=28 years; 89% non-Hispanic White; 46% persistent smokers; and 16% spontaneous quitters). Externalizing problems, as evidenced by conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD), were assessed using diagnostic interviews. History of CD and ADHD varied by smoking status, with persistent smokers most likely to have a history of both disorders and exhibiting the highest levels of symptomatology. In multivariate analyses, a history of CD, but not ADHD symptoms, distinguished women who persisted in smoking during pregnancy from spontaneous quitters. Results suggest that a childhood history of conduct problems is a risk factor for maternal smoking during pregnancy and that psychiatric history is important to consider in developing more targeted cessation interventions.

Lipscomb HJ; Dement JM; Li LM. Health care utilization of families of carpenters with alcohol or substance abuse-related diagnoses. American Journal of Industrial Medicine 43(4): 361-368, 2003. (23 refs.)

Background: Patterns of health care utilization of families of carpenters with and without alcohol and/or substance abuse related diagnoses (ASRD) were compared. Methods: Utilization data for families of 13,657 carpenters for a 10 year period were analyzed. Concordance of diagnoses among family members was assessed and proportionate utilization ratios were used to compare the experiences of families of carpenters with and without ASRD. Results Twenty-eight percent of the spouses with ASRD had a carpenter spouse with a similar diagnosis. Twenty-four percent of the families with a child with ASRD had a parent with one of these diagnoses compared to 9.4% of families without any children with ASRD (P < 0.0001). Families of carpenters with alcohol or ASRD also had different patterns of health care utilization. Conclusions: Utilization patterns were influenced to a significant degree by concordant diagnoses among spouses and children. Excess mental health care was seen among families of carpenters with ASRD above their care for substance abuse treatment.

Lynam DR; Leukefeld C; Clayton RR. The contribution of personality to the overlap between antisocial behavior and substance use/misuse. Aggressive Behavior 29(4): 316-331, 2003. (72 refs.)

The present study tested the ability of the Five Factor Model (FFM), a general model of personality functioning, to account for the stability across time of antisocial behavior (ASB) and substance use/ misuse (SUM), and the correlation between ASB and SUM at a given time. Data from a community-based longitudinal study of 481 men and women were examined. Specifically, we examined relations among substance use and conduct problems through the 10(th) grade, lifetime symptoms of substance abuse and dependence, adult symptoms of antisocial personality disorder through age 21, and a measure of the FFM. Results were virtually identical for men and women. Personality traits accounted for relatively large proportions of the variance in ASB and SUM with R-2 ranging from .19 for early SUM to .30 for early ASB. Additionally, personality profiles of the four measures were highly similar, with similarity coefficients ranging from .87 to .97. Finally, the inclusion of common personality correlates reduced the relations between the four measures by between 13% (early ASB and SUM) and 29% (early and later SUM). It is concluded that personality, particularly the dimensions of Agreeableness and Conscientiousness, is important to understanding ASB and SUM.

Macgowan MJ; Wagner E. Iatrogenic effects of group treatment on adolescents with conduct and substance use problems: A review of the literature and a presentation of a model. IN: Hilarski C, ed. Addiction, Assessment, and Treatment with Adolescents, Adults, and Families. New York: Haworth Social Work Practice Press, 2005. pp. 79-90. (33 refs.)

Group therapy is the most popular approach in the treatment of adolescent substance use problems. Recently, concerns have mounted about possible iatrogenic effects of group therapy based on studies on adolescents with conduct disorder. This paper reviews three possible contributors to response to group treatment among adolescents, and proposes a model of the relations among these variables, specifically in regard to how they independently and interactively contribute to outcomes among youth with conduct disorder and substance use problems.

Marmorstein NR; Iacono WG. Major depression and conduct disorder in a twin sample: Gender, functioning, and risk for future psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry 42(2): 225-233, 2003. (30 refs.)

Objective: Major depression (MDD) and conduct disorder (CD) co-occur in adolescents at rates higher than would be expected by chance. This study described the functioning of adolescents with histories of these disorders and examined whether these patterns of association differed by gender. Method: Subjects with a lifetime DSM-III-R diagnosis of MDD and/or CD were selected from a sample of 17-year-old twins; control subjects had no history of either disorder. The domains of school success, substance dependence, peer relationships, and age of first sexual intercourse were examined. Results: Overall, each disorder separately and especially both disorders together related to increased maladjustment in the domains of school success and substance dependence. For school behavior problems, nicotine dependence, and drug dependence, the combination of MDD and CD related to particularly problematic functioning. Results were similar for males and females. Longitudinal data indicated that the occurrence of these disorders by late adolescence was predictive of subsequent depression and antisocial behavior in early adulthood. Conclusions: The combination of CD and MDD relates to more serious maladjustment, especially relating to school success and substance dependence, than would be expected given the adjustment associated with each disorder alone.

Mueser KT; Crocker AG; Frisman LB; Drake RE; Covell NH; Essock SM. Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders. Schizophrenia Bulletin 32(4): 626-636, 2006. (77 refs.)

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.

Public Domain

Nigg JT; Wong MM; Martel MM; Jester JM; Puttler LI; Glass JM et al. Poor response inhibition as a predictor of problem drinking and illicit drug use in adolescents at risk for alcoholism and other substance use disorders. Journal of the American Academy of Child and Adolescent Psychiatry 45(4): 468-475, 2006. (39 refs.)

Objective: To evaluate the predictive power of executive functions, in particular, response inhibition, in relation to alcohol-related problems and illicit drug use in adolescence. Method: A total of 498 children from 275 families from a longitudinal high-risk study completed executive function measures in early and late adolescence and lifetime drinking and drug-related ratings at multiple time points including late adolescence (ages 15-17). Multi-informant measures of attention-deficit/hyperactivity disorder and conduct disorder were obtained in early childhood (ages 3-5), middle childhood, and adolescence. Results: In multilevel models, poor response inhibition predicted aggregate alcohol-related problems, the number of illicit drugs used, and comorbid alcohol and drug use (but not the number of drug-related problems), independently of 10, parental alcoholism and antisocial personality disorder, child attention-deficit/hyperactivity disorder and conduct symptoms, or age. Multivariate models explained 8% to 20% of residual variance in outcome scores. The incremental predictive power of response inhibition was modest, explaining about 1% of the variance in most outcomes, but more than 9% of the residual variance in problem outcomes within the highest risk families. Other measured executive functions did not independently predict substance use onset. Conclusion: Models of alcoholism and other drug risks that invoke executive functions may benefit from specifying response inhibition as an incremental component.

Putnins AL. Substance use among young offenders: Thrills, bad feelings, or bad behavior? Substance Use & Misuse 41(3): 415-422, 2006. (32 refs.)

The relationships of conduct problems, attention deficit hyperactivity disorder (ADHD) signs, and depression to substance use were examined between 1994 and 1999 among 900 incarcerated young offenders in South Australia, 206 of whom were reassessed when later readmitted to secure care. At the first and second assessments, conduct problems, ADHD signs, and depression scores all had significant concurrent associations with a measure of recent substance use. Prospectively, there were no significant associations between depression and substance use. At the zero-order level, both ADHD signs and conduct problems predicted future substance use. ADHD signs remained significantly predictive after controlling for concurrent associations. The results lend support to the view that substance use is related to general deviance and that the arousal needs associated with increased ADHD signs increase the risk of substance use. There was no support for the view that substance use in this population is self-medication in response to internalizing problems.

Rose RJ; Dick DM; Viken RJ; Pulkkinen L; Kaprio J. Genetic and environmental effects on conduct disorder and alcohol dependence symptoms and their covariation at age 14. Alcoholism: Clinical and Experimental Research 28(10): 1541-1548, 2004. (33 refs.)

Background: Alcohol misuse and conduct disorder (CD) are strongly associated in adolescents. Is their association due to shared genetic and environmental liabilities? We addressed that question with data obtained from structured interviews of 14-year-old Finnish twins. Methods: A total of 1854 twins completed face-to-face interviews. Univariate models, allowing for sex limitation, were fit to symptom counts for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised diagnoses of CD and alcoholism to examine their genetic and environmental influences. Then, bivariate models evaluated the extent to which genetic and environmental influences contributed to the covariation between symptom counts for the two disorders. Results: A total of 822 twins (44% of the sample) reported one or more symptoms of CD; alcohol dependence symptoms were much less common, reported by only 12%. The correlation between the two symptom counts was 0.50. Models fit to the twin data demonstrated that CD symptoms were under significant genetic influence in both boys and girls, although those influences were predominantly sex specific. In contrast, alcohol dependence symptoms were, at this age, under sex-specific effects of common environments, with no evidence of genetic influences. Accordingly, the substantial covariation between alcohol dependence symptoms and those of CD was attributed entirely to shared environmental effects. Conclusions: At age 14, genetic influences on alcohol dependence symptoms are negligible, and the correlated liabilities between these symptoms and those of CD are to be found in environmental factors that are common to both.

Sartor, CE; Lynskey, MT; Heath, AC. Characterizing dynamic risk in the pathway to alcohol dependence: Reply to commentaries. Addiction 103(2): 189-190, 2007. (12 refs.)

Sartor, CE; Lynskey, MT; Heath, AC; Jacob, T.; True, W. The role of childhood risk factors in initiation of alcohol use and progression to alcohol dependence. Addiction 103(2): 216-225, 2007. (76 refs.)

Aims: To identify childhood risk factors that predict (a) age of first drink and (b) time from first use to alcohol dependence (AD) onset, using survival analysis. Participants: The sample consisted of 1269 offspring (mean age = 20.1 years) of male twins from the Vietnam Era Twin Registry; 46.2% were offspring of alcohol-dependent fathers. Measurements: DSM-IV psychiatric diagnoses and substance use behaviors were assessed by structured telephone interview. Findings First drink occurred on average at 15.7 years; AD onset at 19.1 years. A Cox proportional hazard regression analysis revealed conduct disorder (CD) as the most potent predictor of early alcohol initiation (HR 2.48; CI 1.85-3.32). Attention deficit hyperactivity disorder (ADHD), maternal AD, paternal AD, male gender and parental divorce were also associated with early first use (HR 1.20-1.52; Cl 1.04-1.39-1.18-1.96). A Cox proportional hazard regression analysis modeling first drink to AD identified nicotine dependence (HR 3.91: CI 2.48-6.17) and generalized anxiety disorder (GAD) (HR 3.45; Cl 2.08-5.72) as robust predictors of progression to AD. CD (HR 1.75; CI 1.10-2.77) and cannabis abuse (HR 1.88; Cl 1.22-2.90) were also associated with rapid transition to AD. Conclusions: Results highlight the role of psychiatric and substance use disorders in progression from first drink to alcohol dependence, underscore the continuity of risk associated with conduct disorder and indicate that (with the exception of conduct disorder) different factors play a role in transition to alcohol dependence than in initiation of alcohol use. Distinctions between stages are interpreted in a developmental framework.

Schonfeld AM; Mattson SN; Riley EP. Moral maturity and delinquency after prenatal alcohol exposure. Journal of Studies on Alcohol 66(4): 545-554, 2005. (74 refs.)

Objective: Prenatal exposure to alcohol is associated with cognitive, behavioral and social deficits, including delinquency. Although delinquent populations and those with intellectual and behavioral deficits exhibit impaired moral judgment and reasoning, this area remains unexplored in alcohol-exposed individuals. Method: Moral maturity and delinquency were evaluated in 27 participants with prenatal alcohol exposure (ALC group) and 29 nonexposed controls (CON group) matched on age (range: 10-18), gender, handedness, socioeconomic status and ethnicity. Moral maturity was evaluated using the Sociomoral Reflection Measure-Short Form, and delinquency was evaluated with the Conduct Disorder (CD) Questionnaire. Additional measures included social desirability and inhibition. Results: The ALC group performed at a lower level of moral maturity than the CON group. Whereas Verbal IQ primarily predicted this difference, a deficit on the moral value judgment having to do with relationships with others was specific to prenatal alcohol exposure. Furthermore, delinquency was higher in the ALC group, and specific sociomoral values were predictive of delinquent behavior. Finally, half of the children and adolescents with a history of prenatal alcohol exposure but without fetal alcohol syndrome had probable CD. Conclusions: The results of this study indicate that interventions aimed at reducing delinquency in those with prenatal alcohol exposure are necessary, and targeting moral judgment for this purpose may be beneficial.

Shrier LA; Harris SK; Kurland M; Knight JR. Substance use problems and associated psychiatric symptoms among adolescents in primary care. Pediatrics 111(6): E699-E705, 2003. (56 refs.)

Objective. Substance use disorders (SUDs) are associated with other mental disorders in adolescence, but it is unclear whether less severe substance use problems (SUPs) also increase risk. Because youths with SUPs are most likely to present first to their site of primary care, it is important to establish the presence and patterns of psychiatric comorbidity among adolescent primary care patients with subdiagnostic use of alcohol or other drugs. The objective of this study was to determine the association between level of substance use and psychiatric symptoms among adolescents in a primary care setting. Methods. Patients who were aged 14 to 18 years and receiving routine care at a hospital-based adolescent clinic were eligible. Participants completed the Problem Oriented Screening Instrument for Teenagers Substance Use/Abuse scale, which is designed to detect social and legal problems associated with alcohol and other drugs, and the Adolescent Diagnostic Interview, which evaluates for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnoses of substance abuse/dependence and 8 types of psychiatric symptoms. We examined gender-specific associations of no/nonproblematic substance use (NSU), SUP, and SUD with psychiatric symptom presence (any symptoms within each type), score (symptom scores summed across all types), and number of types (number of different symptom types endorsed). Results. Of 538 adolescents (68% female; mean +/- standard deviation age: 16.6 +/- 1.4 years), 66% were classified with NSU, 18% with SUP, and 16% with SUD, and 80% reported having at least 1 type of psychiatric symptom in the previous 12 months. Symptoms of anxiety were most common (60% of both boys and girls), followed by symptoms of depression among girls (51%) and symptoms of attention-deficit disorder (ADD) among boys (47%). Compared with those with NSU, youths with SUP and those with SUD were more likely to report symptom presence for several types of psychiatric symptoms. Girls with SUP or SUD had increased odds of reporting symptoms of mania, ADD, and conduct disorder; girls with SUD were at increased risk for symptoms of depression, eating disorders, and hallucinations or delusions. Boys with SUP had increased odds of ADD symptoms, whereas boys with SUD had increased odds of reporting hallucinations or delusions. Boys with SUP or SUD had increased odds of reporting symptoms of conduct disorder. Youths with SUP and SUD also had higher psychiatric symptom scores and reported a wider range of psychiatric symptom types (number of types) compared with youths with NSU. Conclusions. Like those with SUD, adolescents with subdiagnostic SUP were at increased risk for experiencing a greater number of psychiatric symptoms and a wider range of psychiatric symptom types than youths with NSU. Specifically, adolescents with SUP are at increased risk for symptoms of mood (girls) and disruptive behavior disorders (girls and boys). These findings suggest the clinical importance of SUP and support the concept of a continuum between subthreshold and diagnostic substance use among adolescents in primary care. Identification of youths with SUP may allow for intervention before either the substance use or any associated psychiatric problems progress to more severe levels.

Silberg J; Rutter M; D'Onofrio B; Eaves L. Genetic and environmental risk factors in adolescent substance use. Journal of Child Psychology and Psychiatry and Allied Disciplines 44(5): 664-676, 2003. (81 refs.)

Background: The present study was undertaken with the goal of understanding the causes of association between substance use and both conduct disturbance (CD) and depression in adolescent boys and girls. Method: Multivariate genetic structural equation models were fitted to multi-informant, multi-wave, longitudinal data collected in extensive home interviews with parents and children with respect to 307 MZ male, 392 MZ female, 185 DZ male, and 187 DZ female, same-sex twin pairs aged 12-17 years from the Virginia Twin Study of Adolescent Behavioral Development (VTSABD). Results: Although conduct disturbance and depression were moderately associated with substance use, the pattern of genetic and environmental risk differed for males and females and across the two disorders. Genetic factors were predominant in girls' substance use whereas boys' use was mediated primarily by shared environmental factors reflecting family dysfunction and deviant peers. The patterns of correlations across the two waves of the study were consistent with conduct disturbance leading to substance use in both males and females, but depression leading to smoking, drug use and, to a lesser extent, alcohol use in girls. Conclusions: The comorbidity between substance use and depression, and between substance use and conduct disturbance in childhood/adolescence, probably reflects rather different mediating mechanisms - as well as a different time frame, with conduct disturbance preceding substance use but depression following it. In both, the co-occurrence partially reflected a shared liability but, in girls, genetic influences played an important role in the comorbidity involving depression, whereas in both sexes (but especially in boys) environmental factors played a substantial role. The extent to which these differences reflect genuine differences in the causal mechanisms underlying substance use and CD/depression in boys and girls revealed in the present analysis awaits replication from studies of other general population samples.

Simmons LA; Havens JR. Comorbid substance and mental disorders among rural Americans: Results from the National Comorbidity Survey. Journal of Affective Disorders 99(1-3): 265-271, 2007. (44 refs.)

Background: The purpose of this study was to examine whether rural inhabitants were more likely than urban inhabitants to meet the criteria for comorbid mental health and substance abuse or dependence disorders. Methods: Data were from the National Comorbidity Survey, and included 5185 (532=rural; 4653=urban) persons age 14-54 years of age who were interviewed using the Composite International Diagnostic Interview (CIDI). Logistic regression that accounted for the complex survey data and weighting scheme was utilized. Results: Participants residing in rural areas were more likely to meet the DSM-III-R criteria for past month alcohol abuse or dependence if they also met the diagnostic criteria for past month major depressive disorder or lifetime antisocial personality disorder, adjusting for age, race, gender, education and income. Similarly, rural participants were more likely to meet the criteria for comorbid drug abuse or dependence in the past month if they met the diagnosis for either past month major depressive disorder, generalized anxiety disorder or lifetime antisocial personality disorder, controlling for demographic characteristics. Rural residents with any current mental disorder also were less likely to seek treatment than their urban counterparts. Limitations: Data were collected in 1991 and do not capture changes in prevalence of comorbidities. Also, the small number of rural residents sampled resulted in small cell sizes for some comorbidities. Conclusions: Rural residents were significantly more likely to meet the criteria for substance disorders given they also met the criteria for a mental disorder, and those with any current mental disorder were less likely to seek treatment. Since the overall prevalence of these disorders does not differ between rural and urban inhabitants, findings suggest that rural persons may lack access to adequate treatment for their mental health disorders and subsequently may be self-medicating with alcohol and/or drugs.

Sourander A; Multimaki P; Nikolakaros G; Haavisto A; Ristkari T; Helenius H et al. Childhood predictors of psychiatric disorders among boys: A prospective community-based follow-up study from age 8 years to early adulthood. Journal of the American Academy of Child and Adolescent Psychiatry 44(8): 756-767, 2005. (36 refs.)

Objective: To study early childhood predictors for early adulthood psychiatric disorders. Method: The sample included 2,712 Finnish boys born in 1981. Information about the 8-year-old boys' problem behavior was obtained from parents, teachers, and children. The 10-15-year follow-up information about psychiatric disorders in early adulthood was based on the national military register between the years 1999 and 2004. Results: According to the military register, 10.4% of men had a psychiatric disorder. All informant sources, parents, teachers, and the children themselves predicted early adulthood psychiatric disorders. Conduct symptoms at age 8 independently predicted substance abuse, antisocial personality, and psychotic disorders in early adulthood. Self-reported depressive symptoms, poor school performance, and living in a nonintact family had an independent predictive association with antisocial personality and depressive disorders. Parent-reported emotional symptoms and self-reported psychosomatic symptoms independently predicted anxiety disorders. About one third of those who had used services at age 8 had a psychiatric disorder in early adulthood. Among service users, conduct and hyperkinetic symptoms predicted psychiatric disorders in early adulthood. Conclusions: Efforts to prevent early adult psychiatric disturbance already present in childhood are emphasized. Active screening to detect children in need of early interventions in childhood to prevent negative development in early adulthood is justified.

Spirito A; Mehlenbeck R; Barnett N; Lewander W; Voss A. The relation of mood and behavior to alcohol use in adolescent suicide attempters. Journal of Child & Adolescent Substance Abuse 12(4): 35-53, 2003. (46 refs.)

Background: Substance use has been shown to be an important risk factor for suicidal behavior in adolescence. In this study, rates Of Substance use in a sample of adolescents who had attempted suicide were examined as were the relationships of mood state and behavior problems to substance use.Method: Adolescents (N = 106) treated in an emergency department or pediatric inpatient unit following a Suicide attempt were administered a standardized clinical assessment battery including detailed measures of alcohol involvement.Results: Seven percent of the sample reported alcohol or other drug use at the time of the attempt. About one third of the sample reported having been drunk at least once and one fifth reported at least one alcohol-related problem; 6% of the sample met diagnostic criteria for either alcohol abuse or dependence. Behavior problems were more strongly related to quantity and frequency of alcohol use than mood state. Hopelessness and behavior problems were both related to the severity of alcohol involvement.Conclusions: Results suggest that alcohol use among suicide attempters is more strongly related to conduct than mood disturbance.

Strong DR; Kahler CW; Ramsey SE; Abrantes A; Brown RA. Nicotine withdrawal among adolescents with acute psychopathology: An item response analysis. Nicotine & Tobacco Research 6(3): 547-557, 2004. (51 refs.)

The present study explored the relationship between psychopathology and the experience of nicotine withdrawal among 191 adolescent smokers deprived of nicotine during a psychiatric hospitalization. Using methods based in item response theory, we demonstrated the ability of symptoms of nicotine withdrawal to cohere in measuring the withdrawal syndrome. After controlling for nicotine dependence, we found that several disorders showed significant but modest univariate relationships with individual withdrawal symptoms. After controlling for comorbidity with other disorders, we found that depressive and conduct disorders maintained significant but modest relationships with increased withdrawal severity. Item analyses across groups suggested that girls, individuals with a depressive disorder, and individuals with a conduct disorder tended to report higher levels of nicotine withdrawal but did not appear to inflate their scores because of disorder- or gender-specific reporting bias. Although levels of acute distress were related to withdrawal severity, the six-item withdrawal index showed good discriminant validity in this sample by demonstrating stronger correlations with craving and level of dependence than could be accounted for by levels of distress alone.

Sung MJ; Erkanli A; Angold A; Costello EJ. Effects of age at first substance use and psychiatric comorbidity on the development of substance use disorders. Drug and Alcohol Dependence 75(3): 287-299, 2004. (59 refs.)

In this paper, we examine the effects of age at first substance use, and history of psychiatric disorders, on the development of substance use disorder (SUD) by age 16. We use a prospective, longitudinal design to disaggregate the effects of age at first use and time since first use on the development of adolescent SUD. Second, we test the hypothesis that adolescent SUD is an unlikely progression from early substance use unless children also show other early conduct problems. A population sample of 1420 children from the Great Smoky Mountains Study (GSMS) was assessed annually between ages 9 and 16. Logistic regression models were applied within the hierarchical Bayesian framework, where the covariate effects were described by time-varying parameters having a first-order auto-regressive prior distribution. Posterior analyses based on a Gibbs sampling approach revealed that, controlling for years of exposure, the risk of transition to SUD increased with age at onset for onsets before age 13, but began to fall for onset at 14. Among users, use alone, without early conduct problems, led to a 11% prevalence of SUD by age 16. Past conduct disorder (CD) had a strong additive effect at ages 13-15, but at age 16, when substance use and abuse became more normative, the excess risk from prior CD decreased. Boys, but not girls, with a history of depression were at increased risk of SUD. Anxiety increased the risk of SUD in girls at age 16, but not before that. Results only partially support the study hypothesis; early use was a major predictor of adolescent SUD even in the absence of CD.

Swartz MS; Wagner HR; Swanson JW; Stroup TS; McEvoy JP; Canive JM et al. Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study. Journal of Nervous and Mental Disease 194(3): 164-172, 2006. (38 refs.)

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

Tcheremissine OV; Lane SD; Cherek DR; Pietras CJ. Impulsiveness and other personality dimensions in substance use disorders and conduct disorder. Addictive Disorders and Their Treatment 2(1): 1-7, 2003. (56 refs.)

The study examined relationships among novelty seeking, harm avoidance, reward dependence, impulsivity and venturesomeness, and conduct disorder in subjects with a past diagnosis of a substance use disorder and in controls. Psychometric data from 68 subjects (18-40 years old; 24% female and 76% male) were analyzed using analysis of variance and logistic regression. Twenty-two participants (32%) met standard diagnostic criteria for conduct disorder before age 15; 27 participants (40%) met criteria for a past substance use disorder, with alcohol, marijuana, cocaine comprising the majority of substances; and 9 participants (13%) met criteria for both past substance use disorder and conduct disorder. Statistical analyses revealed that individuals meeting criteria for a past substance use disorder showed lower reward dependence and greater impulsivity than controls, when controlling for the presence of conduct disorder. A substance use disorder-conduct disorder interaction was found on the dimensions of harm avoidance and venturesomeness. Logistic regression showed that the combination of low reward dependence and nonplanning impulsivity could predict a past substance use disorder. Results are discussed in the context of previous data on personality dimensions and substance abuse.

Tomlinson KL; Brown SA; Abrantes A. Psychiatric comorbidity and substance use treatment outcomes of adolescents. Psychology of Addictive Behaviors 18(2): 160-169, 2004. (58 refs.)

Treatment outcomes of 126 adolescents (13-18 years old) with comorbid substance use disorders (SUDs) and Axis I psychiatric disorders (mood, anxiety, conduct, and attention-deficit/hyperactivity disorders) were compared to 81 SUD adolescents with no additional Axis I disorder. Participants completed structured interviews and symptom measures while participating in an adolescent treatment program and at 6 months following treatment. Results indicated that comorbid youth received more treatment during the outcome period; despite this, more comorbid SUD-Axis I disordered adolescents used substances following treatment than SUD-only youth, even after controlling for socioeconomic status and ethnicity. Among comorbid youth, internalizing disordered adolescents were less likely to use substances during the follow-up period, and externalizing disordered youth returned to substance use most rapidly after discharge from treatment.

Wakschlag LS; Pickett KE; Kasza KE; Loeber R. Is prenatal smoking associated with a developmental pattern of conduct problems in young boys? Journal of the American Academy of Child and Adolescent Psychiatry 45(4): 461-467, 2006. (39 refs.)

Objective: Prenatal smoking is robustly associated with increased risk of conduct problems in offspring. Observational studies that provide detailed phenotypic description are critical for generating testable hypotheses about underlying processes through which the effects of prenatal smoking may operate. To this end, we use a developmental framework to examine the association of exposure with (1) oppositional defiant disorder and attention-deficit/hyperactivity disorder in young boys and (2) the pattern of delinquent behavior at adolescence. Method: Using diagnostic measures and repeated measures of delinquency, we compare exposed and nonexposed boys from the youngest cohort of the Pittsburgh Youth Study (N = 448). Results: Exposed boys were significantly more likely to (1) develop oppositional defiant disorder and comorbid oppositional defiant disorder-attention-deficit/hyperactivity disorder but not attention-deficit/hyperactivity disorder alone and (2) to have an earlier onset of significant delinquent behavior. Conclusions: The early emergence and developmental coherence of exposure-related conduct problems is striking and is consistent with a behavioral teratological model. Phenotypically, exposure-related conduct problems appear to be characterized by socially resistant and impulsively aggressive behavior. Whether prenatal smoking plays an etiological role in or is a risk marker for the development of conduct problems, exposed offspring are at increased risk of an early-starter pathway to conduct problems.

Wall AE; Kohl PL. Substance use in maltreated youth: Findings from the National Survey of Child and Adolescent Well-Being. Child Maltreatment 12(1): 20-30, 2007. (47 refs.)

The purpose of this study was to describe the characteristics associated with different levels of substance use in a national probability sample of maltreated 11- to 15-year-olds (n = 1, 179). Bivariate (chi-square tests) and multivariate (logistic regression) analyses were used to examine the association of adolescent substance use with demographics, placement type, and youth and family characteristics. Seventy-one percent of youth reported no use, 20% reported low levels of substance use, and approximately 9% reported moderate to high levels of use. Youth substance use was similar across placement types. Conduct problems and low caregiver relatedness were more prevalent for youth reporting higher levels of substance use. High levels of conduct problems increased the odds of substance use, whereas high caregiver monitoring decreased the odds of substance use. Caregiver monitoring may be a key tactic in attempts to reduce the likelihood of substance use in maltreated youth, regardless of placement type.

Whitbeck LB; Johnson KD; Hoyt DR; Cauce AM. Mental disorder and comorbidity among runaway and homeless adolescents. Journal of Adolescent Health 35(2): 132-140, 2004. (33 refs.)

Purpose: To investigate prevalence of mental disorder and comorbidity among homeless and runaway adolescents in small to medium sized cities in four Midwestern states. Methods: The study presents lifetime, 12-month prevalence, and comorbidity rates for five mental disorders (conduct disorder, major depressive episode, posttraumatic stress disorder, alcohol abuse, and drug abuse) based on UM-CIDI and DISC-R structured interviews from the baseline interviews of a longitudinal diagnostic study of 428 (187 males; 241 females) homeless and runaway adolescents aged 16-19 years (mean age = 17.4 years, SD = 1.05). The data were collected by full-time street interviewers on the streets and in shelters in eight Midwestern cities of various populations. Separate logistic regression models were used to investigate factors associated with meeting criteria for any disorder and two or more disorders. Results: Lifetime prevalence rates were compared with rates for same-aged respondents from the National Comorbidity Survey (NCS). Homeless and runaway adolescents were six times more likely than same-aged NCS respondents to meet criteria for two or more disorders and were from two to 17 times more likely to meet criteria for individual disorders than. Conclusions: Homeless and runaway adolescents in small and mid-sized Midwestern cities report significant levels of mental disorder and comorbidity that are comparable and often exceed that reported in studies of larger magnet cities.

Wilens TE; Gignac M; Swezey A; Monuteaux MC; Biederman J. Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. Journal of the American Academy of Child and Adolescent Psychiatry 45(4): 408-414, 2006. (34 refs.)

Objective: Little is known about the risks and characteristics of attention-deficit/hyperactivity disorder (ADHD) patients who misuse or divert their stimulant medications. As part of a 10-year longitudinal study of youths with ADHD, the authors evaluated medication diversion or misuse at the last follow-up period. Method: Structured psychiatric interviews for diagnosis and a self-report questionnaire regarding medication use in medicated subjects with ADHD compared with controls without ADHD receiving psychotropics for non-ADHD treatment were employed. Results: Of 98 subjects receiving psychotropic medications (mean age of 20.8 +/- 5 years), 55 (56%) were ADHD subjects and 43 (44%) were controls receiving medications for other purposes. The authors found that 11% of the ADHD group reported selling their medications compared with no subjects in the control group (z = 0.00, p < .05). An additional 22% of the ADHD group reported misusing their medications compared with 5% of the control subjects (z = 1.7 p = .09) and that those with conduct or substance use disorders accounted for the misuse and diversion. A minority of subjects reported escalating their doses and concomitant use with alcohol and drugs. Conclusions: The data indicate that the majority of ADHD individuals, particularly those without conduct or substance use disorders, use their medications appropriately. The authors' findings also highlight the need to monitor medication use in ADHD individuals with conduct and/or substance use disorders and to carefully select agents with a low likelihood of diversion or misuse in this group.