Dsm-Iv Research Paper
Early-onset Alcohol Abuse and its Relationship with DSM-IV Disorders
Research Methods & Program Evaluation
Abstract
According to the DSM-IV, antisocial personality disorder diagnosis requires conduct disorder to be presented before the age of 15. However, antisocial personality behavior is not diagnosable before the age of 18. Recent studies have suggested that early-onset alcohol abuse is found to be a relevant cause to the effects of conduct disorder and antisocial behavior. Adolescent alcohol abuse intensifies the influence of childhood conduct disorder and early adult antisocial personality disorder. This particular study would test whether this result would simplify any true findings of early-onset alcohol abuse …show more content…
that co-occurs with conduct disorder and antisocial behavior. A general population was investigated for any plausibility between conduct disorder and antisocial personality disorder to determine if early-onset alcohol abuse significantly mediates the effects of both disorders. The mechanisms that explain these associations are discussed.
Introduction According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), antisocial personality disorder is a “pervasive pattern of violation of the rights of others that begins in childhood or early adolescent and continues into adulthood” (p.645).
Any diagnosis of antisocial personality disorder requires a diagnosis of conduct disorder before the age of 15 and three or more types of adult antisocial behavior, such as unlawful behavior, or deceitfulness. The DSM-IV explains conduct disorder to be a “repetitive and persistent pattern in which the basic rights of others or major age appropriate societal norms or rules are violated” (p. …show more content…
90).
The existence of adult antisocial personality disorder without the presence of conduct disorder may be associated with adolescent alcohol abuse. The plausibility of adolescent alcohol misuse causing adult antisocial personality disorder consists of many elements including, temporal, oral, dose-related liability, and understandable mechanisms (Ridenour, Cottler, Robins, Compton, Spitznagel, and Williams, 2002). Ridenour et al., stated that “if adolescent alcohol misuse plays a casual role in developing antisocial personality disorder then adolescent alcohol misuse must precede antisocial personality disorder, increase severity of adolescent alcohol misuse, increase antisocial personality disorder risk, and understand mechanisms that should be available to explain the association”. This report indicates that the temporal order of substance misuse occurs before antisocial personality disorder. In summary, research on antisocial personality disorder conducted up to the mid 1980’s, Loeber (1988) emphasized that even minor delinquent offenses included drug use initiation.
Substance abuse disorders are evidently more severe than substance use alone and may increase the cause of antisocial personality disorder with its risk of misuse. Before anyone can experience substance abuse, they must first present long term regular substance abuse related symptoms. Adolescents have been subjected to negative peer influences due to substance abuse. For the reason of adolescents having limited time to develop full criteria for substance-related disorders, the DSM-IV diagnosis is an appropriate indication of adolescents substance use related psychopathology (Ridenour, Cottler, Robins, Compton, Spitznagel, & Williams, 2002). Precise alcohol or drug symptoms in adolescents have been linked with subsequent increases in antisocial behavior.
In order to study the effects of adolescent alcohol misuse/abuse on antisocial personality disorder and conduct disorder, adolescents must be in a strategically controlled group. The age of conduct disorder onset has been shown to be a powerful indicator of antisocial personality disorder. In particular, prepubescent males presenting conduct disorder from alcohol abuse have difficulty with temperament, dysfunctional family interactions, and social skill deficits (Ridenour, Cottler, Robins, Compton, Spitznagel, & Williams, 2002). Ridenour and his colleagues have reported that these deficits may continue and possibly even worsen over the life course of prepubescent males with conduct disorder and ultimately leading to antisocial personality disorder. In addition, postprepubesent conduct disorder in males is shown to result from negative social and cultural influences that may concern adulthood and males who present adolescent conduct disorder and may be anticipated to later develop antisocial personality disorder. On the contrary, Ridenour and his colleagues have stated that females with conduct disorder, regardless of onset age have shown to resemble to prepubescent males with conduct disorder due to alcohol misuse/abuse. Although there is research that subjects to the continuousness of conduct disorder into young adulthood antisocial personality behavior, the relationship between the two disorders remains problematic. Conduct disorder appears to influence the development of a wide range of adult disorders and personality disorders other than just antisocial personality disorder (Kjelsberg, 2006). A recent report on the association between personality disorders and conduct disorder demonstrated that individuals with personality disorders who met the criteria for antisocial personality disorder co-occurred with borderline personality disorders and showed more personality disorder comorbidity and greater severity of conduct disorder (Bernstein, Cohen, Skodol, Bezirganian, and Brook, 1996). However, it still remains unclear as to what extent the presence of childhood conduct disorder makes a clinical meaningful difference from adult antisocial personality behavior.
The association between childhood conduct disorder and adult antisocial personality disorder has been well documented. Childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to adult violent behavior. Despite its relation to other childhood disorders such as, Oppositional Defiant Disorder and Attention Deficit-Hyperactivity Disorder, childhood conduct disorder was the only disorder among many to be associated with the adult antisocial personality disorder (Fergusson, Boden, & Horwood, 2010).
The relationship between childhood conduct disorder and adult antisocial personality disorder is found to be complex for several reasons. The first reason, childhood conduct disorder appears to predispose the development of a wide range adult offender population, and the entire spectrum of personality disorders rather than just antisocial personality disorder. Second, although progression rates from childhood conduct disorder to adult antisocial personality disorder have been estimated to be around fifty percent, variable rates of progression have been currently reported ranging from thirty percent to a high sixty one percent in adolescents with concurrent alcohol abuse problems. Finally, it still remains unclear as to what extent the presence of childhood conduct disorder makes a clinically and meaningful difference with adult antisocial personality disorder (Myers, Stewart, & Brown, 1998).
Past studies have also suggested that individuals only meeting the adult criteria for antisocial personality disorder suffer primarily the same disorder as those meeting both adult and child antisocial personality disorder criteria. This finding is questioned in two relevant studies. Howard, Huband, and Duggan, (2010) reported an association between severe childhood conduct disorder and personality disorder. The study then proposed another recent study which highlighted the role of childhood conduct disorder in adult antisocial behavior, indicating the existence of a clinically and meaningful distinction between antisocial adults with and without childhood conduct disorder (Walters & Knight, 2010). As discussed by these authors, further research on the transition from childhood conduct disorder to adult antisocial personality is recommended in order to distinguish the relationship between the two. Factors other than childhood conduct disorder, including early-onset alcohol abuse are at stack in determining a shift in the developmental course towards antisocial personality disorder.
Another interesting finding on early-onset alcohol abuse and childhood conduct disorder is its significant relevance with attention –deficit hyperactivity disorder. Children with attention-deficit hyperactivity disorder have higher rates of substance use and substance use disorder than healthy controls in longitudinal studies of clinical samples (Brooke, Molina, Oscar, Bukstein, Lynch, 2002). In similar studies, substance use disorder had been strongly associated with the development of childhood conduct disorder. This finding suggests that adolescents with early-onset alcohol abuse in children with attention-deficit hyperactivity disorder may be part of a behavioral pattern of violating social norms for which children with attention-deficit hyperactivity disorder are at a greater risk. Future longitudinal research in nonclinical samples has been found to the most adverse outcomes for children with both attention-deficit hyperactivity disorder and childhood conduct disorder compared with children with either disorder, suggested attention-deficit hyperactivity disorder and childhood conduct disorder comorbidity may convey the highest degree of the early-onset type of substance use disorder (Brooke, Molina, Oscar, Bukstein, & Lynch, 2002).
According to these research findings there are some concerns that arise. One concern suggests how common is attention-deficit hyperactivity disorder among adolescents with substance use problems and is attention-deficit hyperactivity disorder and childhood conduct disorder comorbidity in a clinical sample associated with particularly severe substance use disorder. Persistent research on substance abusing adolescents report that a rough one-third of the population meets diagnostic criteria for attention-deficit hyperactivity disorder. However, the findings are slightly limited because of small sample seizes, difficulty obtaining parental report of attention-deficit hyperactivity disorder, and failure to include females in sufficient number to examine gender-related effects. A present study conducted on Attention-Deficit Hyperactivity Disorder and Conduct Disorder Symptomatology in Adolescents with Alcohol use Disorder, data was collected by using the Pittsburgh Adolescent Alcohol Research Center provided the opportunity to test attention-deficit hyperactivity and conduct disorder comorbidity in adolescents with alcohol use disorder in finding a greater deviance in behavior and substance use (Brooke, Molina, Oscar, & Lynch, 2002).
Previous studies have introduced the idea that individuals who met the criteria for antisocial personality disorder suffer in essence the same disorder as individuals who meet full criteria for conduct disorder. However, the study and results were questioned for the existence of a clinical difference between antisocial individuals with and without childhood conduct disorder (Walters & Knight, 2010). Walters and Knight stated “what we now need is relevant and up to date research on the transition from conduct disorder to antisocial personality disorder in order to clarify a nature of their relationship” (p.267). Even with factors indicating childhood conduct disorder determining the development of antisocial personality disorder the factors still remain unclear. An extreme relevant factor is early-onset alcohol abuse, which demonstrates to have a significant risk for persistent antisocial behavior for heavy alcohol abuse and violence in early childhood and late adulthood (Khalifa, Duggan, Howard, Landsmen, 2012). The co-occurrence between conduct disorder and alcohol abuse in adolescents presents a major problem in attempts to identify their role of adult antisocial with violent behaviors. Some authors have stressed the idea that most children and adolescents with conduct disorder will in fact abuse alcohol. Evidence of this suggests that early-onset alcohol abuse and conduct disorder applies interacting effects on adult antisocialism to become merged into disordered conduct (Loeber, Burke, Lahey, Winters, & Zera, 200). The earlier the age of early-onset alcohol abuse the earlier it is to predict a range of adult behaviors, which includes violent recidivism, aggression, heavy alcohol consumption, and violence in young adulthood.
In a study of 477 young adults at a staggering risk for alcohol abuse, it proved that it is possible to determine a group of individuals who met the Diagnostic and Systematic Manual diagnosis of conduct disorder but not for alcohol dependence (Lumsded, Hadfield, Littler, & Howard, 2005). Although in this study, a group of participants presenting conduct disorder and a group of individuals presenting conduct disorder combined with alcohol dependence including the age in which alcohol abuse initiated, this group demonstrated high levels of longitudinal problems such as, alcohol, drug, and adult antisocial problems. The effect of alcohol dependence in this study was complex because the conduct disorder severity was greater in the group with conduct disorder and alcohol dependence. Nonetheless, the study results were consistent and implied that alcohol abuse may moderate or mediate the relationship between conduct disorder and adult antisocial personality behavior. (Lumsded, Hadfield, Littler, & Howard, 2005).
In order to verify these findings, another study was completed by Howard, Finn, Gallagher, and Jose (2011) to determine any possible mediating or moderating factors of early-onset alcohol abuse using a sample with alcohol abuse and another group with conduct disorder only. The study used regression analysis for covariance between conduct disorder and early-onset alcohol abuse. Results of this study determined that early-onset alcohol abuse and conduct disorder showed significant and independent effects on adult antisocial personality disorder. The study also showed that early-onset alcohol abuse significantly mediated and impaired the effect of conduct disorder (Howard, Finn, Gallagher, and Jose, 2011).
Results from other studies have been thoroughly examined adolescent predictors of adult antisocial outcomes from early-onset alcohol abuse as important risk factors for adult antisocial behavior and violent offending. For example, in the Cambridge Study in Delinquent Development, it was founded that heavy consumption of alcohol by the age of eighteen was one of the most important risk factors that predicted offenders to continue violent and aggressive behavior through and after the age of twenty-one (Howard, Finn, Jose, & Gallagher, 2012). In the Christchurch Health and Development Study, results determined that early-onset alcohol abuse predicted violent offending for age groups of fifteen to twenty one and twenty-one to twenty five, even after controlling background and individual factors such as, childhood conduct disorder (Howard, Finn, Jose, & Gallaher, 2012). In another study, Dunedin Multidisciplinary Health and Development Study, researchers concluded that roughly one-half of male members of the birth cohort (1037 children born in 1972-1973 in Dunedin), who subsequently demonstrated a perverse pattern of life persistence antisocial behavior were dependent of alcohol as early as eighteen years old. (Howard, Finn, Jose, & Gallaher, 2012).
In addition to the above findings, studies have reported that measures of early-onset alcohol abuse such as, age of first drink is associated with high risk factors of delinquency and criminal behavior. In one particular forensic sample of adolescent psychiatric patients, it was proven that the younger age of alcohol abuse was significantly associated with the development of a complex personality disorder characterized by the explosiveness and psychopathic traits derived from early-onset alcohol abuse (Gustavson, Stahlberg, Sjodin, Forsman, Nilsson, & Anckarsater, 2007). In consistence with these studies, early-onset alcohol abuse had been proven to be associated with antisocial personality disorder.
The prospective study aimed to determine whether the results obtained from a community sample by Howard et al. (2011) would be similar to a high risk forensic sample of patients with personality disorders that are incarcerated under high security conditions. Keeping in mind the results from the Howard, Finn, Gallagher, and Jose (2011) case, it is hypothesized that individuals with adult antisocial behavior would show significance early-onset alcohol abuse. The critical comparison would be with the group who only presented conduct disorder alone. Regression analysis would be conducted to test the prediction of early-onset alcohol abuse and conduct disorder that would independently predict antisocial behavior as a possible outcome. Further analysis would be necessary to test whether the effect of conduct disorder an antisocial behavior would be mediated by early-onset alcohol abuse. According to Howards, Finn, Gallagher, and Jose’s study hypothesis, early-onset alcohol abuse is a critical component in mediating the relationship between conduct disorder and antisocial behavior.
Method
Participants for this study were 100 male offenders incarcerated at different levels of security. They were recruited from a high secure psychiatric hospital. All participants were given informed consents to participate in the study. Criteria to participate in the study included; at least one definite DSM-IV personality disorder, a full sale IQ score of 70 or higher, no evidence of any severe chronic mental health illness, no past history of head injury or neurological disorder such as epilepsy. Three groups would be constructed to determine which one would match the hypothesis.
Group one would consist of participants with no early-onset alcohol abuse and no conduct disorder. Participants also could not have a history of DSM-IV alcohol abuse or dependence and no history of conduct disorder. These particular patients would present a lack in history of adolescent alcohol abuse, consuming less than forty units of alcohol per week in a six-month period and a DSM-IV diagnosis of conduct disorder. Group two would consist only participants who have a DSM diagnosis of conduct disorder, including a positive score of three or more of the fifteen conduct disorder items. Participants in this group would also not present a history of alcohol abuse or dependence and no history of adolescent alcohol abuse in consumption of less than forty units of alcohol per week within a six-month period between the ages of ten and twenty. Group three would consist of participants with a DSM diagnosis of conduct disorder, including three or more of the fifteen items, a DSM diagnosis of alcohol dependence/abuse, and a present history of adolescent alcohol abuse consisting of alcohol consumption of forty units per week within a six month period before the age of twenty.
Assessment: Procedure and Instruments
The participants who consented to participate in such study were recruited by analyzing their case files to ensure they met the criteria in terms of IQ score and clinical diagnosis. Additional information such as participants clinical diagnosis using the DSM-IV Axis I and II, reported history of offending, and current psychotropic medications including, antipsychotics and antidepressants, would also be recorded. Participants would then undergo the following assessments.
1. Assessment of Psychopathy. The computerized version of the National Institute of Mental Health Diagnostic Interview Schedule (Robins, Helzer, Cottler, and Goldring, 1989) would be used to determine diagnostic assessments of DSM-IV Axis I and II disorders such as, conduct disorder, attention deficit hyperactive disorder, schizophrenia, bipolar affective disorder, and alcohol abuse/ dependence. The National Institute of Mental Health Diagnostic Interview Schedule would be used due to its adequate diagnostic reliability and validity. DSM-IV personality disorders would be assessed by using the International Personality Disorder Examination (Loranger, Sartorius, Andreoli, Berger, Buchheim, Channabasavanna, & Regier, 1994). The ninety-nine-interview questionnaire is designed to assess the ten DSM-IV Axis II personality disorders and personality disorders not otherwise specified. Individual scores of the test would be scored on a three-point scare, zero meaning absent, one meaning partially absent, and two meaning definitely present. This type of scoring would allow the scores to be derived from individual personality disorders and from personality disorder clusters, cluster A, odd and eccentric, cluster B, dramatic, and cluster C, anxious and avoidant.
2. Assessment of Alcohol use. Information regarding consumption of alcohol would be obtained by detailed alcohol history assessments developed for offenders with mental disorders use. More information would be analyzed from gathering collateral information from case notes, which would be collected from interviewing participants regarding their early alcohol usage. Example questions for this type of interview would be, when did you start to drink alcohol regularly, once or more a month? How old were you when you first got drunk? The goal of this interview would be to gather as much information as possible on how much participants drank in units of alcohol per week across their life span. The amount of units consumed for early alcohol abuse was defined as consumption of forty units or more per week within a six-month period before reaching the age of twenty. Information regarding drug use was not researched due to proving early-onset alcohol abuse as a defining determinate of conduct disorder and antisocial personality disorder.
3. Assessment of Violence. The assessment of violence is meant to focus on the quantity and severity of the violent act committed. The quantity of violence was measured based on the number of violent offenses in the patient’s criminal history that was obtained from case files and self-reports. The severity of violence was measured by using a severity of violence rating scale that has been adapted from the original version developed by Gunn and Robertson, which has been validated in hospitalized psychiatric patients by Wong, Lumsden, Fenton, and Fenwick (1993). This scale is comprised of two subscales for each of the offenses and previous criminal history. Scores are rated on a five-point scale describing the range of severity from zero to four, no violence to severe violence.
The study analysis would be conducted in four stages. In the first stage of the analyses, which would be between groups comparisons would be carried out using one-way ANOVA for continuous variables. The second analysis stage would involve multiple linear regressions to examine relationships between antisocial behaviors, which would be treated as the dependent variable. The third analysis stage would examine the degree of early-onset alcohol abuse contemplated the effect of conduct disorder on antisocial behavior. The final stage of analysis would be used to test the prediction that early-onset alcohol abuse would mediate the relationship between conduct disorder and antisocial behavior. This would suggest the estimated direct and indirect total effects of conduct disorder, independent variable on antisocial behavior, dependent variable, through early-onset alcohol abuse.
References
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental
Disorders. (4th ed) Washington, DC: Arthur.
Fergusson, D. M., Boden. J. M., & Horwood, J. (2010).Classification of Behavior Disorders in
Adolescence: Scaling methods, predictive validity, and gender differences. Journal of Abnormal Psychology. 119-699-712.
Gustavson, C., Stahlberg, O., Sjodin. A, K., Forman, A., Nilsson. T., & Anckarsater. H. (2007).
Age at Onset of Substance Abuse: A Crucial Covariate of Psychopathic Traits and Aggression In Adult Offenders. Psychiatry Research. 153, 195-198.
Howard. R., Finn. P., Jose. P., & Gallagher, J. (2012). Adolescent-onset Alcohol Abuse
Exacerbates the Influence of Childhood Conduct Disorder on Late Adolescent and Early Adult Antisocial Behavior. Journal Of Forensic Psychiatry and Psychology. 23, 7-22.
Loranger, A.W., Sartorious, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S.
M., Regier, D. A. (1994). The International Personality Disorder Examination: The World Health Organization and Alcohol, Drug Abuse and Mental Health Administration international pilot study of personality disorders. Journal of General Psychology. 551, 215-224.
Lumsden, J., Hadfield, J., Littler, S., & Howard, R. (2005). The Prevalence of Early-onset
Alcohol Abuse in Mentally Disordered Offenders. Journal of Forensic Psychiatry and Psychology. 16, 651-659.
Molina, B., Bukstein,, M., & Lynch, K. (2002). Attention-Deficit/Hyperactivity Disorder and
Conduct Disorder Symptomatology in Adolescents With Alcohol Use Disorder. Journal of Psychology of Addictive Behaviors. 16, 161-164.
Myers, M.G., Stewart, D.G., & Brown, S. A. (1998). Progression from Conduct Disorder to
Antisocial Personality Disorder Following Treatment for Adolescent Substance Abuse. American Journal of Psychiatry. 155, 479-485.
Ridenour, T. A., Cottler, L. B., Robins, L. N., Compton, W. M., Spitznagel, E. L., &
Cunningham-Williams, R. M. (2002) Test of the Plausibility of Adolescent Substance Use Playing a Casual Role in Developing Adulthood Antisocial Behavior. Journal of Abnormal Psychology. 111,
144-155.
Robins, L., Helzer, J., Cottler, L. B., & Goldring, E. (1989). National Institute of Mental Health:
Quick Diagnostic Interview Schedule-Revised. St. Louis, MO Department of Psychiatry, Washington University School of Medicine.
Wong, M., Lumsden, J., Fenton, G., & Fenwick, P. (1993). Violence Ratings of Special Hospital
Patients. Journal of Forensic Psychiatry. 4 471-40.
Research Methods & Program Evaluation
Abstract
According to the DSM-IV, antisocial personality disorder diagnosis requires conduct disorder to be presented before the age of 15. However, antisocial personality behavior is not diagnosable before the age of 18. Recent studies have suggested that early-onset alcohol abuse is found to be a relevant cause to the effects of conduct disorder and antisocial behavior. Adolescent alcohol abuse intensifies the influence of childhood conduct disorder and early adult antisocial personality disorder. This particular study would test whether this result would simplify any true findings of early-onset alcohol abuse …show more content…
that co-occurs with conduct disorder and antisocial behavior. A general population was investigated for any plausibility between conduct disorder and antisocial personality disorder to determine if early-onset alcohol abuse significantly mediates the effects of both disorders. The mechanisms that explain these associations are discussed.
Introduction According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), antisocial personality disorder is a “pervasive pattern of violation of the rights of others that begins in childhood or early adolescent and continues into adulthood” (p.645).
Any diagnosis of antisocial personality disorder requires a diagnosis of conduct disorder before the age of 15 and three or more types of adult antisocial behavior, such as unlawful behavior, or deceitfulness. The DSM-IV explains conduct disorder to be a “repetitive and persistent pattern in which the basic rights of others or major age appropriate societal norms or rules are violated” (p. …show more content…
90).
The existence of adult antisocial personality disorder without the presence of conduct disorder may be associated with adolescent alcohol abuse. The plausibility of adolescent alcohol misuse causing adult antisocial personality disorder consists of many elements including, temporal, oral, dose-related liability, and understandable mechanisms (Ridenour, Cottler, Robins, Compton, Spitznagel, and Williams, 2002). Ridenour et al., stated that “if adolescent alcohol misuse plays a casual role in developing antisocial personality disorder then adolescent alcohol misuse must precede antisocial personality disorder, increase severity of adolescent alcohol misuse, increase antisocial personality disorder risk, and understand mechanisms that should be available to explain the association”. This report indicates that the temporal order of substance misuse occurs before antisocial personality disorder. In summary, research on antisocial personality disorder conducted up to the mid 1980’s, Loeber (1988) emphasized that even minor delinquent offenses included drug use initiation.
Substance abuse disorders are evidently more severe than substance use alone and may increase the cause of antisocial personality disorder with its risk of misuse. Before anyone can experience substance abuse, they must first present long term regular substance abuse related symptoms. Adolescents have been subjected to negative peer influences due to substance abuse. For the reason of adolescents having limited time to develop full criteria for substance-related disorders, the DSM-IV diagnosis is an appropriate indication of adolescents substance use related psychopathology (Ridenour, Cottler, Robins, Compton, Spitznagel, & Williams, 2002). Precise alcohol or drug symptoms in adolescents have been linked with subsequent increases in antisocial behavior.
In order to study the effects of adolescent alcohol misuse/abuse on antisocial personality disorder and conduct disorder, adolescents must be in a strategically controlled group. The age of conduct disorder onset has been shown to be a powerful indicator of antisocial personality disorder. In particular, prepubescent males presenting conduct disorder from alcohol abuse have difficulty with temperament, dysfunctional family interactions, and social skill deficits (Ridenour, Cottler, Robins, Compton, Spitznagel, & Williams, 2002). Ridenour and his colleagues have reported that these deficits may continue and possibly even worsen over the life course of prepubescent males with conduct disorder and ultimately leading to antisocial personality disorder. In addition, postprepubesent conduct disorder in males is shown to result from negative social and cultural influences that may concern adulthood and males who present adolescent conduct disorder and may be anticipated to later develop antisocial personality disorder. On the contrary, Ridenour and his colleagues have stated that females with conduct disorder, regardless of onset age have shown to resemble to prepubescent males with conduct disorder due to alcohol misuse/abuse. Although there is research that subjects to the continuousness of conduct disorder into young adulthood antisocial personality behavior, the relationship between the two disorders remains problematic. Conduct disorder appears to influence the development of a wide range of adult disorders and personality disorders other than just antisocial personality disorder (Kjelsberg, 2006). A recent report on the association between personality disorders and conduct disorder demonstrated that individuals with personality disorders who met the criteria for antisocial personality disorder co-occurred with borderline personality disorders and showed more personality disorder comorbidity and greater severity of conduct disorder (Bernstein, Cohen, Skodol, Bezirganian, and Brook, 1996). However, it still remains unclear as to what extent the presence of childhood conduct disorder makes a clinical meaningful difference from adult antisocial personality behavior.
The association between childhood conduct disorder and adult antisocial personality disorder has been well documented. Childhood-onset social and behavioral problems form the most relevant psychiatric symptom cluster in relation to adult violent behavior. Despite its relation to other childhood disorders such as, Oppositional Defiant Disorder and Attention Deficit-Hyperactivity Disorder, childhood conduct disorder was the only disorder among many to be associated with the adult antisocial personality disorder (Fergusson, Boden, & Horwood, 2010).
The relationship between childhood conduct disorder and adult antisocial personality disorder is found to be complex for several reasons. The first reason, childhood conduct disorder appears to predispose the development of a wide range adult offender population, and the entire spectrum of personality disorders rather than just antisocial personality disorder. Second, although progression rates from childhood conduct disorder to adult antisocial personality disorder have been estimated to be around fifty percent, variable rates of progression have been currently reported ranging from thirty percent to a high sixty one percent in adolescents with concurrent alcohol abuse problems. Finally, it still remains unclear as to what extent the presence of childhood conduct disorder makes a clinically and meaningful difference with adult antisocial personality disorder (Myers, Stewart, & Brown, 1998).
Past studies have also suggested that individuals only meeting the adult criteria for antisocial personality disorder suffer primarily the same disorder as those meeting both adult and child antisocial personality disorder criteria. This finding is questioned in two relevant studies. Howard, Huband, and Duggan, (2010) reported an association between severe childhood conduct disorder and personality disorder. The study then proposed another recent study which highlighted the role of childhood conduct disorder in adult antisocial behavior, indicating the existence of a clinically and meaningful distinction between antisocial adults with and without childhood conduct disorder (Walters & Knight, 2010). As discussed by these authors, further research on the transition from childhood conduct disorder to adult antisocial personality is recommended in order to distinguish the relationship between the two. Factors other than childhood conduct disorder, including early-onset alcohol abuse are at stack in determining a shift in the developmental course towards antisocial personality disorder.
Another interesting finding on early-onset alcohol abuse and childhood conduct disorder is its significant relevance with attention –deficit hyperactivity disorder. Children with attention-deficit hyperactivity disorder have higher rates of substance use and substance use disorder than healthy controls in longitudinal studies of clinical samples (Brooke, Molina, Oscar, Bukstein, Lynch, 2002). In similar studies, substance use disorder had been strongly associated with the development of childhood conduct disorder. This finding suggests that adolescents with early-onset alcohol abuse in children with attention-deficit hyperactivity disorder may be part of a behavioral pattern of violating social norms for which children with attention-deficit hyperactivity disorder are at a greater risk. Future longitudinal research in nonclinical samples has been found to the most adverse outcomes for children with both attention-deficit hyperactivity disorder and childhood conduct disorder compared with children with either disorder, suggested attention-deficit hyperactivity disorder and childhood conduct disorder comorbidity may convey the highest degree of the early-onset type of substance use disorder (Brooke, Molina, Oscar, Bukstein, & Lynch, 2002).
According to these research findings there are some concerns that arise. One concern suggests how common is attention-deficit hyperactivity disorder among adolescents with substance use problems and is attention-deficit hyperactivity disorder and childhood conduct disorder comorbidity in a clinical sample associated with particularly severe substance use disorder. Persistent research on substance abusing adolescents report that a rough one-third of the population meets diagnostic criteria for attention-deficit hyperactivity disorder. However, the findings are slightly limited because of small sample seizes, difficulty obtaining parental report of attention-deficit hyperactivity disorder, and failure to include females in sufficient number to examine gender-related effects. A present study conducted on Attention-Deficit Hyperactivity Disorder and Conduct Disorder Symptomatology in Adolescents with Alcohol use Disorder, data was collected by using the Pittsburgh Adolescent Alcohol Research Center provided the opportunity to test attention-deficit hyperactivity and conduct disorder comorbidity in adolescents with alcohol use disorder in finding a greater deviance in behavior and substance use (Brooke, Molina, Oscar, & Lynch, 2002).
Previous studies have introduced the idea that individuals who met the criteria for antisocial personality disorder suffer in essence the same disorder as individuals who meet full criteria for conduct disorder. However, the study and results were questioned for the existence of a clinical difference between antisocial individuals with and without childhood conduct disorder (Walters & Knight, 2010). Walters and Knight stated “what we now need is relevant and up to date research on the transition from conduct disorder to antisocial personality disorder in order to clarify a nature of their relationship” (p.267). Even with factors indicating childhood conduct disorder determining the development of antisocial personality disorder the factors still remain unclear. An extreme relevant factor is early-onset alcohol abuse, which demonstrates to have a significant risk for persistent antisocial behavior for heavy alcohol abuse and violence in early childhood and late adulthood (Khalifa, Duggan, Howard, Landsmen, 2012). The co-occurrence between conduct disorder and alcohol abuse in adolescents presents a major problem in attempts to identify their role of adult antisocial with violent behaviors. Some authors have stressed the idea that most children and adolescents with conduct disorder will in fact abuse alcohol. Evidence of this suggests that early-onset alcohol abuse and conduct disorder applies interacting effects on adult antisocialism to become merged into disordered conduct (Loeber, Burke, Lahey, Winters, & Zera, 200). The earlier the age of early-onset alcohol abuse the earlier it is to predict a range of adult behaviors, which includes violent recidivism, aggression, heavy alcohol consumption, and violence in young adulthood.
In a study of 477 young adults at a staggering risk for alcohol abuse, it proved that it is possible to determine a group of individuals who met the Diagnostic and Systematic Manual diagnosis of conduct disorder but not for alcohol dependence (Lumsded, Hadfield, Littler, & Howard, 2005). Although in this study, a group of participants presenting conduct disorder and a group of individuals presenting conduct disorder combined with alcohol dependence including the age in which alcohol abuse initiated, this group demonstrated high levels of longitudinal problems such as, alcohol, drug, and adult antisocial problems. The effect of alcohol dependence in this study was complex because the conduct disorder severity was greater in the group with conduct disorder and alcohol dependence. Nonetheless, the study results were consistent and implied that alcohol abuse may moderate or mediate the relationship between conduct disorder and adult antisocial personality behavior. (Lumsded, Hadfield, Littler, & Howard, 2005).
In order to verify these findings, another study was completed by Howard, Finn, Gallagher, and Jose (2011) to determine any possible mediating or moderating factors of early-onset alcohol abuse using a sample with alcohol abuse and another group with conduct disorder only. The study used regression analysis for covariance between conduct disorder and early-onset alcohol abuse. Results of this study determined that early-onset alcohol abuse and conduct disorder showed significant and independent effects on adult antisocial personality disorder. The study also showed that early-onset alcohol abuse significantly mediated and impaired the effect of conduct disorder (Howard, Finn, Gallagher, and Jose, 2011).
Results from other studies have been thoroughly examined adolescent predictors of adult antisocial outcomes from early-onset alcohol abuse as important risk factors for adult antisocial behavior and violent offending. For example, in the Cambridge Study in Delinquent Development, it was founded that heavy consumption of alcohol by the age of eighteen was one of the most important risk factors that predicted offenders to continue violent and aggressive behavior through and after the age of twenty-one (Howard, Finn, Jose, & Gallagher, 2012). In the Christchurch Health and Development Study, results determined that early-onset alcohol abuse predicted violent offending for age groups of fifteen to twenty one and twenty-one to twenty five, even after controlling background and individual factors such as, childhood conduct disorder (Howard, Finn, Jose, & Gallaher, 2012). In another study, Dunedin Multidisciplinary Health and Development Study, researchers concluded that roughly one-half of male members of the birth cohort (1037 children born in 1972-1973 in Dunedin), who subsequently demonstrated a perverse pattern of life persistence antisocial behavior were dependent of alcohol as early as eighteen years old. (Howard, Finn, Jose, & Gallaher, 2012).
In addition to the above findings, studies have reported that measures of early-onset alcohol abuse such as, age of first drink is associated with high risk factors of delinquency and criminal behavior. In one particular forensic sample of adolescent psychiatric patients, it was proven that the younger age of alcohol abuse was significantly associated with the development of a complex personality disorder characterized by the explosiveness and psychopathic traits derived from early-onset alcohol abuse (Gustavson, Stahlberg, Sjodin, Forsman, Nilsson, & Anckarsater, 2007). In consistence with these studies, early-onset alcohol abuse had been proven to be associated with antisocial personality disorder.
The prospective study aimed to determine whether the results obtained from a community sample by Howard et al. (2011) would be similar to a high risk forensic sample of patients with personality disorders that are incarcerated under high security conditions. Keeping in mind the results from the Howard, Finn, Gallagher, and Jose (2011) case, it is hypothesized that individuals with adult antisocial behavior would show significance early-onset alcohol abuse. The critical comparison would be with the group who only presented conduct disorder alone. Regression analysis would be conducted to test the prediction of early-onset alcohol abuse and conduct disorder that would independently predict antisocial behavior as a possible outcome. Further analysis would be necessary to test whether the effect of conduct disorder an antisocial behavior would be mediated by early-onset alcohol abuse. According to Howards, Finn, Gallagher, and Jose’s study hypothesis, early-onset alcohol abuse is a critical component in mediating the relationship between conduct disorder and antisocial behavior.
Method
Participants for this study were 100 male offenders incarcerated at different levels of security. They were recruited from a high secure psychiatric hospital. All participants were given informed consents to participate in the study. Criteria to participate in the study included; at least one definite DSM-IV personality disorder, a full sale IQ score of 70 or higher, no evidence of any severe chronic mental health illness, no past history of head injury or neurological disorder such as epilepsy. Three groups would be constructed to determine which one would match the hypothesis.
Group one would consist of participants with no early-onset alcohol abuse and no conduct disorder. Participants also could not have a history of DSM-IV alcohol abuse or dependence and no history of conduct disorder. These particular patients would present a lack in history of adolescent alcohol abuse, consuming less than forty units of alcohol per week in a six-month period and a DSM-IV diagnosis of conduct disorder. Group two would consist only participants who have a DSM diagnosis of conduct disorder, including a positive score of three or more of the fifteen conduct disorder items. Participants in this group would also not present a history of alcohol abuse or dependence and no history of adolescent alcohol abuse in consumption of less than forty units of alcohol per week within a six-month period between the ages of ten and twenty. Group three would consist of participants with a DSM diagnosis of conduct disorder, including three or more of the fifteen items, a DSM diagnosis of alcohol dependence/abuse, and a present history of adolescent alcohol abuse consisting of alcohol consumption of forty units per week within a six month period before the age of twenty.
Assessment: Procedure and Instruments
The participants who consented to participate in such study were recruited by analyzing their case files to ensure they met the criteria in terms of IQ score and clinical diagnosis. Additional information such as participants clinical diagnosis using the DSM-IV Axis I and II, reported history of offending, and current psychotropic medications including, antipsychotics and antidepressants, would also be recorded. Participants would then undergo the following assessments.
1. Assessment of Psychopathy. The computerized version of the National Institute of Mental Health Diagnostic Interview Schedule (Robins, Helzer, Cottler, and Goldring, 1989) would be used to determine diagnostic assessments of DSM-IV Axis I and II disorders such as, conduct disorder, attention deficit hyperactive disorder, schizophrenia, bipolar affective disorder, and alcohol abuse/ dependence. The National Institute of Mental Health Diagnostic Interview Schedule would be used due to its adequate diagnostic reliability and validity. DSM-IV personality disorders would be assessed by using the International Personality Disorder Examination (Loranger, Sartorius, Andreoli, Berger, Buchheim, Channabasavanna, & Regier, 1994). The ninety-nine-interview questionnaire is designed to assess the ten DSM-IV Axis II personality disorders and personality disorders not otherwise specified. Individual scores of the test would be scored on a three-point scare, zero meaning absent, one meaning partially absent, and two meaning definitely present. This type of scoring would allow the scores to be derived from individual personality disorders and from personality disorder clusters, cluster A, odd and eccentric, cluster B, dramatic, and cluster C, anxious and avoidant.
2. Assessment of Alcohol use. Information regarding consumption of alcohol would be obtained by detailed alcohol history assessments developed for offenders with mental disorders use. More information would be analyzed from gathering collateral information from case notes, which would be collected from interviewing participants regarding their early alcohol usage. Example questions for this type of interview would be, when did you start to drink alcohol regularly, once or more a month? How old were you when you first got drunk? The goal of this interview would be to gather as much information as possible on how much participants drank in units of alcohol per week across their life span. The amount of units consumed for early alcohol abuse was defined as consumption of forty units or more per week within a six-month period before reaching the age of twenty. Information regarding drug use was not researched due to proving early-onset alcohol abuse as a defining determinate of conduct disorder and antisocial personality disorder.
3. Assessment of Violence. The assessment of violence is meant to focus on the quantity and severity of the violent act committed. The quantity of violence was measured based on the number of violent offenses in the patient’s criminal history that was obtained from case files and self-reports. The severity of violence was measured by using a severity of violence rating scale that has been adapted from the original version developed by Gunn and Robertson, which has been validated in hospitalized psychiatric patients by Wong, Lumsden, Fenton, and Fenwick (1993). This scale is comprised of two subscales for each of the offenses and previous criminal history. Scores are rated on a five-point scale describing the range of severity from zero to four, no violence to severe violence.
The study analysis would be conducted in four stages. In the first stage of the analyses, which would be between groups comparisons would be carried out using one-way ANOVA for continuous variables. The second analysis stage would involve multiple linear regressions to examine relationships between antisocial behaviors, which would be treated as the dependent variable. The third analysis stage would examine the degree of early-onset alcohol abuse contemplated the effect of conduct disorder on antisocial behavior. The final stage of analysis would be used to test the prediction that early-onset alcohol abuse would mediate the relationship between conduct disorder and antisocial behavior. This would suggest the estimated direct and indirect total effects of conduct disorder, independent variable on antisocial behavior, dependent variable, through early-onset alcohol abuse.
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