APSY 651 Final Exam 1 Running Head: APSY 651 Final Exam...APSY 651 Final Exam 4 practice. Responsible professionals will accept comorbidity as a reality and make plans to address the

APSY 651 Final Exam 1

Running Head: APSY 651 Final Exam

Applied Psychology 651 (3-0)

Disorders of Learning and Behaviour

Final Exam

Dianne L. Ballance

University of Calgary

Dr. Brent Macdonald

December 8, 2009


Section 1: Issues of Comorbidity in Child Psychopathology

Issues of comorbidity in child psychopathology are prevalent across the different

childhood disorders. As defined by Mash and Barkley (2003) “comborbidity generally refers to

the manifestation of two or more disorders that co-occur more often than would be expected by

chance alone” (p. 37). As evidenced throughout the text and our class presentations, it is

common for children to exhibit multiple symptoms and disorders. Although challenges with the

definition, study, identification, and treatment surround the issue of comorbidity it clearly exists

within child psychopathology. Considering the prevalence and impact of comorbidity within

children, it necessitates a comprehensive understanding and value on the part of professionals.

Due to the inevitability of encountering comborbidity in future practice as a school psychologist

developing a deeper understanding of its complexities is both practical and constructive. This

discussion will review the concept of comorbidity, issues and challenges, and implications for

practice, including highlights of personal experience, thoughts on the topic, and suggestions for

future personal development and research.

Comorbidity

As mentioned, comorbidity refers to the incidence of co-occurrence of multiple disorders

by children at a time. Mash & Barkley identify the most common co-occurring disorders for

children and adolescents as attention-deficit/ hyperactivity disorder (ADHD) and conduct

disorder (CD), autistic disorder and mental retardation (MR), and childhood depression and

anxiety. Prevalence of comorbidity vary between clinical and community samples,

demonstrating higher rates in clinical samples. Issues with prevalence will be reviewed later in

the discussion; however there is agreement in the field of child psychopathology that

comorbidity is a valid construct. Terms such as ‘co-occurrence’, ‘dual diagnoses’, and


‘covariation’ are often used when discussing comorbidity, and some debate continues into the

definition and nature of true comorbidity.

Clearly our class presentations illustrated incidences of comorbidity. Generalized anxiety

disorder (GAD) reviewed several possible comorbidities including depression, oppositional

defiant disorder (ODD), separation anxiety disorder (SAD), and ADHD. Childhood bipolar

disorder (BPD) illustrated comorbidity with ADHD, CD, anxiety, obsessive compulsive disorder

(OCD), and substance abuse disorders (SAD). The group presenting on communication

disorders highlighted co-occurring diagnoses of other language disorders, ADHD, and various

learning disabilities (LD). Eating disorders were linked with depression, OCD, and personality

disorders. Comorbidities for conduct disorder included ADHD, depression, SAD, and LD.

Information on child maltreatment discussed the relationship of possible outcomes regarding

comorbidity, and the development of symptoms of many possible disorders and diagnoses. The

Mash & Barkley text supports the comorbidities identified during the presentations. The

importance of these examples is that comorbidity is widespread across all disorders with high

rates, which potentially influence our definitions and treatment of disorders. Relationships

between comorbid disorders are not always clear, but will obviously have impact on outcomes

for children. Reflecting on personal experience as a learning support teacher (LST) the concepts

of comorbidity are validated. Research into comorbidity rates and wide variety of potential

concurrent disorders has extended basic concepts built upon this background in special

education. It continues to be a practical challenge in assessment, treatment, evaluation, and

follow-up for meeting the needs of children. Issues associated within one disorder are often

complex to deal with in reality when considering available resources, and levels of understanding

and skills of professionals and families. Comorbidity compounds these issues even further in


practice. Responsible professionals will accept comorbidity as a reality and make plans to

address the unique experience for each child as it will likely change as they move through

different developmental stages.

Evident in the research and class presentations is the perception of comorbidity as a risk

factor for children. The presence of one disorder elevates risk for further disorders, either as a

concurrent disorder or for future disorders, which Mash & Barkley (2003) refer to as

“successive comorbidity” (p. 240). Successive comorbidity suggests overlap between latent

constructs of disorders and also supports the possibility of a developmental progression of

disorders (Mash & Barkley, 2003, p. 318). Knowledge of ‘typical’ comorbid conditions when

addressing a child with a current diagnosis will aid professionals in their assessment and

treatment considerations. Although presentation will be unique for each child, the higher rated

comorbid disorders may be affecting the child currently or potentially in the future. Personal

experience has witnessed poor child outcomes in terms of successive comorbidity from early

behaviour difficulties to later diagnosis of anxiety, and then subsequent substance abuse.

Professionals who value this risk will be prepared to meet children’s ongoing needs. The idea of

prevention can be addressed when disorders commonly lead to earlier onset or prediction of later

comorbid disorders. As research has shown successive comorbidity such as ODD and later CD,

or anxiety and depression, or BPD and SAD, will influence preventative treatment options. As

comorbidity may escalate symptoms it could result in more pernicious outcomes for children,

and every effort on the part of the professional to provide early effective treatment has the

potential to prevent increased severity of symptoms and associated comorbidity.

Comorbidity illustrates the complexities in genetic, environmental, and developmental

processes. Multiple models must be used to examine expression, etiologies, and developmental


pathways of comorbidity. In applying Bronfenbrenner’s ecological systems theory to

comorbidity it becomes apparent the wide variety of mechanisms that need to be considered

when we seek to assess, diagnose, and provide effective treatment for children. Including

information and resources from each level in the system from the individual to the community

will provide professionals a thorough understanding and potentially maximize services.

Collaboration with professionals from the different systems can result in better outcomes for

children (parents, teachers, psychologists, paediatricians, family school liaison workers, etc.),

which has been evidenced in personal experience, and suggested in class as a means of

increasing children’s resilience. How children interact with these influences will affect their

presentation of disorders, which is evident in a transactional theory or approach. In addition,

growth and development of children through developmental pathways will change their

presentation, current risk factors, and possible outcomes. Noted by Mash & Barkley (2003)

young children may present different symptomology than older adolescents within the same

disorder which may affect rates of comorbidity (p. 240, 318). Gender has also been identified as

playing a role in rates of comorbidities. Mash & Barkley (2003) review comorbidity of

depressed children noting that girls have higher rates of anxiety and boys have higher rates of

ADHD and disruptive behaviours (p. 241). Developing further knowledge of how gender and

developmental progression affect comorbidity will be part of future personal professional

growth. An individualized and problem solving approach when working with children with

comorbidity will be fundamental to discovering and attending to these complexities

Issues and Challenges of Comorbidity

Due to the complex nature of comorbidity there are specific challenges that need to be

identified and addressed in professional practice. One of the major challenges is the notion of


‘artifactual comorbidity’ versus ‘true comorbidity’, and how differentiations are made in

practice. Mash & Barkley (2003) repeatedly discuss throughout the text the reasons why

comorbidity may be exaggerated or artificially produced, specifically referring to sampling bias

of clinical situations, confusion surrounding conceptualizations and definitions of disorders, high

overlap of symptoms and criteria between disorders, differing rates for different developmental

stages and progression, and shared causal associations in either genetic or environmental effects.

These issues were repeated during several of the class presentations, mainly focusing on

diagnostic issues, and multifactory etiologies. Research indicates that community samples

provide more accurate rates of comorbidity as clinical samples most often include children with

multiple and more severe disorders. Referrals and resulting treatment are more common for

children with multiple or more severe disorders. In my experience it is often the children with

more complex and severe needs that parents and teachers make repeated referrals and requests

for additional support in resources, throughout their school experience. It becomes difficult to

identify which disorder precipitates the other, the relationship between the disorders, and

identifying underlying causal factors that “trigger the joint display of such symptomology”

(Mash & Barkley, 2003, p. 169). However, it is important to be able to make distinctions

between disorders (e.g. identifying ADHD vs. mood disorders) for best treatment practice. This

process of distinction has been evidenced in personal experience as ongoing assessment

contributes to interventions resulting in clearer determination (e.g. intial diagnosis of ADHD and

Gifted was later distinguished as Asperger’s and Gifted). The value of identifying these issues is

in increasing our professional abilities to draw meaningful conclusions about characteristics of

disorders, potential influences, risk factors, and underlying constructs which may affect


diagnosis and treatment. Accuracy of diagnoses will make direct implications for children

regarding early intervention and appropriate treatment.

A practical challenge of comorbidity addresses children who present with additional

symptomology but do not merit a secondary diagnosis. The question of whether this is a

reflection of assessment, stages of early onset of secondary disorders, influences from the

various systems or developmental pathways, or simply a period of increased symptoms due to

other factors would need to be investigated. This would be an area of interest for future research

in addition to practical methods of addressing children’s needs in this type of situation.

Implications for Practice

Given the complexities and challenges associated with comorbidity psychologists and

other professionals will need to be involved in a collaborative problem solving and treatment

approach. Each stakeholder in the community or team will have different expertise and potential

contributions to meet the diagnosis and ongoing needs of children. Acting as a community

‘partner’ will enhance the effectiveness of this approach. The role of the psychologist will need

to move from an individualized consultant perspective to a systems perspective, where

involvement is part of the larger diverse systems outside the child. One challenge of

collaboration would be timely assessment and treatment. It will be the responsibility of

individuals to develop competent collaboration skills required in this model.

Contributions of psychologists will need to follow the professional code of ethics, utilize

the four pillars of assessment and empirically based strategies for assessment and interventions,

education of stakeholders regarding the value of psychologists contributions, assisting others

when needed with their engagement in the collaborative model, focusing on problem solving

models and professional flexibility. Awareness, knowledge, and understanding the ecologies of


disorders and comorbidity will assist psychologists in becoming proactive in their services.

Developing knowledge of the contributions of other stakeholders would also assist

psychologist’s collaborative efforts, and cross-discipline communication. Challenges of

collaboration and the realities of available time and workloads would need to be addressed

directly for the benefit of children and their families. Ideally through an effective collaborative

model the provision of better services for addressing comorbidity in child psychopathology will

be established.

Connected to the issue of comorbidity is the practice of differential diagnosis, in which

distinctions are made between disorders by comparing signs and symptoms to determine causes

and accurate identification of conditions. Psychologists have the ability to make valuable

contributions to this process. The use of reliable instruments that are able to separate symptoms

in combination with additional proficient assessment methods are valuable tools for

differentiation of disorders. Understanding the links between common comorbid disorders,

potential successive comorbidity, and prognosis of the different comorbidities will provide

insight into differential diagnoses and current services. As evidence shows that some disorder

clusters have poorer prognosis than others, as in the case of Cluster B personality disorder

comorbidity mentioned by Mash & Barkley (2003), it will likely increase risk factors for

children (p. 707. In some cases increased reliability in diagnoses and early intervention will

reduce rates of comorbidity, which has been noted in MR and autism comorbidity in recent

years. Collaborative treatment may contribute to differential diagnosis in some instances where

medication and psychotherapy influence symptoms and resulting diagnoses and treatment.

Differential diagnosis will provide psychologists with meaningful information that can be used in

the collaborative framework.


Reflecting upon almost ten years in the field of special education there are many practical

limitations and challenges to the theoretical implementation of meeting the needs of children

with comorbid disorders in the school environment. Issues of funding, available resources, skills

of teachers, lack of understanding and knowledge regarding disorders and treatment, time for

meetings and planning for intervention, willing participation of stakeholders and professionals,

complex student demographics in classrooms, resistance to change, duties outside the classroom

that affect levels of involvement, plus many other additional challenges in the educational

environment. A particular challenge in special education is adequately addressing children’s

complex needs through the Individual Program Plan and resulting interventions. Choosing the

priority needs that can realistically be met through current presentation, and available resources

and personnel can be a difficult process. Often as professionals we have to balance between

global and realistic goals. Children with comorbidities with even higher levels of complexity

will amplify this challenge. Experience as a LST provided many opportunities to act as an

advocate for children in multiple situations and with different professionals. Advocating from

the beginning stages of referral, through in-depth assessments, diagnosis, and implementation of

treatment, promoted increased knowledge and understanding of children’s conditions resulting in

improved collaboration and consistency of service. Obvious benefits come from ongoing

involvement with individual children as well as in the system level. Continued involvement is

especially relevant for comorbidity due to its dynamic complex nature. Integral to supporting

children with comorbidities is keeping current with new theories and approaches through

research and personal professional development. Perhaps one of the largest barriers among these

challenges is the traditional role of the psychologist that limits services to assessment and

recommendations. Children that have the complexities associated with comorbidity require


additional resources and ongoing support. Potentially psychologists may be able to provide

many of those services when they are advocated for and supported at the system level.

Conclusion

Mash & Barkley discuss the importance of studying and understanding comorbidity as

“essential to understanding the underlying risk factors, the relationships among ... symptoms, the

developmental continuities and discontinuities, and the validity of ... syndromes themselves” (p.

315). The result is an increased ability to draw meaningful conclusions for diagnosis and

treatment. Considering the high rates of comorbidity, developing a comprehensive

understanding is one of the components in providing competent school psychology services.

Knowlege of comorbidities can guide assessment and practice, however, the awareness of the

multiple etiologies, systems and pathways need to be considered to allow for ongoing

transformation. Research can guide the practice of psychology, and professionals can prevent its

potential limitations by participating in collaboration and a problem solving approach.

Regardless of diagnosis and comorbidity, children can benefit from support and

interventions to address their current symptoms and presentation. Psychologists can potentially

be involved in all the stages in addressing children’s needs, providing ongoing service and

collaboration including prior to diagnoses.

It will be an ongoing process to combine and consolidate personal experience as an LST

and new learning’s within the School and Applied Psychology program. Being at the beginning

of the program there will be many upcoming opportunities to build the knowledge base,

assessment skills, specific psychological interventions and services, that are required to

implement the concepts discussed in this paper in the role of school psychologist. Experience in

class and personal research has consolidated and enhanced previous thoughts of the issues and


challenges of comorbidity from a basic level to developing a deeper understanding and

appreciation of its complexities. Future practice will optimally bring the skills and knowledge

from the background in special education to enhance school psychology services.


Section II: Conduct and Oppositional Defiant Disorders and Substance Use Disorders

Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), and Substance Use

Disorders (SUD) are of interest when considering prevalence, comorbidity, associated risks,

potential pernicious outcomes for children, and societal concerns, that have significance for

research and implications for psychological services. These disorders will likely be encountered

in future practice either independently or concurrently, and often are associated with

considerable debate and attention, as witnessed through our class presentations, discussion board,

and personal experience. A recent reduction in local funding has affected the general

acknowledgement and resources for these disorders and deficits in both these areas will result in

challenges for individuals, families, and the larger community. Developing an understanding of

the critical issues will hopefully lead to skills in advocating for services and meeting the needs of

children with these disorders. This discussion will examine diagnostic challenges, critical issues,

roles of gender, and associated risk factors.

Conduct and Oppositional Defiance Disorders

Conduct Disorder and Oppositional Defiance Disorders are disorders of behaviour in

children and adolescents. The Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-

TR] by the American Psychiatric Association (2000) identifies the essential feature of CD as “a

repetitive and persistent pattern of behaviour in which the basic rights of others or major age-

appropriate societal norms or rules are violated” (p.93). Conduct Disorder includes serious overt

and covert antisocial behaviours that result in personal and social impairment for children and

adolescents (Mash and Barkley, 2003, p. 152). The DSM-IV-TR (2000) reviews descriptive

features of CD that include little empathy and concern for the well-being of others,

misperceptions of the intentions of others as hostile and threatening, callousness and lack of guilt


or remorse, tendency to blame others, self-esteem issues, low frustration tolerance, irritability,

temper outbursts, recklessness, participation in illegal activities, early onset of sexual behaviour,

low academic achievement, and the possibility of low intelligence (verbal IQ). A distinguishing

feature for CD is that the aggressive and antisocial actions are not normative during childhood.

The essential feature for ODD identified by the DSM-IV-TR (2000) is “a recurrent pattern of

negativistic, defiant, disobedient, and hostile behaviour toward authority figures” (p. 100).

Common features include problematic temperament, high motor activity, low self-esteem or

overly inflated self-esteem, mood lability, low frustration tolerance, conflicts with others, and the

use of alcohol or drugs. Behaviours associated with ODD are considered normative during

childhood; the distinguishing factor is the severity and frequency compared to age and sex

norms. As evidenced, there is high behaviour overlap among CD and ODD that may potentially

relate to shared diagnostic models, etiologies, and risk factors.

Diagnostic Challenges

Common definition and diagnostic challenges that exist for most disorders as evidenced

throughout the text and our class presentation are evident in ODD/CD, given the scope of this

paper they will not be reviewed, and only relevant unique challenges will be included. ODD/CD

criteria are descriptions of behaviours, which do not adequately describe the psychological

features that identify risk or psychopathology in children. Research into affective or

interpersonal traits (e.g. ‘callous’ and ‘unemotional’) is at the beginning stages, but holds

promise for validation of diagnoses. The criteria including age of onset subtypes creates two

subgroups of children with different levels of risk, profiles, and persistence. An understanding

of the subtypes is necessary for understanding, predicting, and treating children with ODD/CD.

The heterogenic nature (variety of ways aggression is expressed) of ODD/CD contributes to


difficulties in classifying subcategories and precise definitions. Professionals in the field also

question the validity of ODD as a diagnostic category citing difficulties with the constraints of

classification, overmedicalization, and inclusionary symptoms that exist within normal

development. A problem with the current definition is conceptualizing ODD/CD as solely

intraindividual that results in individual treatment decisions, which possibly ignore systemic

prevention and treatment strategies. Understanding the larger context in which ODD/CD occurs

will provide meaningful information for diagnosis and treatment.

Critical Issues

Controversy and debate regarding the theoretical conceptualizations of ODD/CD exists

within the field. Mash & Barkley (2003) discuss the multiple causal pathways in etiology and

developmental diversity, and heterogeneity of behaviours, mechanisms, and risk variables that

result in complexity of the issues surrounding ODD/CD.

In particular the overlap of behavioural patterns of Attention-Deficit/Hyperactivity

Disorder (ADHD) and high rate of comorbidity between ODD/CD and ADHD has implications

for etiology, diagnosis, treatment considerations, and validity of these behavioural categories.

Children with both ODD/CD and ADHD display a more pernicious form of psychopathology,

earlier onset of ODD/CD, and negative outcomes later in life. This comorbidity results in

stronger predictors of escalation and persistence of ODD/CD than when occurring alone.

The issue of developmental progressions is associated with ODD/CD outcomes.

Research shows relative stability in antisocial behaviour over time, though the patterns and

expressions of the behaviour change with development. Study of these patterns may contribute

to prediction and prevention. Further details of these pathways will not be discussed in

consideration of the constraints of the paper, however, Mash & Barkley (2003) noted two key


concepts; 1) pathways expand into multiple trajectories over time for many children with

ODD/CD, and 2) the trajectory of ODD to CD has relatively low predictive power as most

children with ODD do not later on develop CD diagnosis (although very high rates of children

with CD previously met ODD criteria). In these situations ODD may “signify an extreme of

normal development variation, linked with important triggering factors...transitory in nature, and

not portending escalation to a ‘toxic’ course” (p. 162). Research into the protective factors will

provide professionals valuable knowledge for prevention, early intervention, and treatment.

Role of Gender

The majority of research has pertained largely to males with ODD/CD, and only recently

has there been more focused attention on female manifestation of this disorder. The study of

gender differences discussed by Mash & Barkley (2003) provides an in-depth discussion of

which only the key points will be summarized.

Rates of ODD/CD are similar for boys and girls in early childhood, however by preschool

years males typically predominate, and by adolescence girls demonstrate a rise in rates and the

ratio becomes closer to even for both genders. The type of aggression tends to be different,

where boys typically manifest in direct physical and verbal aggression, and girls more often

present with indirect aggression or relational aggression. Theories of socialization have been

presented to explain these different expressions, noting that from early development girls

intraindividual processes (play styles, levels of activity, cognitive and emotion-regulation

capacities, etc.) combine with socialization patterns that promote internalizing expressions of

aggression. Boys early development typically includes different processes (more physical and

active involving greater risks) which may result in boys missing the socialization processes

regarding norms and aggression. Due to the nature of how girls express aggression it may have


lead to underestimates of prevalence. Of particular concern for girls is the rise in adolescence

presentation, and higher rates of comorbidity, resulting in significant mental health problems that

may not be addressed individually or at a system level. Controversy regarding additional

symptom presentation in girls continues that might contribute to future indicators continue (e.g.

somatisation, sexual promiscuity, substance use/abuse).

Different developmental trajectories have also been suggested for each gender. Studies

currently demonstrate that boys outnumber girls for early onset of the disorders and risk factors.

As girls enter adolescence their presentation of covert and externalizing symptoms increases with

a peak of physical aggression in early adolescence, which indicates a particular period of risk

(boys’ peak age is at the end of adolescence). Some reliability has been shown that early

physiological development and maturation interactions with environmental risks may represent a

generative mechanism for behaviour problems. Predictive relationships for girls with ODD/CD,

and examination of girls with externalizing aggression are areas that require further study. As

research is relatively new, developing practical applications of pathways is somewhat limited.

Risk Factors

Multiple risk factors exist for ODD/CD ranging from intraindividual to systems

mechanisms. Intraindividual factors include; comorbid disorders of ADHD, low achievement or

Learning Disabilities, other internalizing disorders (depression, anxiety), genetic influences

(temperament, neuropsychological, and neurophysiological factors), cognitive processing, and

patterns of emotion dysregulation. Familial factors identified as increasing risk consist of

parental psychopathology (parental Antisocial Personality Disorder [ASPD], substance use

disorders, and depression), family structure and conflict (single-parents, large family size,

divorce, young age of mothers), parents with low levels of education, poor supervision, harsh


and inconsistent parenting styles, insecure parent attachment and high conflict parent-child

interactions, family socialization of aggression, and abuse. These family risk factors are often

associated with other risk factors, which contributes to the complex nature of influences. Peer

rejection and association with antisocial peer groups are related to the development of aggression

in different ways for different subgroups of children with ODD/CD. Peer rejection is strongly

related to early onset, and peer antisocial association is related to later-onset; however, both

processes are noted to have multiple levels and transactional influence.

Low levels of socioeconomic status (SES) and its associated risks (impoverishment, high

crime rates, family crowding, multiple family transitions, unemployment, school-based violence

etc.) are indentified risks for ODD/CD. Research links the developmental pathways and

propensity of life course persistence of these disorders to the constellation of socioeconomic in

combination with other risk factors. Poverty and low social support in socioeconomic

disadvantage “propel the continuation, intensification, and chronicity of early aggressive

behaviour patterns into later childhood and adolescence” (Mash & Barkley, 2003, p. 165).

Components of low SES operate in a transactional manner which influences levels of current

risk. Particularly interesting is the potential influence of interactive and protective factors (e.g.

positive family variables) to reduce risk and effects of low SES environments. No one risk

factor may be identified as the sole causal mechanism, as emphasized by Mash & Barkley (2003)

“combinations of risk factors, interacting and transacting in chain-like fashion, are crucial for the

development of persistent aggression and ASB” (p. 170).

Substance Use Disorders

Substance Use Disorders (SUD) refer to Substance Dependence and Substance Abuse

disorders, and are related to the maladaptive use of alcohol and other drugs (Mash & Barkley,


2000, p. 200). Both disorders include a pattern of substance use that leads to significant

impairment or distress. The DSM-IV-TR (2000) provides the following features of Substance

Dependence; repeated self-administration, tolerance, withdrawal, and compulsive use that may

include physiological dependence. Those with Substance Dependence may take the substances

in larger amounts or over longer periods of time, and the individual’s failure to abstain from

using the substance despite evidence of the difficulties it is causing. Features of Substance Abuse

include recurrent and significant adverse consequences related to the repeated use of substances,

with failure to fulfill major role obligations, use in physically hazardous situations, multiple legal

problems, and recurrent social and interpersonal problems. Individuals with Substance Abuse

will repeatedly demonstrate intoxication or other substance related symptoms, absences, and

continued use despite the persistent negative consequences. An important feature of SUD is it’s

heterogeneity that results in different possible trajectories. For the purpose of this discussion the

broader term of SUD will be used in accordance with how information is referenced for both

disorders by Mash & Barkley (2003).

Diagnostic Challenges

Unique diagnostic challenges for SUD are summarized. Research suggests the separate

diagnosis of Substance Dependence and Substance Abuse does not adequately reflect the nature

of substance use problems in adolescence, noting that the concept and definition vary across the

different systems when applied to adolescents. The type and pattern of adolescent

symptomology is not reflected by the current adult criteria. Additionally seen in adolescents with

SUD are affective symptoms, blackouts, reduced activity levels, cravings, risky sexual

behaviour, poor academic achievement, engagement in delinquent behaviours or deviant peer

group, and frequent negative interactions with peers. There is variability in how teens


experience physiological dependence and the symptoms are demonstrated in different situations.

As research in the field progresses in identifying unique features of adolescents’ modifications to

the diagnostic criteria and classification system may result.

Critical Issues

Some substance use is normative within the adolescent years; however, it involves many

possible adverse outcomes and consequences for both individuals and communities. SUD

increases the risk and level of severity of these consequences with long-term impact. Mash &

Barkley (2003) discuss SUD consequences; impaired driving, mortality, morbidity, impaired

developmental competence and psychosocial functioning, and polydrug use. The ramifications of

these consequences and outcomes are a critical issue for individual and public health concern.

Societal conceptualizations and attitudes of SUD will shape resulting legislation, prevention

programs, and treatment options. Professionals may examine additional issues resulting from

research to contribute to understanding SUD, as they are not included in the scope of this paper.

Comorbidity of SUD and other disorders is a critical issue in understanding the complex

connections and consistency of patterns. Most commonly SUD is comorbid with ADHD,

ODD/CD, and to a lesser degree mood and anxiety disorders. Connections of SUD and ADHD

are controversial when considering the concurrent presence of OD/CDD. Given the high rate of

comorbidity, SUD may be considered a manifestation resulting from behavioural problems.

‘Self-medicating’ is often referred to in this situation, and will present different treatment

considerations that affect a wide range of health providers and collaboration of services.

Developmental progression is discussed by Mash & Barkley (2003) “substance use and

substance use disorders show systematic age-related patterns from adolescence into adulthood”

(p. 207). As substance use typically begins in adolescence, some use is identified as statistically


normative, with the majority of adolescents demonstrating benign outcomes. Early onset is

linked with increased chance of developing SUD, with patterns of steep escalation and more

pernicious outcomes. Late onset has been linked to decreased parental supervision experienced

in late adolescence. Research identifies peak use and diagnosis of SUD at the stage of

“emerging adulthood” (Mash & Barkley, 2003, p. 208), yet prevention programs are targeted for

earlier stages of development. This gap may indicate an area for future research and

development. The protective factor of transitioning into adult roles is noted, citing reduced rates

of use and SUD during that stage of development. SUD is not necessarily a persistent life

disorder, although efforts in treatment to address use and relapse are necessary.

Role of Gender

Examination of gender provides further insights into SUD. Noted by Mash & Barkley

(2003) generally girls tend to use fewer drugs on a less frequent basis at the higher grades, while

at younger grades there are similar rates (p. 205). Prevalence may be affected by developmental

processes during adolescence. Males are reported to have higher use of heroin, LSD, steroids,

tobacco, and daily use of alcohol and marijuana; while girls show higher rates of inhalants,

tranquilizers, and amphetamines. Investigation to the motives behind drug choice (use)

demonstrates that males and females use drugs for different reasons; social and mood

enhancement for males and coping and conformity for females. A noted difference occurs at

older ages when females report higher use of tobacco for regulation of weight and anxiety.

Different motives will need to be addressed in prevention and treatment programs at all levels.

Risk Factors

Risk factors for SUD are identified within a range of levels. Due to the heterogenic

nature of SUD, multiple mechanisms likely contribute to the condition. Much of the research


into risk factors is completed for substance use, but it is suggested that similar effects exist for

SUD. Mash & Barkley (2003) review three submodels to explain vulnerability that include

specific risk factors. In depth details of the models will not be discussed given the scope of the

paper, but a brief review of the associated risks is summarized; temperament and personality

(poor self-regulation, low self-esteem, impulsivity, aggression, neurochemical and

neuroendicrine responses, ‘heritability’), cognitive functioning (low executive functioning),

parenting and socialization (history of use/abuse, style, support, monitoring, conflicts,

socialization of drugs), school failure and academic aspirations (increase stress and negative

attachment, weaken school attachment), peer influences (deviant peer groups, peer selection and

influence), childhood conduct problems, environmental stress, emotional distress or negative

affect, alcohol (drug) expectancies and pharmacological effects, and macro-level influences of

school and neighbourhoods (social norms, drug access, sanctions/punishments). Of note is the

concept of ‘intergenerational transmission’ of risk which involves multiple interrelated

biophysical pathways interacting with the consequences of SUD and environments. More

research into the effects of SES as a risk factor is needed due to differing results; however, SUD

is present among all levels of SES. Any of the factors identified may play a role in increased risk

or potential protective factors, and the interplay between factors are not exclusive. A complex

transactional process occurs within the multiple levels of mechanisms. Prevention and treatment

programs can be applied to these multi-layers to increase positive outcomes of SUD.

Critical Comparison of Disorders

Many commonalities exist between ODD/CD and SUD, as might be expected as they are

all disorders of behaviour with a high rate of comorbidity between the disorders. The


heterogenic nature of the group of disorders contributes both to the similarities as well as salient

differences.

Examination of diagnostic features illustrates a few similarities among all three disorders

that exist which include; low self-esteem, low frustration tolerance, reckless behaviour, and

illegal activity. Both ODD and SUD involve symptoms of normative behaviour that are

demonstrated with either higher severity or frequency in comparison to age norms. Distinctive

features between the disorders provide clarification and greater detail for diagnosis. Of note in

this regard are pharmalogical effects and physiological symptoms for Substance Dependence

Disorder, alcohol or drug use as an inclusionary criteria for ODD, various forms of aggression

for ODD/CD, hostile and negativistic symptoms for ODD/CD, the concept of role obligations in

SUD, and ODD recognized in children are key differences.

Critical issues provide insight into some of the shared concerns surrounding the disorders.

ODD/CD and SUD have high comorbid rates with ADHD, and to a lesser extent mood and

anxiety disorders. Age of onset (early) and comorbidity are related to more pernicious outcomes,

gender results in different expressions, and multiple risk factors are common within these

disorders. Rather than a review of the majority of risk factors, perhaps clearer insight is

provided by what differentiates the disorders in these issues. Genetic vulnerability is more

widely accepted in SUD, ODD/CD show more relative stability, family structure and low SES

are not identified as risk factors for SUD, and SUD has higher involvement with system level

prevention and treatment programs. Regardless of similarities and differences, ODD/CD and

SUD are heterogeneous in nature and involve transactional processes of multiple level factors,

pathways, variables, and mechanisms. Simple explanations or conceptualizations will not lead to

a deeper appreciation or understanding of the disorders or implications for practice.


Conclusion

In general terms ODD/CD and SUD result in personal impairment on many levels (social,

academic, etc.), with violation of social norms that impact communities and result in high levels

of social concern. Public interpretations of children and adolescents with these disorders

(accurate or not) result in significant ramifications for the individuals associated with the ‘labels’

and system level prevention and treatment programs. Professionals may use research and

knowledge of the disorders, and practical experience to advocate for these children and services.

.


References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders, Fourth Edition, Text Revision. Washington, DC. American Psychiatric

Association.

Mash, E. J., Barkley, R. A. (2003). Child Psychopathology (2nd

ed.). New York, NY: The

Guilford Press.

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