The Conduct Disorder–Alcohol Link: Implications for Prevention Strategies

Abstract

To the Editor.—According to recent articles in Pediatrics, underage drinking poses enormous challenges to health care systems.1,2 Alcohol use in youth also contributes to school truancy, getting into fights, carrying weapons, using illicit drugs, and engaging in suicidal and risky sexual behaviors.1,2 Most tragically, underage drinking leads to nearly 5000 deaths per year. Alcohol-related mortality in this population is primarily attributable to motor vehicle crashes, homicides, suicides, falls, burns, and drowning.1The adverse consequences of underage drinking underlie the importance of preventing early alcohol use. In the United States, initial efforts to curtail this problem have focused on school-based programs. Drug Abuse Resistance Education (DARE) was intended to increase the awareness of alcohol's harmful effects and teach children strategies for resisting peer pressure.3 Although school-based programs have been widely implemented, their effectiveness has been called into question.3Additional strategies for limiting underage drinking include population-based measures that limit youth access to alcohol, such as enforcing minimum legal drinking age laws and restricting alcohol advertising.3 Overall, these preventive measures have been universal in scope and targeted the general adolescent population. However, this “one-size-fits-all” approach is yet to exert a demonstrable impact on youth alcohol consumption. Hence, the question of whether a primary prevention model by which interventions that target modifiable risk factors in high-risk populations can be applied to alcohol prevention is of interest.Among adolescents, a history of conduct disorder (CD) (lying, aggression, serious violation of rules) is one of the strongest risk factors for early drinking.4 Efforts to understand this relationship indicate that symptoms of CD significantly correlate with early onset of first drink as well as a rapid progression from first drink to the development of alcohol use disorders.4 Although the prognostic implications of this comorbidity have received considerable attention, the potential utility of averting CD as an alcohol-prevention strategy has been largely overlooked. The lack of emphasis on this key risk factor may reflect underlying views of CD as intractable. However, evidence that early-stage CD is responsive to parent training5 challenges the wisdom of this clinical lore and offers opportunities for novel interventions in the alcohol-prevention field.