Indian Journal of Health Social Work
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AGGRESSION AND SUBSTANCE USE DISORDER IN ADOLESCENTS: IN CHANGING ERA
Arzu Ahlawat1, Kavya Ahuja2, Prashant Srivastava3
1Bachelor’s in Psychology, Lady Shri Ram College for Women, Delhi University, Delhi. 2M.Sc Clinical Psychology Scholar, Amity University, Gurugram, Haryana. 3Psychiatric Social Worker, Dept. of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, Haryana. Correspondence: Prashant Srivastava, e-mail: 21prashantsrivastava@gmail.com
ABSTRACT
Background:Aggression is a word used daily to characterise the behaviour of others and perhaps even of ourselves. Aggression as behaviour is intended to harm another individual who does not wish to be harmed. With an ever growing population, aggression is one of the major issues faced by many youngsters these days. This vigoursly attributes towards teenagers’ consumptions of drugs leading to aggressive behaviour and to control it as well.
Aim:
To know the association between aggression and substance use disorder.
Conclusion:
Substance involvement is a critical factor in the assessment and treatment of youth aggression. Despite high levels of need, adolescents with aggression and comorbid substance use tend to be underserved. Several interventions have been developed that are effective in reducing aggressive, delinquent behaviors and substance use. Treatment is most likely to be effective when it addresses dysfunction and risk factors across multiple domains (e.g., individual, family, school, peer systems).
Keywords: Voilence, substance, adolescents
INTRODUCTION
Adolescence as we all know is a traditional stage of physical and psychological development that generally occurs during the period from puberty to adulthood. Adolescence is usually associated with the teenage years but can prolong until depending on each of the person’s psychological development. During the transformative teenage years, psychological changes affect a child and shape them in a different manner therefore, adoles cent maturat ion is a personal phase of development where a child has to establish his/her own beliefs, values and what needs to be accomplished in life. The phase of adolescence constantly and realistically appraise the kids with material happiness around often leading to being extremely self-conscious. However, self-evaluation process leads to the beginning of long-range goal setting, emotional and social independence and the making of a mature adult. Adolescence as a phase of life marked by chaos and distress. During this period of life adolescents are not just prone to high risk anti-social activities but they also experience stress and high levels of negative emotions due to biological changes that occur during puberty (Gottfredson & Hirschi, 1990). Various studies have provided evidence that adolescent phase of life is marked by hassles, negative emotions and heightened anguish (Agnew & Brezina, 1997; Compass & Wanger, 1991). Aggression is a term widely used in the literature on problem behaviour, but it is rarely defined and it is often not distinguished from “anti -social behaviour ”. The word “aggression” covers a multitude of behaviours from open defiance and hostility to covert anti-social acts such as stealing or lying. Lewis defines human “aggression” as “behaviours by one person intended to cause physical pain, damage or destruction to another” (Lewis, 1996). Other writers have expanded the concept to include “instrumental aggression” which is aimed at securing extraneous rewards, not the pain of the victim, while others stil l have used the term “hostile aggression” to encompass the aim of inflicting injury on others. Bandura (1973) makes the point that such distinctions are misleading as most aggression has some other goal than injury to the victim. He defines “aggression” as “behaviour that results in personal injury and in the destruction of property”. The injury may be psychological or physical in nature. Aggression as purely physical with acts involving hitting or pushing, psychological aggression can also be very damaging. Addi tionall y, aggression can heavi ly be influenced by factors biological, environmental and/or social factors.
MOTIVATION THEORY IN AGGRESSION
Inspiration speculations of animosity state that hostility is a human intuition. That is, motivation theories see aggression as part of human nature. People are motivated to be aggressive because it’s just part of thier personality. There are many different types of motivation theories . The e volutionary theory of aggression says that aggression is a human instinct because it makes sure that we get the resources we need to survive into adulthood and pass on our genetic material. That is, the aggressive people survive, and their children are aggressive like they are, and so on through generations. Another motivational theory is Sigmund Freud’s psychoanalytic theory of aggression, which says that aggression is a human instinct related to our dre ad of death. Thus , aggression is part of our dealing with (or not dealing with) our own mortality.
SUBSTANCE USE DISORDER (SUD) AND AGGRESSION
Early substance use initiation is a serious concern because it is associated with significantly increased risks for developing substance use disorders (King & Chassin, 2007). Substance-involved youth are also likely to become involved in the mental health system, and the majority meet criteria for another Axis I disorder (Deas, 2006). There are multiple pathways through which cooccurrence may develop. Some disorders, including mood and conduct disorders, are associated with increased SUD risk (Armstrong & Costello, 2002). Alternatively, SUDs, especially with early onset, may increase the risk of other psychiatric conditions (Armstrong & Costello, 2002; Lamps, Sood, & Sood, 2008).
DRUGS USE AND AGGRESSION
Drugs use can change a person’s physical or mental state, with a vast majority being used to treat medical conditions. Some however are used outside the medical setting for their effects on the mind. These are referred to as recreational drugs. Psychoactive drugs have an effect on the cognitive thought process of an individual, which in turn may manifest into a range of behaviours. These drugs may be taken for fun, excitement, to feel good, better or different, or to combat negative feelings. Some teenagers may be bored or curious, because their friends and family are involved in it or because they have a dependence on the drug. Over a period of time, alcohol and drugs have been l inked to anger and aggression. Stimulants, anabolic steroids, marijuana and other drugs have either been used to get rid of uncomfortable emotional states or have been impl icated in the precipitation of anger and aggression. Moodaltering substances impair perception through their ability to regulate neurotransmitters’ levels. Amongst teenagers, it has become customary to use drugs to suppress their emotions of frustration or isolation which they are unable to elucidate. Some of the common drugs which are used illegally are cannabinoids, with marijuana being used most. These drugs not only have effects in relaxation, but also cause slowed reaction time. Let’s get “mellow” and “let’s chill out” are subjective terms used to describe the cannabis experience. Many marijuana consumers use this drug to reduce levels of anger and anxiety. This in turn, for many teenagers, is helpful in overcoming their problems and not become impatient giving a soothing effect to the mental state. On the other hand, the main class of drug that should be suspected in causing aggressive behaviour are stimulants such as cocaine, amphetamine, methamphetamine and synthetics nicknamed “bath salts” and “spice”. They all cause a person to feel energetic and euphoric. One of the major downsides of these drugs is that they cause paranoia, aggression and even delusional behaviour leading to a criminal behaviour sometimes. Such drugs if used frequently can cause major damage to the body and brain and particularly during the age of development, it might cause addiction and severe behavioural problems amongs t teenagers. Often during teenage years, to vanquish their problems like disturbance of emotions or aggression, they tend to consume drugs like hallucinogens in which their thought process and make them believe what they see are real Anabolic steroids also cause rage and aggress ion, as wel l as mania and delusional behaviour. Such steroids are usually swallowed or injected to the body which can cause premature stoppage of growth, high blood pressure and many other af ter ef fe ct s to the body a nd mind. Consumption of steroids can get teenagers into physical fights with others or commit aggressive crimes. Consumption of these drugs leads a teenager during their development age into factors like:
1. Withdrawal from their decisions or activities which they would prefer to do;
2.Avoidance having the fear to face problems, running away from daily life situations;
3.Attack self-turning for impulsive behaviour such as cutting, burning, sexual angst and aggression;
4.Attack others in order to overcome their aggression and stressful situation which might intend to hurt others or put others to enhance their self-image.
Hence, as stated above how consumption of drugs is affecting the aggression levels specially amongst teenagers which is turning out on their development stages and also affecting their brain cells which increases chances of irrational thoughts, mood swings, irritability and being paranoid. Drugs majorly contribute to aggressive behaviour as it causes high blood pressure or rapid shift in emotions. Not all drugs have the same effect, some might lower the rates of aggression but in most cases, it leads to increase in violent or aggressive behaviour. Aggression nowadays has become very common amongst teenagers and the reason falling in for drugs is as it creates the means for teenagers to escape from reality and live in their own bubble.
Inspiration speculations of animosity state that hostility is a human intuition. That is, motivation theories see aggression as part of human nature. People are motivated to be aggressive because it’s just part of thier personality. There are many different types of motivation theories . The e volutionary theory of aggression says that aggression is a human instinct because it makes sure that we get the resources we need to survive into adulthood and pass on our genetic material. That is, the aggressive people survive, and their children are aggressive like they are, and so on through generations. Another motivational theory is Sigmund Freud’s psychoanalytic theory of aggression, which says that aggression is a human instinct related to our dre ad of death. Thus , aggression is part of our dealing with (or not dealing with) our own mortality.
SUBSTANCE USE DISORDER (SUD) AND AGGRESSION
Early substance use initiation is a serious concern because it is associated with significantly increased risks for developing substance use disorders (King & Chassin, 2007). Substance-involved youth are also likely to become involved in the mental health system, and the majority meet criteria for another Axis I disorder (Deas, 2006). There are multiple pathways through which cooccurrence may develop. Some disorders, including mood and conduct disorders, are associated with increased SUD risk (Armstrong & Costello, 2002). Alternatively, SUDs, especially with early onset, may increase the risk of other psychiatric conditions (Armstrong & Costello, 2002; Lamps, Sood, & Sood, 2008).
DRUGS USE AND AGGRESSION
Drugs use can change a person’s physical or mental state, with a vast majority being used to treat medical conditions. Some however are used outside the medical setting for their effects on the mind. These are referred to as recreational drugs. Psychoactive drugs have an effect on the cognitive thought process of an individual, which in turn may manifest into a range of behaviours. These drugs may be taken for fun, excitement, to feel good, better or different, or to combat negative feelings. Some teenagers may be bored or curious, because their friends and family are involved in it or because they have a dependence on the drug. Over a period of time, alcohol and drugs have been l inked to anger and aggression. Stimulants, anabolic steroids, marijuana and other drugs have either been used to get rid of uncomfortable emotional states or have been impl icated in the precipitation of anger and aggression. Moodaltering substances impair perception through their ability to regulate neurotransmitters’ levels. Amongst teenagers, it has become customary to use drugs to suppress their emotions of frustration or isolation which they are unable to elucidate. Some of the common drugs which are used illegally are cannabinoids, with marijuana being used most. These drugs not only have effects in relaxation, but also cause slowed reaction time. Let’s get “mellow” and “let’s chill out” are subjective terms used to describe the cannabis experience. Many marijuana consumers use this drug to reduce levels of anger and anxiety. This in turn, for many teenagers, is helpful in overcoming their problems and not become impatient giving a soothing effect to the mental state. On the other hand, the main class of drug that should be suspected in causing aggressive behaviour are stimulants such as cocaine, amphetamine, methamphetamine and synthetics nicknamed “bath salts” and “spice”. They all cause a person to feel energetic and euphoric. One of the major downsides of these drugs is that they cause paranoia, aggression and even delusional behaviour leading to a criminal behaviour sometimes. Such drugs if used frequently can cause major damage to the body and brain and particularly during the age of development, it might cause addiction and severe behavioural problems amongs t teenagers. Often during teenage years, to vanquish their problems like disturbance of emotions or aggression, they tend to consume drugs like hallucinogens in which their thought process and make them believe what they see are real Anabolic steroids also cause rage and aggress ion, as wel l as mania and delusional behaviour. Such steroids are usually swallowed or injected to the body which can cause premature stoppage of growth, high blood pressure and many other af ter ef fe ct s to the body a nd mind. Consumption of steroids can get teenagers into physical fights with others or commit aggressive crimes. Consumption of these drugs leads a teenager during their development age into factors like:
1. Withdrawal from their decisions or activities which they would prefer to do;
2.Avoidance having the fear to face problems, running away from daily life situations;
3.Attack self-turning for impulsive behaviour such as cutting, burning, sexual angst and aggression;
4.Attack others in order to overcome their aggression and stressful situation which might intend to hurt others or put others to enhance their self-image.
Hence, as stated above how consumption of drugs is affecting the aggression levels specially amongst teenagers which is turning out on their development stages and also affecting their brain cells which increases chances of irrational thoughts, mood swings, irritability and being paranoid. Drugs majorly contribute to aggressive behaviour as it causes high blood pressure or rapid shift in emotions. Not all drugs have the same effect, some might lower the rates of aggression but in most cases, it leads to increase in violent or aggressive behaviour. Aggression nowadays has become very common amongst teenagers and the reason falling in for drugs is as it creates the means for teenagers to escape from reality and live in their own bubble.
ASSESSING RISK OF AGGRESSION AND
VIOLENCE
Although it is possible to make a general assessment of relative risk, it is impossible to predict an individual , specific act of aggression and violence, given that such acts usually occur when the perpetrator is highly emotional due to their conditions. During a clinical session, the same person may be guarded, less emotional, and even thoughtful, thereby making any signs of violent intent. And also when the patient explicitly expresses an intention to harm someone else, the relative risk for acting on that plan is still significantly influenced by the following life circumstances and clinical factors as well.
Personality disorders:
Pers nality disorders like, borderline personality disorder, antisocial personal i ty disorder, conduct disorder, and other personality disorders often manifest and are the reasons for aggression or violence. When a personality disorder occurs in conjunction with another psychiatric disorder, the combination may also increase risk of aggression and violent behavior.
Nature of symptoms:
One of the major symptoms followed up for aggression usually are, patients with paranoid delusions, command hallucinations, and florid psychotic thoughts are more likely to become violent than other patients. For clinicians, it is an important factor to understand the patient’s own percept ion of psychotic thoughts, because this may reveal when and how a patient may feel compelled to fight back or become highly aggressive.
Age and gender:
Young people are more likely than older adults to act violently and aggressive. According to various studies it is also believed that men are more likely than women to act violently.
Social stress:
People who are poor or homeless, or otherwise have a low socioeconomic status, are more likely than others to become aggressive.
Personal stress, crisis, or loss:
Major personal factors like unemployment, divorce, or separation in the past year increases a patient’s risk of violence. People who were victims of crime in the past year are also more likely to assault someone or show aggressive behavior as well.
Early exposure:
The risk of aggression and violence rises with exposure to aggressive family fights during childhood, physical abuse by a parent, or having a parent with a criminal record.
ASSESSMENT OF AGGRESSION AND SUBSTANCE USE DISORDER
Childhood aggression predicts early onset and frequency of substance use in adolescence (Pulkkinen & Pitkanen, 1994), consistent with a common cause or deviance proneness model (Martel et al., 2009). This model appears to operate through both direct and indirect pathways, al though underlying mechanisms are not yet clear (Zucker, 2008). Aggression has been classified in terms of both function and form. Function can be classified as either proactive (i.e., calculated and goal-oriented, motivated by external reward) or reactive (i.e., defensive, impulsive responding to threat or frustration) (Dodge & Coie, 1987 ) . Proactive aggression is associated with delinquency and violence in youth, but reactive aggression has been a less consistent predictor (Card & Little, 2006; Raine et al., 2006). Proactive and reactive aggression have been prospectively linked to SUDs via separate pathways (Fite, Colder, Lochman, & Wells, 2008). Proactive aggression predicts substance use directly and via association with delinquent peers, whereas reactive aggression is indirectly associated with peer delinquency and rejection by peers (Fite & Colder, 2007).
Aggression form can be categorized as either direct or relational (Card, Stucky, Sawalani, & Little, 2008). Direct aggression is defined as behavior directed at individuals with the intent to harm (Coie & Dodge, 1998), while relational aggression refers to acts intended to manipulate or damage relationships (Crick & Grotpeter, 1995). Early direct (Swaim, Deffenbacher, & Wayman, 2004) and relational (Herrenkohl, Catalano, Hemphill, & Toumbourou, 2009; Skara et al ., 2008) aggression are associated with subsequent substance use. Several measures of aggression form are available, including observer rating scales (Coie & Dodge, 1998) and the self report Reactive-Proactive Aggression Questionnaire (Raine et al., 2006). Two methodological issues are common to these measures.
PSYCHO-SOCIAL INTERVENTION AND TREATMENT
Treatment for adolescent substance use disorder and comorbid problems such as aggression has often been poorly integrated (Lamps et al., 2008). Barriers to successful treatment include poor coordination between delivery systems (E. H. Hawkins, 2009), a relative lack of research into developmentally appropriate interventions (Lysaught & Wodarski, 1996), and a lack of funding specific to SUDs and comorbid disorders (E. H. Hawkins, 2009). Moreover, animosity is related with poor treatment results (Crowley, Mikulich, MacDonald, Young, & Zerbe, 1998). Consequently, there is increasing interest in interventions that address youth needs across multiple areas, including problem-solving and communication skills, family, mental health, and substance use disorder (Libby & Riggs, 2005). When treating youth in secure settings, five general strategies are recommended (Greenwood, 2008). First, intervention should focus on malleable problem behaviors (e.g., problem-solving skills, peer associations, family dysfunction). Second, interventions should be evidence-based and tailored to individual needs. Third, institutional treatment programs should focus on youth at highest risk for relapse and recidivism, who have both the most room for improvement and for whom failure will tend to have more severe consequences (Latessa, Listwan, & Hubbard, 2005). Fourth, consistent implementation of evidence-based interventions is critical to positive outcomes. Finally, interventions are most effective when provided by mental health professionals (Greenwood, 2008).
Family Therapy:
Family therapy aims to create more adaptive patterns of family interaction, reducing problem behaviors thought to be a result of family dysfunction (Waldron, 1997). Multiple family therapies have been developed for the treatment of youth substance use disorders, aggression, and delinquency. Those with the most empirical support include Multisystemic Therapy (MST; Henggeler et al., 1991), Functional Family Therapy (FFT; Alexander & Parsons, 1973), and Multidimensional Family Therapy (MDFT; Liddle, 2010). Evidence indicates that family therapy is more effective than individual therapy for youth substance use disorders and other problem behaviors (Diamond & Josephson, 2005).
Cognitive-behavioral therapy (CBT):
CBT for substance use disorders (Wright, Beck, Newman, & Liese, 1993) is based on the idea that problem behaviors result from maladaptive cognitions (Winters, 1999). Youth who use dr ugs ma y have di s t or t ed expectancies about the positive effects of drugs and may not consider the negative consequences. Failure to develop problemsolving, social, and self-control skills or adaptive strategies for coping with peer pressure and negative emotions are also thought to contribute to substance use, aggression, and delinquency. CBT aims to correct maladaptive beliefs by examining their rational basis and substituting beliefs that are consistent with adaptive behavior (Winters, 1999). Meta-analytic studies and reviews have shown CBT to effective for SUDs (Dennis et al ., 2004a; Dennis et al ., 2004b) and delinquency (Lipsey, Landenberger, & Wilson, 2007) in male and female adolescents. The inclusion of anger management and problemsolving components appears to be particularly important in terms of minimizing aggression (Lipsey et al., 2007).
Motivat ional enhancement therapy (MET):
MET is a brief therapy based on motivational interviewing (W. R. Miller & Rollnick, 1991). MET interventions focus on increasing motivation to change by addressing ambivalence. Therapists empathize with clients and collaboratively assist clients in developing discrepancy between their current behaviors and their goals (Feldstein & Ginsburg, 2006). MET has been shown to be an effective treatment for substance use disorders (Dunn, Deroo, & Rivara, 2001).
Contingency management (CM) and community reinforcement (CR):
CM interventions are based on operant conditioning principles, in which behavior is a function of its consequences (Higgins & Silverman, 2008) . CM requires that nonabstinence be readily detectible (Higgins, Alessi, & Dantona, 2002). Rewards are given for verified abstinence and other targeted behaviors (e.g., nonaggression), but withheld for nonabstinence (Higgins , Ales si , & Dantona, 2002). Abstinent clients may receive vouchers with monetary values that increase with longer abstinence (Higgins et al., 1991) or may draw slips of paper from a bowl which may contain either written reinforcement or a voucher (Petry & Martin, 2002). CM is wellestablished as an effective treatment for adult SUDs (Higgins & Silverman, 2008), and several recent studies have assessed its use for youth substance use disorders and conduct problems. For example, adolescent outpatient interventions combining CM with CBT and/or motivational enhancement have been reported to reduce marijuana use and externalizing behaviors (Carroll et al., 2006) and cigarette smoking (Krishnan-Sarin et al., 2006).
CONCLUSION AND FUTURE RECOMMENDATIONS
Substance involvement is a critical factor in the assessment and treatment of youth aggression. Despite high levels of need, adolescents with aggression and comorbid substance use tend to be underserved. Several interventions have been developed that are effective in reducing aggressive, delinquent behaviors and substance use. Treatment is most likely to be effective when it addresses dysfunction and risk factors across multiple domains (e.g., individual, family, school, peer systems). Family-based therapies focus on reducing dysfunction in family and other systems that is thought to influence problem behaviors. The literature demonstrates that family therapies are superior to other modalities (Diamond & Josephson, 2005) and should be considered first-line treatments for youth SUDs and aggression.
REFERENCES
Agnew, R, & Brezina, T. (1997). Relational problems with peers, gender, and delinquency. Youth & Society, 29, 84- 111.
Alexander, J., & Parsons, B. (1973). Shortterm behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81, 219-225.
Armstrong, T. D., & Costello, E.J. (2002). Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Journal of Consulting and Clinical Psychology, 70, 1224-1239.
Bandura, A. (1973). Aggression. A Social Learning Analysis. Prentice Hall Inc.
Card, N. A., & Little, T. D. (2006). Proactive and reactive aggression in childhood and adolescence: A meta-analysis of differential relations with psychosocial adjustment . International Journal of Behavioral Development, 30, 466-480.
Card, N. A., Stucky, B. D., Sawalani, G. M., & Little, T. D. (2008). Direct and indirect aggression during childhood and adolescence: A meta-analytic review of gender differences , intercorrelations, and relations to maladjustment. Child Development, 79, 1185-1229.
Carroll, K. M., Easton, C., Nich, C., Hunkele, K. A., Neavins, T. M., & Sinha, R. (2006). The use of contingency management and motivational/skillsbuilding therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology, 74, 955-966.
Chassin, L. (2008). Juvenile justice and substance use. The Future of Children, 18, 165-183.
Coie, J. D., & Dodge, K. A. (1998). Aggression and antisocial behavior. In W. Damon & N. Eisenberg (Eds.), Handbook of child psychology. Social, emotional, and personality development, 3, 779- 862.
Compass, B.E., & Wanger, B.M. (1991). Psychosocial stress during adolescence: Intrapersonal and interpersonal processes. In Colten ME, Gore S. (Eds.), Adolescent stress: Causes and Consequences New York: AldineDeGruyter. International Journal of Prevention and Treatment of Substance Use Disorders, 67, 92- 116.
Crick, N. R., & Grotpeter, J. K. (1995). Relational aggression, gender, and social-psychological adjustment. Child Development, 66, 710-722.
Crowley, T.J., Mikulich, S. K., MacDonald, M., Young, S. E., & Zerbe, G. O. (1998). Subs tance-dependent , conduct – disordered adolescent males: Severity of diagnosis predicts 2-year outcome. Drug and Alcohol Dependence, 49, 225-237.
Deas, D. (2006). Adolescent substance abuse and psychiatric comorbidities. Journal of Clinical Psychiatry, 67, 18-23.
Dennis, M., Godley, S. H., Diamond, G., Tims, F., Babor, T., & Donaldson, J. (2004a). The Cannabis Youth Treatment (CYT) s t udy : Mai n f indings f rom two ra ndomi z ed t r ia l s . Jo ur na l of Substance Abuse Treatment, 27, 197- 213.
Dennis, M., Godley, S. H., Diamond, G., Tims, T. M., Babor, T., & Donaldson, J. (2 00 4b) . T he Ca nnabi s Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213.
Diamond, G., & Josephson, A. (2005). Familybased treatment research: A 10-year update. Journal of the American Academy of Chi ld & Adoles cent Psychiatry, 44, 872-887.
Dodge, K. A., & Coie, J. D. (1987). Socialinformation- processing factors in reactive and proactive aggression in children’s peer groups. Journal of Personality and Social Psychology, 53, 1146-1158.
Dunn, C., Deroo, L., & Rivara, F. P. (2001). The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction, 96, 1725-1742.
Feldstein, S. W., & Ginsburg, J. I. D. (2006). Motivational interviewing with dually diagnosed adolescents in juvenile justice settings. Brief Treatment and Crisis Intervention, 6, 218-233.
Although it is possible to make a general assessment of relative risk, it is impossible to predict an individual , specific act of aggression and violence, given that such acts usually occur when the perpetrator is highly emotional due to their conditions. During a clinical session, the same person may be guarded, less emotional, and even thoughtful, thereby making any signs of violent intent. And also when the patient explicitly expresses an intention to harm someone else, the relative risk for acting on that plan is still significantly influenced by the following life circumstances and clinical factors as well.
Personality disorders:
Pers nality disorders like, borderline personality disorder, antisocial personal i ty disorder, conduct disorder, and other personality disorders often manifest and are the reasons for aggression or violence. When a personality disorder occurs in conjunction with another psychiatric disorder, the combination may also increase risk of aggression and violent behavior.
Nature of symptoms:
One of the major symptoms followed up for aggression usually are, patients with paranoid delusions, command hallucinations, and florid psychotic thoughts are more likely to become violent than other patients. For clinicians, it is an important factor to understand the patient’s own percept ion of psychotic thoughts, because this may reveal when and how a patient may feel compelled to fight back or become highly aggressive.
Age and gender:
Young people are more likely than older adults to act violently and aggressive. According to various studies it is also believed that men are more likely than women to act violently.
Social stress:
People who are poor or homeless, or otherwise have a low socioeconomic status, are more likely than others to become aggressive.
Personal stress, crisis, or loss:
Major personal factors like unemployment, divorce, or separation in the past year increases a patient’s risk of violence. People who were victims of crime in the past year are also more likely to assault someone or show aggressive behavior as well.
Early exposure:
The risk of aggression and violence rises with exposure to aggressive family fights during childhood, physical abuse by a parent, or having a parent with a criminal record.
ASSESSMENT OF AGGRESSION AND SUBSTANCE USE DISORDER
Childhood aggression predicts early onset and frequency of substance use in adolescence (Pulkkinen & Pitkanen, 1994), consistent with a common cause or deviance proneness model (Martel et al., 2009). This model appears to operate through both direct and indirect pathways, al though underlying mechanisms are not yet clear (Zucker, 2008). Aggression has been classified in terms of both function and form. Function can be classified as either proactive (i.e., calculated and goal-oriented, motivated by external reward) or reactive (i.e., defensive, impulsive responding to threat or frustration) (Dodge & Coie, 1987 ) . Proactive aggression is associated with delinquency and violence in youth, but reactive aggression has been a less consistent predictor (Card & Little, 2006; Raine et al., 2006). Proactive and reactive aggression have been prospectively linked to SUDs via separate pathways (Fite, Colder, Lochman, & Wells, 2008). Proactive aggression predicts substance use directly and via association with delinquent peers, whereas reactive aggression is indirectly associated with peer delinquency and rejection by peers (Fite & Colder, 2007).
Aggression form can be categorized as either direct or relational (Card, Stucky, Sawalani, & Little, 2008). Direct aggression is defined as behavior directed at individuals with the intent to harm (Coie & Dodge, 1998), while relational aggression refers to acts intended to manipulate or damage relationships (Crick & Grotpeter, 1995). Early direct (Swaim, Deffenbacher, & Wayman, 2004) and relational (Herrenkohl, Catalano, Hemphill, & Toumbourou, 2009; Skara et al ., 2008) aggression are associated with subsequent substance use. Several measures of aggression form are available, including observer rating scales (Coie & Dodge, 1998) and the self report Reactive-Proactive Aggression Questionnaire (Raine et al., 2006). Two methodological issues are common to these measures.
PSYCHO-SOCIAL INTERVENTION AND TREATMENT
Treatment for adolescent substance use disorder and comorbid problems such as aggression has often been poorly integrated (Lamps et al., 2008). Barriers to successful treatment include poor coordination between delivery systems (E. H. Hawkins, 2009), a relative lack of research into developmentally appropriate interventions (Lysaught & Wodarski, 1996), and a lack of funding specific to SUDs and comorbid disorders (E. H. Hawkins, 2009). Moreover, animosity is related with poor treatment results (Crowley, Mikulich, MacDonald, Young, & Zerbe, 1998). Consequently, there is increasing interest in interventions that address youth needs across multiple areas, including problem-solving and communication skills, family, mental health, and substance use disorder (Libby & Riggs, 2005). When treating youth in secure settings, five general strategies are recommended (Greenwood, 2008). First, intervention should focus on malleable problem behaviors (e.g., problem-solving skills, peer associations, family dysfunction). Second, interventions should be evidence-based and tailored to individual needs. Third, institutional treatment programs should focus on youth at highest risk for relapse and recidivism, who have both the most room for improvement and for whom failure will tend to have more severe consequences (Latessa, Listwan, & Hubbard, 2005). Fourth, consistent implementation of evidence-based interventions is critical to positive outcomes. Finally, interventions are most effective when provided by mental health professionals (Greenwood, 2008).
Family Therapy:
Family therapy aims to create more adaptive patterns of family interaction, reducing problem behaviors thought to be a result of family dysfunction (Waldron, 1997). Multiple family therapies have been developed for the treatment of youth substance use disorders, aggression, and delinquency. Those with the most empirical support include Multisystemic Therapy (MST; Henggeler et al., 1991), Functional Family Therapy (FFT; Alexander & Parsons, 1973), and Multidimensional Family Therapy (MDFT; Liddle, 2010). Evidence indicates that family therapy is more effective than individual therapy for youth substance use disorders and other problem behaviors (Diamond & Josephson, 2005).
Cognitive-behavioral therapy (CBT):
CBT for substance use disorders (Wright, Beck, Newman, & Liese, 1993) is based on the idea that problem behaviors result from maladaptive cognitions (Winters, 1999). Youth who use dr ugs ma y have di s t or t ed expectancies about the positive effects of drugs and may not consider the negative consequences. Failure to develop problemsolving, social, and self-control skills or adaptive strategies for coping with peer pressure and negative emotions are also thought to contribute to substance use, aggression, and delinquency. CBT aims to correct maladaptive beliefs by examining their rational basis and substituting beliefs that are consistent with adaptive behavior (Winters, 1999). Meta-analytic studies and reviews have shown CBT to effective for SUDs (Dennis et al ., 2004a; Dennis et al ., 2004b) and delinquency (Lipsey, Landenberger, & Wilson, 2007) in male and female adolescents. The inclusion of anger management and problemsolving components appears to be particularly important in terms of minimizing aggression (Lipsey et al., 2007).
Motivat ional enhancement therapy (MET):
MET is a brief therapy based on motivational interviewing (W. R. Miller & Rollnick, 1991). MET interventions focus on increasing motivation to change by addressing ambivalence. Therapists empathize with clients and collaboratively assist clients in developing discrepancy between their current behaviors and their goals (Feldstein & Ginsburg, 2006). MET has been shown to be an effective treatment for substance use disorders (Dunn, Deroo, & Rivara, 2001).
Contingency management (CM) and community reinforcement (CR):
CM interventions are based on operant conditioning principles, in which behavior is a function of its consequences (Higgins & Silverman, 2008) . CM requires that nonabstinence be readily detectible (Higgins, Alessi, & Dantona, 2002). Rewards are given for verified abstinence and other targeted behaviors (e.g., nonaggression), but withheld for nonabstinence (Higgins , Ales si , & Dantona, 2002). Abstinent clients may receive vouchers with monetary values that increase with longer abstinence (Higgins et al., 1991) or may draw slips of paper from a bowl which may contain either written reinforcement or a voucher (Petry & Martin, 2002). CM is wellestablished as an effective treatment for adult SUDs (Higgins & Silverman, 2008), and several recent studies have assessed its use for youth substance use disorders and conduct problems. For example, adolescent outpatient interventions combining CM with CBT and/or motivational enhancement have been reported to reduce marijuana use and externalizing behaviors (Carroll et al., 2006) and cigarette smoking (Krishnan-Sarin et al., 2006).
CONCLUSION AND FUTURE RECOMMENDATIONS
Substance involvement is a critical factor in the assessment and treatment of youth aggression. Despite high levels of need, adolescents with aggression and comorbid substance use tend to be underserved. Several interventions have been developed that are effective in reducing aggressive, delinquent behaviors and substance use. Treatment is most likely to be effective when it addresses dysfunction and risk factors across multiple domains (e.g., individual, family, school, peer systems). Family-based therapies focus on reducing dysfunction in family and other systems that is thought to influence problem behaviors. The literature demonstrates that family therapies are superior to other modalities (Diamond & Josephson, 2005) and should be considered first-line treatments for youth SUDs and aggression.
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Pulkkinen, L., & Pitkanen, T. (1994). A prospective study of the precursors to problem drinking in young adulthood. Journal of Studies on Alcohol, 55, 578- 587.
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Swaim, R. C., Deffenbacher, J. L., & Wayman, J . C. ( 200 4) . Concur r ent a nd pr ospect i v e e f fe ct s of mul t i – dimensional aggression and anger on adolescent alcohol use. Aggressive Behavior, 30, 356-372.
Waldron, H. B. (1997). Adolescent substance abuse and family therapy outcome: A review of randomized trials. In T. H. Ol le ndi ck & R. J . P r inz (Eds .) . Advances in clinical child psychology,19, 199-234.
Winters, K. C. (1999). Treating adolescents with substance use disorders: An overview of practice issues and treatment outcome. Substance Abuse, 20, 203-225.
Wright, F. D., Beck, A. T., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse: Theoretical rationale. National Institute on Drug Abuse Research Monograph Series, Behavioral Treatments for Drug Abuse and Dependence, 137, 123-146.
Zucker, R. A. (2008). Anticipating problem alcohol use developmentally from childhood into middle adulthood: What have we learned? Addiction, 10(1), 100-108.
Conflict of interest: None
Role of funding source: None
Fite, P. J., Colder, C. R., Lochman, J. E., & Wells, K. C. (2008). The relation between chi ldhood proactive and reactive aggression and substance use initiation. Journal of Abnormal Child Psychology, 36, 261-271.
Gottfredson, M.R., & Hirschi, T. A. (1990). General Theory of Crime. Stanford, California: Stanford University Press.
Greenwood, P. (2008) . Prevent ion and intervention programs for juvenile offenders. The Future of Children, 18, 185-211.
Hawkins, E. H. (2009). A tale of two systems: Co-occur ring mental heal th and substance abuse disorders treatment for adolescents. Annual Review of Psychology, 60, 197-227.
Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J., Smith, L., & Hall, J. A. (1991). Effects of mul tisystemic therapy on drug use and abuse in serious offenders: A progress report from two outcome studies. Family Dynamics of Addiction Quarterly, 1, 40-51.
Herrenkohl, T. I., Catalano, R. F., Hemphill, S. A., & Toumbourou, J. W. (2009). Longitudinal examination of physical and r el at i ona l aggres s i on as precursors to later problem behaviors in adolescents. Violence and Victims, 24, 3-19.
Higgins, S. T., & Si lverman, K. (2008). Co nt i nge ncy ma nageme nt in substance abuse treatment. In S. T. Higgins, K. Silverman, & S. H. Heil (Eds.), Contingency management in substance abuse treatment (pp. 1-18). New York: Guilford Press.
Higgins, S. T., Alessi, S. M., & Dantona, R. L. (2002). Voucher-based incentives: A subs t anc e a bus e t rea tme nt innovation. Addictive Behaviors, 27, 887-910.
Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., 7 Foerg, F. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148, 1218-1224.
Krishnan-Sarin, S., Duhig, A. M., McKee, S. A., McMahon, T. J ., Li s s , T., & McFetridge, A. (2006). Contingency management for smoking cessation in adolescent smokers. Experimental and Clinical Psychopharmacology, 14, 306-310.
Lamps, C. A., Sood, A. B., & Sood, R. (2008). Youth wi th substance abuse and comorbid mental health disorders. Current Psychiatry Reports, 10, 265- 271.
Latessa, E. J., Listwan, S. J., & Hubbard, D. J. (2005). Correctional interventions: Changing offender behavior. Boston: Roxbury Publishing.
Lewis, D.O. (1996). Development of the Symptom of Violence, In Lewis M. (Ed.), Child and Adolescent Psychiatry. A Compre hens i v e Tex t boo k. Baltimore: Williams and Wilkins, 334- 44.
Libby, A. M., & Riggs, P. D. (2005). Integrated substance use and mental health treatment for adolescents: Aligning organizational and financial incentives. Journal of Chi ld and Adolescent Psychopharmacology, 15, 826-834.
Liddle, H. A. (2010). Theory development in a family-based therapy for adolescent drug abuse. Journal of Clinical Child Psychology, 28, 521-532.
Lipsey, M. W., Landenberger, N. A., & Wilson, S. J. (2007). Effects of cognitivebehavioral programs for criminal offenders (Campbell Collaboration Systematic Review).
Lysaught, E., & Wodarski, J. S. (1996). A dualfocused intervention for depression and addiction. Journal of Child and Adolescent Substance Abuse, 5, 55- 71.
Martel, M. M., Pierce, L., Nigg, J. T., Jester, J. M., Adams, K. M., & Puttler, L. I. (2009). Temperament pathways to childhood disruptive behavior and adolescent substance abuse: Testing a cascade model. Journal of Abnormal Child Psychology, 37, 363-371.
Mi l le r, W. R., & Ro l l ni c k, S. (1 991 ) . Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
Petry, N. M., & Martin, B. (2002). Low-cost contingency management for treating co ca ine – a nd opio id- abus i ng methadone pat ients . Journal of Consulting and Clinical Psychology, 70, 398-405.
Pulkkinen, L., & Pitkanen, T. (1994). A prospective study of the precursors to problem drinking in young adulthood. Journal of Studies on Alcohol, 55, 578- 587.
Raine, A., Dodge, K., Loeber, R., Gatzke-Kopp, L., Lynam, D., & Reynolds, C. (2006). The reactive-proactive aggression questionnaire: Differential correlates of reactive and proactive aggression in adoles cent boys . Aggres s i ve Behavior, 32, 159-171.
Swaim, R. C., Deffenbacher, J. L., & Wayman, J . C. ( 200 4) . Concur r ent a nd pr ospect i v e e f fe ct s of mul t i – dimensional aggression and anger on adolescent alcohol use. Aggressive Behavior, 30, 356-372.
Waldron, H. B. (1997). Adolescent substance abuse and family therapy outcome: A review of randomized trials. In T. H. Ol le ndi ck & R. J . P r inz (Eds .) . Advances in clinical child psychology,19, 199-234.
Winters, K. C. (1999). Treating adolescents with substance use disorders: An overview of practice issues and treatment outcome. Substance Abuse, 20, 203-225.
Wright, F. D., Beck, A. T., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse: Theoretical rationale. National Institute on Drug Abuse Research Monograph Series, Behavioral Treatments for Drug Abuse and Dependence, 137, 123-146.
Zucker, R. A. (2008). Anticipating problem alcohol use developmentally from childhood into middle adulthood: What have we learned? Addiction, 10(1), 100-108.
Conflict of interest: None
Role of funding source: None
It’s a matter of great pride for me that All India Association of Medical Social Work Professionals is launching first issue of “Indian Journal of Health Social Work” on the auspicious occasion of 6th Annual National Conference of AIAMSWP, 2019.