درمان رفتار ضد اجتماعی: یک زمینه برای پیشگیری از سوء مصرف مواد

Abstract A large body of literature illustrates an association between antisocial behavior and substance abuse. In the present paper, this association is reviewed from a behavioral-economic standpoint. It is suggested that childhood antisocial behavior is a behavioral complement of substance abuse, and that prosocial behavior is a substitute for substance abuse. Based on this formulation, efforts to reduce or prevent antisocial behavior may be conceptualized as prevention programs for substance abuse. Four empirically supported approaches for the treatment of antisocial behavior are reviewed with respect to their promise for preventing and treating substance abuse. Taken together, they suggest that successful interventions for substance abuse may occur at various points over the course of development, beginning in infancy and extending into adolescence. You become a narcotics addict because you do not have strong motivations in any other direction. Junk wins by default. (Burroughs, 1977, p. xv) Several authors have identified a contradictory or paradoxical aspect of addiction Heyman, 1996 and Herrnstein & Prelec, 1992. It is that the behavior of addicts is characterized as being “out of control” or “impulsive,” but at the same time calculated and planful. Similarly, addicted individuals oftentimes proclaim a desire to rid themselves of substance use yet may go to extraordinary lengths to engage in it. These inconsistencies—between what individuals say they want and their actual behavior—have been explained in terms of the matching law Herrnstein & Prelec, 1992 and Heyman, 1996. In short, the matching law is a theory of choice stating that behavior is frequently determined by relative value functions rather than overall value functions Herrnstein, 1974 and Herrnstein, 1997. That is, while behavior is influenced by both immediate reinforcement contingencies (i.e., the pleasures of immediate gratification) and more delayed contingencies (i.e., the pleasures of larger later rewards), the latter tend to be discounted Green et al., 1994 and Vuchinich & Simpson, 1999. Therefore, despite the fact that long-term goals may involve abstaining from substance use or some other addictive activity, the matching law illustrates that the immediate rewards for imbibing may overwhelm our capacity to act in accordance with our long-term ambitions. The matching law formulation of substance abuse highlights the interrelationship between the value functions for substitutable activities (i.e., drinking alcohol versus not drinking alcohol). Unlike economic formulations that assume individuals allocate behavior so as to maximize rewards, the matching law formulation suggests conditions under which individuals fail to maximize outcomes (Rachlin, 1995). The utility of this formulation for understanding substance abuse lies in the fact that it can explain choices that appear to both the addict and to others as self destructive and unreasonable. The details of this formulation will be discussed more completely below. In addition to having substitutes, however, activities also have complements. The presence of complements increases the value of some activity, thereby increasing its rate and likelihood of occurrence. The present paper explores antisocial behavior as a complement for substance abuse and prosocial behavior as a substitute for substance abuse. The focus is on why the emergence of antisocial behavior in children sets the stage for substance abuse, and how this may inform treatment. 1 The present paper is organized into four sections. A recently proposed theory of substance abuse based on matching theory is reviewed and recognized as incomplete with respect to explaining substance abuse. An expanded conceptualization, based also on matching theory, is proposed. This conceptualization is organized around the notion that many cases of substance abuse and addiction emerge from early forms of antisocial behavior. According to this perspective, the emergence of antisocial behavior is associated with increased rewards for substance use relative to rewards available for alternatives to substance use. This outcome is the result of at least two processes inherent in the development of conduct disorder: (1) the emergence of social skills deficits and (2) a tendency to overly discount delayed and probabilistic rewards. Both of these outcomes reduce the rewards obtained for activities that are substitutes for substance use. In the final sections of this paper, a developmentally informed framework is presented for prevention and treatment intervention based on the complementary relationship between antisocial behavior and substance abuse.

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Conclusion The number of variables involved in the biopsychosocial risk-factor matrix for drug and alcohol problems is staggering (Zucker, Boyd, & Howard, 1994). For instance, having limited his review to individual-level risk factors for alcoholism alone, Sher (1994) identified at least 13 broad classes of variables with more than 30 potentially causal connections between them. Despite the multifactorial nature of the problem, Sher noted, “there might be a very limited number of final common pathways which could serve to make preventive efforts less complex” (p. 101). In this paper, it has been argued that one important pathway to substance abuse concerns preadolescent antisocial behavior. According to the present conceptualization, preadolescent antisocial behavior does not necessarily cause substance abuse, but rather signifies the emergence of a class of deviant behaviors that ultimately includes substance abuse. The members of this behavior class are united in sharing a common set of behavioral complements (i.e., poverty) and behavioral substitutes (i.e., prosocial behavior). To the extent that antisocial behavior and its complements emerge in lieu of prosocial behavior—a substitute for substance abuse—the likelihood for substance abuse is increased. The intervention approach advocated here concerns identifying and altering the substitutes and complements of substance abuse. This formulation is consistent with a probabilistic etiologic model of substance abuse in that it is recognized that no single variable or factor is solely responsible for the emergence of problematic substance use (Zucker, 1994). In addition, the present formulation recognizes limitations in deriving treatments solely from etiologic models based on quasi-experimental longitudinal studies (Stoolmiller, Patterson, & Snyder, 1998). That is, it may be that manipulating factors that appear from the standpoint of etiologic models to be only weakly or distally related to substance abuse may result in dramatic or unpredicted effects. Such effects would derive from the fact that the factors that cause and the factors that maintain substance abuse may differ. It is also possible that variables discounted because of a small direct effect have large indirect (i.e., mediated or moderated) effects (Baron & Kenny, 1986). Finally, it may also be that variables with primarily indirect effects are highly malleable compared to those with direct effects. Under such circumstances, manipulation of variables with indirect effects may yield the most effective treatments. Consistent with this formulation, a number of interventions developed in response to antisocial behavior have been reviewed and examined with respect to their potential for reducing the incidence and prevalence of substance abuse. These interventions span a range of development that extends from infancy to adolescence. Preliminary findings support the notion that substance use and abuse are sensitive to changes in the availability of their complements and substitutes. In particular, results support the idea that programs that reduce antisocial behavior and increase prosocial behavior result in reductions in substance use and abuse. Therefore, according to the present conceptualization, it may be that solutions to the problem of substance abuse are to be found in a more molar context than has traditionally been examined within the field of substance abuse (Rachlin, 2000). Future explorations must attempt to identify the substitutes and complements of substance abuse, and the effect of systematically manipulating these variables. The theory and data reviewed in this paper suggest the potential benefits of efforts to alter the demand for addictive behaviors by attending to the context that maintains them. Moreover, efforts to increase the rewards obtained for prosocial behavior—via contingency management, skill building, or cognitive restructuring—may reduce both antisocial behavior and substance abuse.