Self-Destructive Behavior

Roger Nuñez MD

Miriam T. Vincent MS, MD

Daisy Arce MD

INTRODUCTION

Children and adolescents who display self-destructive attitudes most likely are involved in several risk behaviors that may result in injury or even death (Jessor, 1991). One common risk behavior among adolescents is unsafe and premature sexual activity, which contributes to unintended pregnancies and the spread of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). Other self-destructive behaviors include smoking, drinking alcohol, using drugs, missing school, carrying weapons, participating in potentially violent groups, contributing to unintentional and intentional injuries, eating poorly, and self-mutilating.

Primary care providers are in an ideal position to address the needs of children who are or may be at risk for self-destructive behavior. They have the advantage of knowing children and their families for many years and thus can anticipate the development of self-destructive behavior. The following chapter provides a framework for the identification of and intervention in the cycle of self-destructive behavior.

PATHOLOGY OF SELF-DESTRUCTIVE BEHAVIOR: CAUSES AND DETERMINANTS

Examining any self-destructive behavior in isolation is difficult because all such behaviors can be antecedents to or consequences of any of the others. Many biologic, genetic, environmental, and psychological factors have been proposed to explain the general development of self-destructive behaviors; however, no single theory or combination of different theories has been able to do so fully. One well-known theory is the primary socialization theory, which asserts that all human social behaviors are learned or at least have major components that are learned. The theory’s core is that adolescents are enmeshed in a social network consisting of primary socialization sources, including the family, school, peer clusters, and media (Oetting & Donnermeyer, 1998; Strasburger, 1997). Any interference with bonding or communication of norms through primary socialization sources will become a risk factor for the development of self-destructive behavior. Table 26-1 presents primary socialization sources and risk factors for self-destructive behavior.

The Role of the Family

Family factors can contribute significantly to the onset of self-destructive behavior in children and teens. Lack of supervision, general parental permissiveness, and, conversely, parental rigidity, are all problems. The absence of appropriate adult role models (including parents themselves), family history of substance abuse or alcoholism, biogenetic predisposition, history of mental health dis- order, parental rejection, physical or sexual abuse, history of domestic violence, poor financial and housing status, and unemployment are all familial risk factors for self-destructive attitudes.

Parental use, patterns, and opinions about tobacco, alcohol, and other drugs range from permissiveness to rigid condemnation. Children of alcoholics and substance abusers are at tremendously increased risk for use (Heyman & Adger, 1997). Survivors of childhood sexual abuse have higher rates of self-harm, eating disorders, sexual dysfunction, and teen pregnancy than do others (Romans, 1996; Jarvis, 1997; Elders, 1998). Primary care providers must be prepared to identify all these risk factors associated with the family to design management and monitoring strategies for troubled adolescents and their families.

The Role of Schools

Schools are primary sources for acquiring and testing prosocial norms. Reiff (1998) reports that better students do poorly when moved into worse schools, while poorer students often improve when placed in better schools. Better schools are best characterized as those that emphasize academics, allow teachers autonomy to meet the education needs of individual students, and have programmatic flexibility systems of incentives and rewards that allow students to assume responsibility for their own behaviors.

Epidemiologic studies support the premise that children who fail to form appropriate bonds in school are at increased risk for drug use, early pregnancy, and other deviant behaviors. Adolescent school failure, a powerful indicator of self-destructive behavior, results from an array of forces, many of which are outside the adolescent’s control (Reiff, 1998). School failure is the result of a long process. Because schools frequently measure progress through grades and group achievement testing, many opportunities are available for preventing school failure.

Low self-esteem is a significant predictor of school failure (Reiff, 1998). Because strong family relationships and success in school contribute so greatly to it, self-esteem in a teen likely signifies good bonding with these primary socialization sources, which in turn are likely to discourage self-destructive behavior (Oetting, Deffenbacher, & Donnermyer, 1998). Both children and adolescents who have low self-esteem about their academic ability require individualized opportunities for successful academic experiences.

One disorder likely to result in self-destructive behavior is attention deficit hyperactivity disorder (ADHD). The symptomatic inattention, forgetfulness, and inability to stay focused on a task are likely to create bonding problems both at home and in school. ADHD is associated with anger and aggression, which are likely to disrupt further the child’s bonding with family, school, and prosocial peers (Barkley, 1997). If parents and teachers are able to deal effectively with
a child who has ADHD, bonding with the family or school will not suffer. The probability of substance use and other self-destructive behavior will not be increased (Oetting et al., 1998). Successful management of conduct disorder (CD), an externalized behavioral/emotional disorder, is the same as for ADHD: behavioral techniques, cognitive-behavioral training, and possibly stimulant medication (Reiff, 1998). ADHD and CD are easily recognizable in the classroom. Early intervention can support the formation of prosocial bonds. Refer to Chapter 21 for more information.

Teachers, coaches, and peers are less likely to identify internalized behavioral and emotional disorders, depression, or anxiety. Primary care providers must inquire about and identify any internalizing behavior problems in children who are performing poorly in school. Clinicians may be the only professionals outside school who are prepared to diagnose and treat these children. Chapter 28 provides more information on internalized behavioral and emotional disorders.

The Role of Peers

Literature spanning the last 5 decades strongly supports the influence of peers on self-destructive behavior (Oetting & Donnermeyer, 1998). Strong selection factors in the formation of peer clusters, some of which are external to the individual and imposed by culture, the environment, or chance, include age differences, gender, ethnicity, living in the same neighborhood, and classroom seating. Although superficially it may appear paradoxical, weak bonds with healthy peers can lead ultimately to strong bonds with deviant peers. Healthy peers often reject younger children who express deviant attitudes.

The Role of Personal Traits

Personality theory views behavior as emerging from and explained by personality traits. This approach has a fundamental problem. Personality traits rarely account for more than a small proportion of the variance in behavior, particularly self-destructive behavior. In contrast, socialization links, such as schools, families, and peers, can account for a large proportion of variance in behavior. Traits are likely to lead to self-destructive behaviors when they interfere with bonding with family, school, or peers or if personal traits interfere with the transmission of prosocial norms (Oetting et al., 1998). Children with underlying issues, such as obsessive-compulsive disorder (OCD), CD, or ADHD, may find the comfort with deviant peers that they cannot attain with family or normal children (Kaplan, 1996).

Even in the presence of a genetic predisposition to anger and aggression, behaviors are learned traits. Anger and aggression appear early in a child’s development. Early problems in family–child bonding can lead the child to act out and use anger as a means of expression. This is particularly true when parents model anger or when their discipline is inconsistent or overly harsh. Such modeled behaviors exacerbate the child’s anger and stimulate further problematic parent–child interactions, reinforcing anger and aggression. A child with high levels of anger and aggression may affect others in a peer cluster. When children of similar traits interact, their anger and aggression can become normalized within that peer cluster. Thus, anger and aggression become part of the group’s subculture. The result is a peer cluster with poor bonds to prosocial influences and a high potential for self-destructive behavior (Oetting et al., 1998).

Low self-esteem results from being unable to conform to conventional standards of family, school, and peer groups. Children with low self-esteem then form links with deviant peers to reduce self-derogation. Low self-esteem seems to occur only at specific times, after failure with prosocial primary socialization sources and before bonding with deviant peers.

Although not directly related to low self-esteem, evidence suggests that sensation seeking may have at least a partial genetic basis (Benjamin et al., 1996). Members of a sensation-seeking cluster may encourage one another to perform risky, deviant behaviors, including excessive drinking, high-speed driving, and using drugs.

The Role of Media and Advertising

Television and other media represent one of the most important and least recognized influences on the health and behavior of children and adolescents. Objections to various programming and advertising practices have come from common sense, philosophical, aesthetic, humanistic, and public health perspectives. An increasing number of studies document the existence of serious problems (Strasburger, 1997; Strasburger & Donnerstein, 1999).

Children and adolescents are a captive audience for entertainment producers. On average, young people watch 16 to 17 hours of television weekly, beginning as early as age 2 years (Nielsen Media Research, 1998). Video games and video cassettes comprise an additional 2 to 4 hours of viewing per week. Some teenagers spend as many as 35 to 55 hours each week in front of the television set. Regardless of all other issues, the viewing of television, video cassettes, and video games exerts a significant displacement effect of 2 to 3 hours per day, meaning that children and adolescents spend less time engaged in physical activity, reading, or interacting with friends. Many adolescents also spend many hours listening to the radio, although they generally use music to accompany other activities. Few data currently are available about young people’s use of the Internet, but past evidence suggests that “surfing the Net” will prove as popular as television, videos, video games, and music (William, Montgomery, & Pasnik, 1997).

Whether at the movies, on videos or television, or in music, young people view an estimated 10,000 acts of violence each year. The National Television Violence Study examined 10,000 hours of television programming for 3 years and found that 61% of programming contains violence. Children’s programming is the most violent, and 26% of violent interactions on these programs involve the use of guns (Federman, 1998). Researchers have concluded that children learn their attitudes about violence at a very young age; once learned, these attitudes tend to be lifelong (Eron, 1995).

A comprehensive analysis of music videos demonstrated that 22.4% of all videos played on Music Television (MTV) portrayed overt violence. Heavy metal music, which is more rebellious than other types of rock music, abounds with lyrics that glorify hatred and abuse (Shank & Gabel, 1996; DuRant et al., 1997; Christenson & Roberts, 1998). Caucasian male teens who engaged in five or more risky behaviors were most likely to name a heavy metal music group as their preferred music choice.

Although more than 1000 studies have linked media violence to real life violence, only five studies have demonstrated any connection between media with high sexual content and changes in the sexual behavior or attitudes of teens. Thus, for sexual activity, inferences must be drawn from the violence literature. The Internet offers unparalleled access to hard core pornography with just a few keystrokes (Log-On Data Corporation, 1996). Playboy or Playgirl has been read by 92% of males and 84% of females by age 15 (Strasburger & Donnerstein, 1999). Data suggest that the media (television, movies, and magazines) account for 39% of teenagers’ sexual information (Kaiser Family Foundation, 1997). The glut of inappropriate sexual messages in the mainstream media, coupled with the absence of appropriate messages about abstinence and the use of birth control, may partially account for the United States continuing to have the highest teenage pregnancy rate in the western world (Alan Guttmacher Institute, 1996).

Correlation studies indicate a positive relationship between alcohol and tobacco advertisement and exposure and consumption (Schooler, Feighery, & Flora, 1996; Strasburger & Donnerstein, 1999). Commercials involving cartoon characters, such as the Budweiser frogs (promoting an alcoholic product), had a 73% recall by children 9 to 11 years old (Leiber, 1996). In one well-publicized study, children as young as 6 years old were likely to mistake Old Joe Camel as being the Mouseketeer logo for the Disney channel or to associate him directly with cigarette smoking (Fischer, Schwart, Richards, Goldstein, & Rojas, 1991). One third of teenagers own cigarette promotional items, and these adolescents are four times more likely to be smokers (Sargent et al., 1997). One third of all adolescent smoking is causally related to tobacco promotional activities (Pierce, Chol, Gilpin, Farkas, & Berry, 1998).

Few studies have examined the factors that may lead susceptible individuals to undertake acts of sefl-mutilation. Showcasing criminal acts in the mainstream media has likely influenced susceptible individuals to undertake self-mutilating acts (Catalano, Morejon, Alberts, & Catalano, 1996). The mainstream media has taken notice (Egan, 1997). Just as anorexia nervosa and bulimia nervosa did several years ago, self-mutilation is making its way into public consciousness. If predictions are correct, a large number of self-mutilators, especially repetitive cutters and burners, can be expected to seek treatment, and pressure will be exerted to develop innovative, effective therapy (Kehrberg, 1997).

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