University Child Mental Health Unit, Mulberry House, Alder Hey Hospital, Eaton Road, Liverpool L12 2AP, UK.
Correspondence: E-mail: jonathan.hill{at}liverpool.ac.uk
* Paper presented at the second conference of the British and Irish Group for
the Study of Personality Disorders (BIGSPD), University of Leicester, UK, 31
January to 3 February 2001.
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ABSTRACT |
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Aims To address six key areas concerning the relationship between early conduct problems and antisocial personality disorder.
Method Review of recent research into early identification of and intervention in child conduct problems, following up to possible adult antisocial behaviour.
Results Conduct problems are predictive of antisocial personality disorder independently of the associated adverse family and social factors. Prediction could be aided through identification of subtypes of conduct problems. There is limited evidence on which children have problems that are likely to persist and which will improve; children who desist from early conduct problems and those with onset in adolescence are also vulnerable as adults.
Conclusions The predictive power of the childhood precursors of antisocial personality disorder provides ample justification for early intervention. Greater understanding of subgroups within the broad category of antisocial children and adults should assist with devising and targeting interventions.
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INTRODUCTION |
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METHOD |
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RESULTS |
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Early identification
It may be that the problem will be solved simply through better treatment
techniques; however, attention to six issues in early identification may also
be of value in generating ideas for the development of interventions. First,
conduct problems in young children are associated with many other adverse
factors such as ineffective parenting practices, discordant and unstable
families, poor peer relationships and educational failure. It is important to
clarify whether it is the child's disorder that requires early identification,
or these associated factors or both. Second, conduct problems in childhood are
generally identified on the basis of a broad cluster of behaviours. The
identification of subtypes may lead to a better understanding of underlying
mechanisms, and hence to improved matching of treatment to clinical needs.
Third, in approximately 50% of children with early conduct problems these do
not persist into adolescence and adult life. Ways of distinguishing persisters
and desisters are needed. Fourth, given the intractability of behaviour
problems in some young children, we need to ask whether identification at an
earlier age is possible. Fifth, the adult outcomes of children who show early
conduct problems and then desist, and of those whose problems start in
adolescence, need to be considered. Finally, we need to attend to the adult
outcomes that we are attempting to anticipate. It may be that specific
antisocial outcomes have different antecedents from those of antisocial
personality disorder.
What is predictive?
It is possible that, because conduct problems are associated with a wide
range of adverse individual, family and social factors, the conduct problems
per se are not the antecedents of antisocial personality disorder but
are markers for these other difficulties that are the true antecedents. In
general, the evidence supports conduct problems as true antecedents
(Farrington et al,
1990). For example, studies that have assessed both conduct
problems and quality of peer relationships, and then followed children over
several years, have consistently found that early conduct problems predict
later antisocial behaviours (Tremblay
et al, 1995; Woodward
& Fergusson, 1999). By contrast, the role of peer
relationships has been less clear. This should not, however, be interpreted to
mean that the associated factors are unimportant. For example in the Dunedin
Multidisciplinary Health and Development Study, violent crime at the age of 18
years was predicted by the combination of temperamental lack of control (quick
to show negative emotions when frustrated, poor impulse control) and number of
changes of parental figure before the age of 13 years, which probably
reflected a range of family adversities
(Henry et al,
1996).
Sources of heterogeneity in the conduct disorders
Longitudinal studies from childhood to adulthood have used a wide range of
ways to characterise conduct problems. Generally they have made use of summary
scores generated from a range of questionnaires completed by teachers and
parents (Farrington et al,
1990; Fergusson et
al, 1996; Moffitt et
al, 1996). The consistency of the findings may suggest that
it does not matter much how the problem is defined. Equally, there are
pointers to potentially important kinds of heterogeneity. Children with
conduct problems and hyperactivity/inattention differ from those with
pure conduct disorder in that their problems are more severe and
likely to persist, and they are more likely to have neuropsychological
deficits (Lynam, 1996). Lynam
(1998) has argued that
children with attention-deficit hyperactivity problems are fledgling
psychopaths, implying that they are more likely to show in adult life
the combination of callousness, superficial charm and antisocial behaviour
that characterises a sub-group of adults with antisocial personality disorder.
Frick and colleagues give priority to callousunemotional traits in
childhood. In a series of studies they have demonstrated that children with
antisocial problems who exhibit these traits differ from other children with
antisocial problems (Barry et al,
2000) in apparently having fewer verbal deficits
(Loney et al, 1998)
and in coming from families that are not characterised by dysfunctional
parenting practices seen generally in the conduct disorders (Wootton et
al, 1997). Children exhibiting callousunemotional traits may also
have a deficit in processing behavioural evidence of distress in others.
Associations between scores assessing callous and unemotional characteristics
and a reduced ability to recognise fear and sadness have been shown in young
adolescents recruited in mainstream schools and children with identified
emotional and behavioural problems (Blair
& Coles, 2003; Stevens
et al, 2001).
Loeber et al (1993) have proposed that three contrasting patterns of childhood antisocial problems reflect different pathways for different behaviour patterns: an overt pathway characterised by bullying, followed by early fighting and proceeding to more serious violence; a covert pathway starting with lying and stealing, and going on to more serious damage to property; and an authority conflict pathway in which oppositional and defiant behaviours are prominent.
A further distinction, between reactive and proactive antisocial behaviours, cuts across this three-category typology. Reactive acts occur in response to actual or perceived threat from others, whereas proactive behaviours are initiated by the individuals (Dodge & Coie, 1987). Reactive aggression is thought to involve angry retaliation, in contrast to the cold unprovoked calculation of proactive aggression. Dodge et al (1997) reported that, compared with children showing proactive aggression, reactive children were more likely to have been physically abused, to have poor peer relationships, to have shown aggression from an earlier age and to have attention-deficit and hyperactivity symptoms. A central idea in Dodge's model is that reactive aggression is mediated by a readiness to perceive hostile intent in the actions of others. However, the evidence for this is inconsistent. At this stage these can be considered as promising subtypes that may lead to a more precise specification of mechanisms, and hence provide pointers to different kinds of intervention. Longitudinal studies to determine whether they differ in course are needed.
Who are the persisters and desisters?
We have already referred to the poor outlook of children with both conduct
disorder and ADHD symptoms. On the basis of retrospective reports within a
large epidemiological study, Robins & Price
(1991) found that the number
of childhood antisocial problems is associated with risk of antisocial
personality disorder. Studies within childhood provide some further clues
regarding risk of persistence. Loeber et al
(2000) found that early
fighting and hyperactivity predicted persistence of antisocial behaviours over
a 6-year period among boys referred for conduct problems. In a prospective
study of a representative general population sample from ages 7-9 years to
14-16 years, persisters had the highest levels of family adversity and lower
IQ and self-esteem (Fergusson et
al, 1996). Children with early conduct problems that did not
persist had levels of these risk factors that were intermediate between those
of persisters and of children who lacked early behavioural problems.
Persisters were more likely than those whose early antisocial behaviours had
remitted to have a deviant peer group in adolescence. Whether this was a
reflection or a cause of persistence is not clear; however, it is consistent
with Sampson and Laub's argument that a key factor in determining persistence
may be the presence or absence of social bonds and controls
(Sampson & Laub,
1994).
Earlier predictors
We might suppose that, given the stability of conduct problems from the age
of 3 years onwards, earlier precursors should be readily identifiable.
However, the findings have been inconsistent. For example, the idea has been
extensively investigated that early difficult temperament,
comprising traits such as predominantly negative emotions and ready
frustration, contributes to irritable parenting, which in turn increases the
risk for conduct problems. Studies using assessments of temperament based on
parental reports have yielded some positive findings, but these are vulnerable
to parental attributions. Recent studies have failed to demonstrate
consistently that observational measures of temperament made in the first year
of life predict later conduct problems
(Belsky et al, 1998;
Aguilar et al, 2000).
Early attachment difficulties might be expected to increase the risk for later
conduct problems. Here again the evidence is not convincing
(Hill, 2002). It is likely
that the quality of parenting in infancy is predictive of later conduct
problems (Belsky et al,
1998) and it may be that the most promising approaches to the
identification of early predictors will examine specific interactions between
infant characteristics and early social experience
(Shaw et al, 1996;
Belsky et al,
1998).
Desisters and later onsets
We have focused so far on boys who show early conduct problems that persist
into adult life. It has generally been assumed that those whose conduct
problems remit have recovered. However, recent evidence from the
Dunedin Study suggests that although these children are not at increased risk
for antisocial outcomes, they are by no means free of difficulties
(Moffitt et al,
2002). At the age of 26 years they had higher rates of depression
and anxiety disorders, both self- and informant-rated, and they were socially
isolated, with few friends. They shared the poor educational and work records
of the life-course persistent group who were antisocial as adults. Likewise,
those with onset in adolescence, provisionally termed by Moffitt
adolescence limited, were not free of problems by the age of 26
years. Compared with those who were not significantly antisocial in childhood
or adolescence, these young men had higher rates of documented and
self-reported drug and property crimes, and their informants reported more
depression and anxiety symptoms.
Heterogeneity within antisocial personality disorder
Thus far in this paper the assumption has been made that the DSM-IV
antisocial personality disorder category best summarises the antisocial
outcomes of interest. There is little doubt that it succeeds as a broad-brush
characterisation of antisocial behaviour and associated wider social
dysfunction. However, it lacks specificity. In common with all DSM diagnoses,
it requires the presence of a number of maladaptive behaviours or mental
states identified from a larger set. Hence, the requirements can be met in
numerous ways. This may limit the investigation of more specific causal
factors, and so a more precise specification of the adult antisocial outcomes
may be needed.
The identification of psychopathic disorder makes the point. DSM-IV antisocial personality disorder is present in 50-80% of convicted offenders, but a much smaller group of 15-30% are judged to have characteristics such as grandiosity, callousness, deceitfulness, shallow affect and lack of remorse (Hart & Hare, 1989). These individuals are more likely than other offenders to have a history of severe and violent offences, and they may also have a distinctive deficit in interpersonal sensitivity. In a comparison of prisoners with and without psychopathic disorder, the groups did not differ in their ability to attribute correctly happiness, sadness and embarrassment to protagonists in short stories. However, in response to guilt stories, those with psychopathic disorder were more likely to attribute happiness or indifference to the protagonists (Blair et al, 1995). It has been proposed that psychopathy is associated with a failure to inhibit aggression in response to signs of distress in others, arising from a deficit in processing behavioural evidence of that distress (Blair et al, 1997). There is supportive evidence that, compared with other offenders, adults with psychopathic disorder have reduced autonomic responses to distress cues (Chaplin et al, 1995; Blair et al, 1997). As we saw earlier, a subgroup of children with antisocial problems who exhibit callousunemotional traits has been identified that may parallel adults with psychopathic disorder. No studies have yet tested for continuity between child and adult psychopathic traits by following these children into adult life.
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DISCUSSION |
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Clinical Implications and Limitations |
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LIMITATIONS
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