UMD PSYC 434 - Predicting Future Antisocial Personality Disorder in Males From a Clinical Assessment in Childhoo

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Predicting Future Antisocial Personality Disorder in Males From a ClinicalAssessment in ChildhoodBenjamin B. LaheyUniversity of ChicagoRolf Loeber and Jeffrey D. BurkeUniversity of PittsburghBrooks ApplegateWestern Michigan UniversityIt is essential to identify childhood predictors of adult antisocial personality disorder (APD) to targetearly prevention. It has variously been hypothesized that APD is predicted by childhood conduct disorder(CD), attention-deficit/hyperactivity disorder (ADHD), or both disorders. To test these competinghypotheses, the authors used data from a single childhood diagnostic assessment of 163 clinic-referredboys to predict future APD during early adulthood. Childhood Diagnostic and Statistical Manual ofMental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) CD, but not ADHD, signifi-cantly predicted the boys’ subsequent APD. An interaction between socioeconomic status (SES) and CDindicated that CD predicted APD only in lower SES families, however. Among children who met criteriafor CD, their number of covert but not overt CD symptoms improved prediction of future APD,controlling for SES.Keywords: conduct disorder, ADHD, antisocial personality disorder, covert antisocial behavior, aggres-sionAntisocial personality disorder (APD) is a profoundly impairingdisorder characterized by individuals engaging in irresponsible andantisocial behavior without remorse. Because APD is refractive totreatment in adulthood, understanding the childhood predictors oflater APD to inform research on preventive intervention is apressing priority for both the public health and criminal justicesystems.Childhood Conduct Problems as a Predictor of AdultAntisocial PersonalityMany studies of clinic and population-based samples in severalcountries have shown that childhood conduct problems predictserious adult antisocial behavior (Hill, 2003; Kratzer & Hodgins,1997; Robins, 1978). The accuracy of prediction of which childrenwill not become antisocial adults is greater than the prediction ofwhich children will become antisocial adults, however. That is,although the great majority of antisocial adults had a childhoodhistory of conduct problems, many children with serious conductproblems do not go on to exhibit serious antisocial behavior inadulthood (Maughan & Rutter, 2001). For example, in a seminalstudy that helped set the stage for modern developmental psycho-pathology, Robins (1966) interviewed adults who had been childguidance outpatients as children or adolescents during the 1920s.Two psychiatrists made the diagnosis of sociopathy in the adultsafter reading the interviews and reviewing records. Retrospectivereview of the child guidance clinic charts showed that 36% ofyouth with high levels of child or adolescent conduct problemsnoted in their charts were diagnosed with sociopathy. Conversely,82% of the adults with sociopathy had high levels of early conductproblems noted in their charts. Robins (Robins, Murphy, Woo-druff, & King, 1971) later replicated the findings of her 1966 studyusing the school records of 235 African American males who hadattended school during the 1940s.It is important to note, however, that Robins’ influential earlystudies used a much broader definition of both childhood conductproblems and adult antisocial personality than contemporary Di-agnostic and Statistical Manual of Mental Disorders (3rd ed., rev.;DSM–III–R; American Psychiatric Association, 1987) andDSM–IV definitions of conduct disorder (CD) and APD. Althoughsome DSM CD behaviors were included in her list of child behav-ior problems (fighting, lying, running away from home, vandalism,rape, and truancy), her list also included childhood psychopathiccharacteristics (absence of guilt, recklessness, impulsivity, and useof aliases), other problem behaviors (bad language, substance use,and promiscuous sexual intercourse), consequences and correlatesof problem behavior (expulsions from school and arrests, poorschool grades, and dropping out of school), and a behavior nolonger considered to be problematic in most cases (masturbation).Thus, although children who meet contemporary DSM criteria forCD would have been considered to have conduct problems inRobins’ studies, children without any DSM symptoms of CD alsoBenjamin B. Lahey, Department of Psychiatry, University of Chicago;Rolf Loeber and Jeffrey D. Burke, Department of Psychology, Universityof Pittsburgh; Brooks Applegate, Department of Psychology, WesternMichigan University.This study was supported by Grant R01 MH42529 from the NationalInstitute of Mental Health. We appreciate the helpful comments of KateKeenan on a draft of this article.Correspondence concerning this article should be addressed to BenjaminB. Lahey, who is now at the Departments of Health Studies and Psychiatry(MC 2007), University of Chicago, 5841 South Maryland Avenue, Chi-cago, IL 60637. E-mail: [email protected] of Consulting and Clinical Psychology Copyright 2005 by the American Psychological Association2005, Vol. 73, No. 3, 389 –399 0022-006X/05/$12.00 DOI: 10.1037/0022-006X.73.3.389389could have been said to have multiple conduct problems accordingto Robins’ broader definition.In a follow-back study of a British sample of boys, many ofwhom were reared in group foster homes (Zoccolillo, Pickles,Quinton, & Rutter, 1992), 40% of boys given ad hoc retrospectivechart-review diagnoses of CD met DSM–III criteria for APD inadulthood. In a similar British study, 60% of a group of childrenwho had attended a psychiatry clinic in the past were located andinterviewed in adulthood (Fombonne, Wostear, Cooper, Har-rington, & Rutter, 2001). On the basis of retrospective chartreviews, all selected children had met an unspecified ad hocdefinition for childhood major depression, with about half of theselected children also meeting an ad hoc definition for childhoodCD. In adulthood, 45% of the children who were said to exhibitboth childhood depression and CD met criteria for APD accordingto research diagnostic criteria that antedated DSM–III, comparedwith 1% of the children with only childhood depression. Thesefollow-back studies provide highly useful information, but they arelimited because the information recorded in even the most system-atic medical charts in the past rarely map well onto contemporarydiagnostic criteria. The association between childhood CD andadult APD also has been examined in studies of adults with currentAPD who


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