Continuity of aggressive antisocial behavior from childhood to adulthood: The question of phenotype definition

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Abstract

Aiming to clarify the adult phenotype of antisocial personality disorder (ASPD), the empirical literature on its childhood background among the disruptive behaviour disorders, such as attention deficit/hyperactivity disorder (AD/HD), oppositional defiant disorder (ODD), conduct disorder (CD), or hyperkinetic conduct disorder (HKCD), was reviewed according to the Robins and Guze criteria for nosological validity. At least half of hyperactive children develop ODD and about a third CD (i.e. AD/HD + CD or HKCD) before puberty. About half of children with this combined problem constellation develop antisocial personality disorder (ASPD) in adulthood. Family and adoption/twin studies indicate that AD/HD and CD share a high heritability and that, in addition, there may be specific environmental effects for criminal behaviours. “Zones of rarity” delineating the disorders from each other, or from the normal variation, have not been identified. Neurophysiology, brain imaging, neurochemistry, neurocognition, or molecular genetics have not provided “external validity” for any of the diagnostic categories used today. Deficient mental functions, such as inattention, poor executive functions, poor verbal learning, and impaired social interaction (empathy), seem to form unspecific susceptibility factors. As none of today's proposed syndromes (e.g. AD/HD or psychopathy) seems to describe a natural category, a dimensional behavioural phenotype reflecting aggressive antisocial behaviours assessed by numbers of behaviours, the severity of their consequences and how early is their age at onset, which will be closely related to childhood hyperactivity, would bring conceptual clarity, and may form the basis for further probing into mental, cognitive, biological and treatment-related co-varying features.

Introduction

That problem behaviours in children may herald psychosocial problems in adult life is basically a universal insight and the mainstay of most educational efforts. The association has also been demonstrated in a number of longitudinal studies and forms the nucleus in phenotype definitions of adult impulsive behaviours, physical aggression, violation of societal norms, and deficient emotional reactions, that is antisocial personality disorder (ASPD, American Psychiatric Association (APA), 1994), dissocial personality disorder (ICD-10, World Health Organization, 1993) or psychopathy (Hare, 1980). Nevertheless, the nosological categories proposed to capture specificproblem constellations both overlap and are heterogeneously defined.

Attention-Deficit Hyperactivity Disorder (AD/HD) is an umbrella term by definition consisting of three problem domains, inattention, hyperactivity and impulsivity, listed in two separate sets of criteria that may be met individually or together. Two persons who both have this diagnosis may theoretically not share a single criterion. The International Classification of Diseases, tenth edition (ICD-10, WHO, 1993) has based its corresponding definition on hyperactivity (Hyperkinetic Disorder), noting attention deficits as a common complication. If hyperkinesia is combined with outright antisocial behaviours, the diagnosis of hyperkinetic conduct disorder (HKCD) may be made. In the DSM-IV, Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are instead treated as two separate disorders.

Other diagnostic categories that have been implicated in the context of childhood aggressive behaviours are the autism spectrum disorders (ASD), describing deficits in social interaction or “empathy”, verbal and/or non-verbal communication and flexibility, and “paediatric mania” or bipolar disorder with irritable, elated mood swings. A brief overview of the current diagnostic definitions that may be related to early-onset antisocial behaviours provided by the DSM-IV and the ICD-10 is given in Table 1.

Assessing the validity of diagnostic concepts in psychiatric nosology is a continuous process, where, in the absence of knowledge about specific aetiological factors, definitions have to be regarded as preliminary and subject to revision. A seminal paper by Robins and Guze (1970) argued that a valid classification should be based on systematic empirical studies rather than on “a priori principles”, according to five specific criteria (Table 2). We have reviewed the literature by these criteria in order to

  • 1.

    assess the validity of current categorical diagnoses and

  • 2.

    propose more specific clinical descriptions of the development of aggressive antisocial behaviours.

Section snippets

Method

The studies assembled for this review were identified using systematic PubMed searches in October–November 2007 by the search terms detailed in Table 3. Hand-searches according to the reference lists of the most important textbooks on the field (Lahey et al., 2003, Patrick, 2006, Quay and Hogan, 1999, Stoff et al., 1997) were also performed to identify studies published in non-indexed sources. Selected references of importance for the research questions were added for a revision of the

Criteria 3 and 4: Delineation and homotype progression

Six studies on clinic-referred children and six population-based prospective, longitudinal studies following hyperactive children into adulthood were identified (Table 4). All these studies had included children according to behavioural criteria at base-line. Detailed figures for the follow-up of cases and controls in relation to our defined outcome parameters are given in the bottom row of the table with p-values for comparisons. Studies included in the meta-analyses are indicated in the

Summary and proposition

The literature on longitudinal development of hyperactivity is quite consistent on some basic figures: the majority of children identified as hyperactive, at least during some period, develop a pattern of social interaction characterized by opposition, which, in at least a third, progresses into pre-adult aggressive antisocial behaviour. In about a fifth of the original group, this will persist into an ASPD in adulthood. This behaviour progression corresponds to the HKCD and ASPD or dissocial

Acknowledgements

This paper was written with funding from the Forensic Psychiatric Clinic at the Malmö University Hospital, Region Skåne, Landstinget Kronoberg, Stiftelsen Lindhaga and Stiftelsen Professor Bror Gadelius Minnesfond and Lund University (under the ALF agreement), the Swedish National Research Counsil (2005-6783), and a guest professorship for HA at the Université de Paris XII Val de Marne (INSERM, U 841, IMRB). Sidika Basic, Agneta Brimse, Åse Holl, Anita Larsson, and Susanne Rosenthal provided

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    This study is based on a lecture by Professor Henrik Anckarsäter given in a symposium on early age at onset of psychiatric disorders, organized by Professor Marion Leboyer at the ECNP annual meeting in Paris, France, September 2006.

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