Adrenal androgen and gonadal hormone levels in adolescent girls with conduct disorder
Introduction
Antisocial behavior in adolescent girls is increasingly prevalent, whether defined as delinquency or conduct disorder CD, a pervasive and persistent pattern of violating the rights of others and noncompliance with rules. Between 1980 and 2003, arrest rates for assaults by girls increased 269% in the US. In 2003, girls accounted for 24% of arrests for aggravated assault, 35% of forgery arrests, and 40% of embezzlement charges for American delinquents (Synder, 2005). Epidemiologic studies show that as many as 10% of 15–17 year-old girls in the general US population meet DSM-III, DSM-III-R, or DSM-IV criteria for CD (Cohen et al., 1993; Costello et al., 2003; Kashani et al., 1989). In the UK, a population study of over 10,000 5–15 year-olds (90.8% Caucasian) reported that 3.5% of 15-year-old girls met criteria for DSM-IV criteria (5.5% of the boys the same age met criteria for CD) (Maughan et al., 2004). Two Canadian studies reported that 2.9–3.6% of 15 to 17-year-old girls met DSM-III-R criteria for CD (Breton et al., 1999; Romano et al., 2001). A large cohort study of New Zealand children followed from birth reported that 8% of the girls met DSM-IV criteria for CD at age 15 (Moffitt et al., 2001). CD is the second most common psychiatric disorder in epidemiologic studies of adolescent girls in the US, UK, and New Zealand (Cohen et al., 1987; Graham and Rutter, 1973; Kashani et al., 1987; McGee et al., 1990; Rutter et al., 1970).
Adolescent antisocial behavior exacts high societal costs and causes significant suffering to families and individuals (Jones et al., 2002; Scott et al., 2001). Furthermore, such behavior in girls is not confined to adolescence; it is associated with a 40-fold increase in adult criminality, an increased rate of early mortality, depression and substance use, poor physical health, and a high rate of intergenerational transmission of antisocial behavior (Pajer, 1998).
Unfortunately, treatment for CD in girls is not very successful. This may be partially due to our limited understanding of the mechanisms underlying female antisocial behavior. This gap is particularly evident with biological factors, such as possible effects of adrenal androgen or gonadal hormone levels. These hormones have been studied in male antisocial behavior because of a hypothesized role for androgens in the etiology of violence, but only two studies have examined this question in girls. Maras et al. (2003) measured plasma testosterone, 5-α-dihydrotestosterone (DHT) levels, and externalizing behavior in 87 14-year-old boys and girls in Germany. Groups were assigned according to behavioral scores on the Child Behavioral Checklist (CBCL) and the Teacher Report Form (TRF). There were no significant correlations between hormone levels and behavior for girls. Granger and colleagues studied 107 girls and 106 boys (mean age of 13 years) to assess the relationship between diurnal variation in salivary testosterone levels and problem behavior (Granger et al., 2003). Problem behavior was defined as high externalizing behavior scores and DSM-IV symptoms of CD or oppositional defiant disorder (ODD). A steeper decline in testosterone levels throughout the day was associated with problem behavior in girls.
Research on hormone levels in women with antisocial behavior is also meager. Dabbs et al. (Dabbs and Hargrove, 1997) measured salivary testosterone levels and behavior in 87 women, 17–60 years old, in a maximum security prison in the US. Testosterone levels were not associated with criminal violence, but were associated with aggressive-dominant behavior in prison. However, this was only the case in the younger women. His group also measured salivary testosterone concentrations in 29 young men and women (mean age was 25 years) living in an “area frequented by young people of a rebellious nature …” (Banks and Dabbs, 1996). They were compared to age- and sex-matched local college students. There was no significant correlation between the number of antisocial acts and testosterone in the women in the “delinquent” group.
It is difficult to draw any conclusions from these studies for three reasons. First, there are too few studies and the samples are not representative of the population of females with antisocial behavior. Second, testosterone was the only hormone studied; there are no data about any other hormones. Even if we focus on the broader issue of general aggression (e.g., aggression in sports), as is often done with males, aggression in females has been less often associated with testosterone than with androstenedione, DHEA, or DHEA-S levels (Albert et al., 1990, Albert et al., 1991, Albert et al., 1992; Fishbein, 1992; Inoff-Germain et al., 1988; Kapusta, 1998; Mazur, 1995; Susman et al., 1987a, Susman et al., 1987b). Third, gonadal and adrenal hormone levels are affected by variables such as menstrual cycle phase (Abraham, 1974; Bloch et al., 1998; Couchman and Hammond, 1999), body mass index, race, and social class (Ukkola et al., 2001). None of the studies controlled for these factors, making the results difficult to interpret.
Although we do not know if females with antisocial behavior are similar to males, data from males can be used to generate hypotheses about hormone—antisocial behavior associations. Testosterone levels are higher in men with antisocial behavior who are violent or socially dominant in prison (Banks and Dabbs, 1996; Dabbs et al., 1991; Ehrenkranz et al., 1974; Kreuz and Rose, 1972; Mazur, 1995). Again, testosterone is the only hormone that has been studied. Unlike men with aggressive antisocial behavior, there is no consistent association between testosterone and aggression as a personality trait in the population of Non-antisocial boys or men (Gerra, 1997; Meyer-Bahlburg et al., 1974; Rowe et al., 2004; Schaal et al., 1996).
These findings highlight the concept that general aggression and antisocial behavior are not synonymous. Indeed, aggressive behaviors are only one sub-domain of the DSM-IV criteria for CD (see Table 1) and aggression can also be part of other disorders such as intermittent explosive disorder (APA, 1994). Furthermore, general aggression is part of a healthy repertoire of self-defining behaviors, even in girls.
Studies of boys with antisocial behavior are less conclusive than those of men, although more hormones have been studied. Testosterone levels in boys with CD or delinquency have been reported as elevated (Maras et al., 2003; Scerbo and Kolko, 1994), lower (Booth et al., 2003), or not different from comparison groups (Constantino et al., 1993; Dmitrieva et al., 2001; Granger et al., 2003; Mattson et al., 1980; Rowe et al., 2004; van Goozen et al., 1998). DHEA-S levels have been reported to be elevated in boys with CD or ODD (Dmitrieva et al., 2001; van Goozen et al., 1998, van Goozen et al., 2000). Androstenedione (van Goozen et al., 1998) and estradiol (Dmitrieva et al., 2001) levels did not differ in boys with CD or ODD, but were positively correlated with high delinquency scores on behavior ratings (Susman et al., 1987a, Susman et al., 1987b). The conflicting findings in males are likely to be due to differences in sample definition, heterogeneity in pubertal stage, small sample sizes, differences in techniques for measuring hormones, and no assessment of the effect of possible confounders such as demographic variables.
In summary, there are too few studies on girls or women with antisocial behavior to draw conclusions about whether adrenal androgen or gonadal hormones are important biological correlates. However, data from boys led us to hypothesize that girls with antisocial behavior may have higher androgen levels (from either adrenal or ovarian sources) or lower estradiol levels. Therefore, we conducted this study to answer three questions. First, is adolescent antisocial behavior in girls associated with abnormal levels of adrenal androgen or gonadal hormones? Second, do girls with antisocial behavior display higher levels of general aggression than girls without such behavior? Third, is there an association between general aggression and adrenal or gonadal hormones in adolescent girls if antisocial behavior is not present?
Section snippets
Participants
We recruited 15–17 year old girls from the community, through newspaper ads and posters. The ads sought girls with behavior problems such as “truancy, fighting, stealing, and lying.” The ads also stated that we were interested in girls without these problems. Details of the recruitment and subject selection are presented elsewhere (Pajer et al., 2001a).
Exclusion criteria for both groups were: age outside the 15–17-year range, pubertal development less than Tanner Stage V, history of head trauma
Participant characteristics
The demographic and psychiatric profiles of the sample are displayed in Table 2. Girls in the CD group were slightly, but significantly older than the girls in the NC group. Ethnicity and social classes proportions were not significantly different. None of the NC girls had any psychiatric illness by design. The three most common co-morbid psychiatric disorders in the CD sub-sample were some type of substance use disorder (38%), anxiety disorders (25.3%), and depressive disorders (10.6%). Two
Discussion
This study improved upon methodologic problems in previous studies by using girls with research diagnoses of CD and comparing them to girls without any psychiatric or medical disorders. Our sample was homogeneous with regards to pubertal stage. The data collection occurred at a standardized time (during the day and the menstrual cycle), we collected three samples, and we investigated more hormones than other studies, also assessing free levels of testosterone and estradiol. Our data analysis
Acknowledgments
This study was supported by a grant from NIMH (MH01285-04, PI: Pajer). The authors are grateful for the efforts of Judith Navratil, Barbara LeBeau, Shirley Conti, Stephen Neal, Deborah McCaskill, and Phyllis Wanetick in collecting these data and for the additional assistance of James Perel, Ph.D. and his laboratory. The authors also thank the young women who participated in this study.
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