s11 Full
s11 Full
s11 Full
4 4 ) , s 11 ^ s 1 4
METHOD
Selective review of findings published over
the past 10 years in childhood predictors
of antisocial personality disorder, and
consideration of issues still to be addressed
in relation to early identification of
individuals at risk.
None.
*Paper presented at the second conference of the British
and Irish Group for the Study of Personality Disorders
(BIGSPD),University of Leicester,UK, 31January to
3 February 2001.
RESULTS
Clinical policy
From a clinical and policy perspective, the
strength of the continuity from conduct
problems to antisocial personality disorder
is ample grounds for making strenuous
efforts to prevent the appearance of aggressive and disruptive behaviours in young
children, and to intervene early once they
have been identified. It is not the purpose
of this paper to review the evidence for
the effectiveness of prevention programmes
and of early interventions for conduct problems, but a brief summary highlights the
need for further refinements in early identification. A small number of adequately
designed randomised controlled trials of
preventive programmes to reduce conduct
problems have been carried out, some of
which have yielded promising results.
Equally, whereas there have been some
significant improvements, often the effects
have been quite small; and some studies
have shown no benefits (LeMarquand
et al,
al, 2001). There is substantial support
for the effectiveness of parent management
training programmes in reducing overall
levels of conduct problems in children
(Kazdin, 2000), and for the effectiveness
of stimulants where conduct problems are
associated with attention-deficit hyperactivity disorder (ADHD) (Swanson et al,
al,
2001). Nevertheless, there has been considerable variability in outcomes. Parent
training has been found to be less effective
for the higher-risk families characterised
by socio-economic disadvantage, marital
discord or single parent status, high parental stress and maternal unresolved loss or
trauma (Routh et al,
al, 1995; Kazdin, 1997).
Children with more severe or chronic problems or with comorbid conditions are less
likely to do well (Ruma et al,
al, 1996).
Evidence of the long-term effectiveness of
psychosocial treatments for conduct
problems, and of stimulants for conduct
problems comorbid with ADHD, is lacking.
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,
s11
HI
HIL L
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,
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,
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
s1 2
E A R LY I D E N T I F I C AT I ON OF R I S K F O R A N T I S O C I A L P E R S ON A L I T Y D I S O R D E R
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 Laubs 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,
al, 1998; Aguilar et al,
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,
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,
al, 1996;
Belsky et al,
al, 1998).
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.
DISCUSSION
Children at risk for future antisocial personality disorder are readily identified, but
evidence on the long-term effectiveness of
prevention and treatment programmes is
limited. Some progress has been made in
identifying subgroups of children with antisocial problems in which different causal
processes operate, and therefore for which
there are different treatment needs. The
available research does not yet tell us
whether differences in the patterning, or associated features, of childhood conduct
problems are predictive of distinctive adult
outcomes. If is possible that this review
was subject to selection bias.
REFERENCES
Aguilar, B., Sroufe, L. A., Egeland, B., et al (2000)
s13
HI
HIL L
CLINICAL IMPLICATIONS
&
&
&
LIMITATIONS
&
&
&
JONATHAN HILL, MRCPsych, University Child Mental Health Unit, Mulberry House, Alder Hey Hospital,
Eaton Road, Liverpool L12 2AP, UK. E-mail: jonathan.hill@
jonathan.hill@liverpool.ac.uk
s14
JONATHAN HILL
BJP 2003, 182:s11-s14.
Access the most recent version at DOI: 10.1192/bjp.182.44.s11
References
Reprints/
permissions
You can respond
to this article at
Downloaded
from
This article cites 30 articles, 0 of which you can access for free at:
http://bjp.rcpsych.org/content/182/44/s11#BIBL
To obtain reprints or permission to reproduce material from this paper, please
write to permissions@rcpsych.ac.uk
/letters/submit/bjprcpsych;182/44/s11
http://bjp.rcpsych.org/ on October 18, 2016
Published by The Royal College of Psychiatrists