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

Lifetime adversity predicts depression, anxiety, and cognitive impairment in a nationally representative sample of older adults in the United States

OBJECTIVE

Although life stress and adversity are well-known risk factors for mental health problems and cognitive impairment among older adults, limited research has comprehensively examined the impact of both childhood and adulthood adversity on psychiatric and cognitive impairment symptoms over a prolonged period. To address this issue, we investigated how lifetime adversity exposure is related to symptoms of depression, anxiety, and cognitive impairment in a nationally representative, longitudinal sample of older adults in the United States.

METHOD

We analyzed data from the Health and Retirement Study (1992-2016). The sample included 3496 individuals (59.9% female), aged ≥64 years old (Mage = 76.0 ± 7.6 years in 2016). We used the individual-level panel data and ordinary least squares regressions to estimate associations between childhood and adulthood adversities, and later-life depression, anxiety, and cognitive impairment.

RESULTS

Many participants experienced a significant early life (38%) or adulthood (79%) stressor. Moreover, experiencing one childhood adversity (vs. none) was associated with a 17.4% increased risk of adulthood adversity. Finally, as hypothesized, childhood adversity exposure was related to experiencing more depression and anxiety symptoms in later life, whereas adulthood stressor exposure predicted more cognitive impairment as well as more depression and anxiety symptoms.

DISCUSSION

These findings demonstrate significant associations between lifetime adversity and symptoms of depression, anxiety, and cognitive impairment in older adults. Screening for lifetime stressors may thus help healthcare professionals and policymakers identify individuals who could potentially benefit from interventions designed to reduce stress and enhance resilience.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BACKGROUND

Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the 'triply troubled'. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB.

METHODS

A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB.

RESULTS

A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression.

CONCLUSIONS

The present study helps disentangle the heterogeneity of the 'triply troubled' patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

Comorbidity of mental health and autism spectrum disorder: perception of practitioners in management of their challenging behaviour

The relationship between mental health problems, Autism Spectrum Disorder (ASD) and challenging behaviour among children and adolescents is complex and multifaceted. The study investigated practitioners' perception of comorbidity of mental health and ASD in the management of challenging behaviours among children and adolescents in Kenya. Target population was 3490 practitioners. Sample size was 1047, comprising of 38 assessment staff, 27 mental health workers 548 regular teachers, 294 teachers from special schools, and 140 teachers from special units for children with ASD. Stratified and purposive sampling techniques were used. Interviews and structured questionnaires were used. Test-retest yielded a coefficient of 0.78 while Cronbachs' reliability coefficient was 0.830. There was a positive significant correlation between perception of challenging behaviours and mental health problems (r = .415, p = .000). Challenging behaviour perceptions have a negative significant effect on behaviour management strategies, (β = -0.163, p = .000) implying that the choice of management strategies is dependent on the perceptions. Challenging behaviours accounts for 2.7% variance in the choice of the management strategies, R2 = .027, F(1,1045) = 28.471, p = .000.The practitioners' perception of mental health and comorbid ASD, showed that children with ASD, when enduring life stressors, can be at a higher risk of mental health difficulties than their peers There is need for multidisciplinary synergy in developing effective challenging behaviour programmes for children and adolescents with ASD.

Incidence and comorbidities of disruptive behavior disorders diagnosed in Finnish specialist psychiatric services

PURPOSE

Disruptive behavior disorders (DBD), including oppositional defiant disorder (ODD) and conduct disorder (CD), are some of the most common psychiatric conditions in childhood. Despite this, there has been limited research on DBDs. We examined the incidence, comorbidity and gender differences of DBDs diagnosed by specialist services.

METHOD

This was a nationwide register study of 570,815 children and adolescents born in 1996-2005. The 7050 individuals diagnosed with DBD by specialist healthcare services were matched to 26,804 controls.

RESULTS

By the age of 15, the cumulative incidence of diagnosed DBDs was 3.5% for boys and 1.4% for girls. The yearly incidence rate increased for girls after 13 years of age, while the incidence for boys was relatively stable between 8 and 15 years of age. When we compared subjects born between 1996-1998 and 1999-2001, we found that by the age of 12, the cumulative incidence per 100 people had increased from 0.56 to 0.68 among girls and from 2.3 to 2.6 among boys. This indicated a minor increase in treated incidence. The parents of children diagnosed with DBDs had lower educational levels than the parents of controls. Children with DBD were also more likely to have been diagnosed with other psychiatric disorders.

CONCLUSION

Although DBDs were 3.5 times more common among boys during the whole follow-up period, the yearly incidence during adolescence was fairly similar between boys and girls. DBD existed alongside various psychiatric disorders at a relatively young age and only a minor increase in treated incidence was found during childhood.

Helping Clinicians to Detect ODD in Children with ADHD in Clinical Settings

The objectives of this study were to provide a basic tool for pediatricians or other physicians to suspect and detect ODD in children with ADHD and to distinguish the symptomatic profile of ODD from ADHD. 101 subjects with ADHD, 83 with both ADHD and ODD and 342 controls aged 8 to 15 years were included in the study. A semi-structured interview was performed for evaluation of psychiatric diagnoses. Both parents and teachers completed DSM-IV Disruptive Behavior Disorders Rating Scale. We found differences among all three diagnostic subsamples in two-by-two analyses for all dimensions (Inattention, Hyperactivity/Impulsivity and ODD) both according to parent and teacher reports (p < 0.03 for all analyses). Based on parental ODD scores, ROC Curve analyses between 'only ADHD' and 'ADHD+ODD' groups showed that AUC was equal 0.80 (95%CI = 0.73-0.86) and the best cutoff point for ODD diagnosis in the ADHD subjects was 0.68. This study demonstrates the presence of a basic tool for detection and suspicion of ODD in children with ADHD for primary care clinicians or pediatricians in clinical settings. Findings also indicate that patients with ODD and ADHD have more severe inattention, hyperactivity/impulsivity and oppositional symptoms than those with only ADHD have.

Patterns of Lifetime Criminality in Mentally Disordered Offenders - Findings From a Nationally Representative Cohort

Background: Treatment of mentally disordered offenders (MDOs) is challenging as their behavior and clinical conditions can be traced to a complex constellation of major mental disorders, substance use and antisocial lifestyle. Finding subgroups of these offenders, which could guide treatment and risk assessment, is desirable. There are few long-term, prospective studies of risk factors for persistent criminal behavior among MDOs. Aims: The aims are (1) to provide a map of lifetime criminality in MDOs, (2) to identify subgroups of offenders, and (3), if such clusters exist, to test whether they differ in lifetime criminality and patterns of negative events during in-patient treatment. Methods: Background data on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment 1999-2005 (n = 125) was collected. Data on negative events during treatment (violence, threats, absconding and substance use) from date of admittance until discharge or until June 30, 2008 was gathered. Court decisions for 118 of the cohort-individuals were collected from the 1^st of January 1973 until December 31, 2013. We used hierarchical cluster analysis to identify subgroups and MANOVA-analysis to examine differences between these clusters on lifetime criminality variables and negative events. A MANCOVA was used to control for time in treatment. Results: The cohort was sentenced to a total of 3,380 crimes (944 violent) during the study period. Median age at first crime was 20 years (range 15-72), and at first violent crime 27 years (range 15-72). A subgroup (n = 26) was characterized by childhood adversities, neurodevelopmental disorders and later substance use disorders and was more often associated with substance-related crimes, financial crimes and lower age at first crime. During treatment, this cluster showed higher rates of substance use and threats. When controlling for treatment time, no differences in negative events were found. Conclusions: This study replicated findings from prison populations of the existence of a more criminally persistent phenotype characterized by early-onset neurodevelopmental and behavior disorders, childhood adversities and later substance use disorders. We did not find this cluster of variables to be related to negative events during inpatient treatment when controlling for length of stay.

Content, diagnostic, correlational, and genetic similarities between common measures of childhood aggressive behaviors and related psychiatric traits

BACKGROUND

Given the role of childhood aggressive behavior (AGG) in everyday child development, precise and accurate measurement is critical in clinical practice and research. This study aims to quantify agreement among widely used measures of childhood AGG regarding item content, clinical concordance, correlation, and underlying genetic construct.

METHODS

We analyzed data from 1254 Dutch twin pairs (age 8-10 years, 51.1% boys) from a general population sample for whom both parents completed the A-TAC, CBCL, and SDQ at the same occasion.

RESULTS

There was substantial variation in item content among AGG measures, ranging from .00 (i.e., mutually exclusive) to .50 (moderate agreement). Clinical concordance (i.e., do the same children score above a clinical threshold among AGG measures) was very weak to moderate with estimates ranging between .01 and .43 for mother-reports and between .12 and .42 for father-reports. Correlations among scales were weak to strong, ranging from .32 to .70 for mother-reports and from .32 to .64 for father-reports. We found weak to very strong genetic correlations among the measures, with estimates between .65 and .84 for mother-reports and between .30 and .87 for father-reports.

CONCLUSIONS

Our results demonstrated that degree of agreement between measures of AGG depends on the type (i.e., item content, clinical concordance, correlation, genetic correlation) of agreement considered. Because agreement was higher for correlations compared to clinical concordance (i.e., above or below a clinical cutoff), we propose the use of continuous scores to assess AGG, especially for combining data with different measures. Although item content can be different and agreement among observed measures may not be high, the genetic correlations indicate that the underlying genetic liability for childhood AGG is consistent across measures.

ADHD Among Offenders: Prevalence and Relationship With Psychopathic Traits

Objective: Longitudinal studies have shown a strong association between ADHD and criminal behavior. The aims of this study were to examine the prevalence of adult ADHD in a high-security facility and to investigate the relationship between ADHD symptoms and psychopathic traits in criminal offenders. Material and Methods: Participants were recruited between October 2015 and January 2016 among the inmates from a high-security all-male correctional facility in Portugal. Self-report scales were used to measure ADHD symptoms, current psychopathology, and psychopathic traits. An interview was conducted to collect sociodemographic data, along with information about adverse childhood experiences, substance use, and criminal record. The statistical analysis was conducted using STATA 13 with the significance level set at .05. Results: From the final sample of 101 male prisoners, 17 participants (16.8%) screened positive for ADHD. Participants positive for ADHD had higher levels of general psychopathology and psychopathic traits. Psychopathic traits remained significantly higher in ADHD offenders after controlling for age, substance abuse, and early childhood adversities (OR = 1.07, p = .002) and this was explained by differences in the Meanness subscale (OR = 1.11, p = .013). Discussion/conclusions: The present study shows that ADHD symptoms are highly prevalent among offenders and might have a modulating effect on the course of delinquent behavior. The cross-sectional association between ADHD symptoms and psychopathic traits reinforces the previously documented correlation between these disorders and can lead to a better understanding of the prevalent criminal behavior in ADHD patients.

Effects of 12-Week Methylphenidate Treatment on Neurometabolism in Adult Patients with ADHD: The First Double-Blind Placebo-Controlled MR Spectroscopy Study

Attention deficit hyperactivity disorder (ADHD) is a frequent neurodevelopmental disorder that often persists into adulthood. Methylphenidate (MPH) is the first-line treatment for ADHD; however, despite its wide usage, little is known about its neurometabolic effects. Until now, no randomized and blinded clinical trials have been conducted addressing the neurometabolic signals of MPH administration in adults with ADHD. In the current study, the authors investigated how MPH intake and group psychotherapy (GPT) influence brain neurometabolism over the course of three months. The authors hypothesized a decrease in the anterior cingulate cortex (ACC) glutamate concentration following MPH administration. This study was part of a double-blind multicenter trial (Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS)) investigating the effects of MPH and GPT in patients with adult ADHD. Using single-voxel magnetic resonance spectroscopy (MRS) of the pregenual ACC and the left cerebellar hemisphere (CHL), we investigated the concentration of glutamate plus glutamine (Glx), N-acetyl-aspartate, creatine, total choline containing compounds, and myo-inositol in patients before and after 12 weeks of treatment. Neither MPH nor GPT significantly influenced the Glx concentration or any of the other metabolite concentrations in the ACC and CHL after 12 weeks. Therefore, contrary to the hypothesis, no change in the prefrontal Glx signal was detected after MPH treatment. Given that MRS does not differentiate between glutamate in the synaptic cleft and in neuronal tissue, MPH-induced down-regulation of glutamatergic neurotransmission in the ACC might only affect the concentration of glutamate in the synaptic cleft, while the general availability of glutamate in the respective neuronal tissue might be unaffected by MPH intake. The observed lack of any MPH-induced normalization in metabolite concentrations is less surprising, considering that the baseline sample did not significantly differ from a healthy control group. Future studies of other regions, such as the basal ganglia, and the use of novel methods, such as whole brain MRS and multimodal imaging approaches, are necessary.

Associations Between Conduct Disorder, Neurodevelopmental Problems and Psychopathic Personality Traits in a Swedish Twin Youth Population

Previous research has found a complex relationship between psychopathic traits, neurodevelopmental problems (NDPs), and conduct disorder (CD) in children. This study explores associations between psychopathic traits, assessed with the Child Problematic Traits Inventory-Short Version (CPTI-SV), and CD in children with and without coexisting NDPs (i.e., attention deficit/hyperactivity disorder [ADHD] and autism spectrum disorder [ASD]) in a community-based sample of Swedish twins (n = 8762). Findings indicate weak to moderately strong correlations between psychopathic traits and CD, ADHD, and ASD, respectively. Furthermore, in univariable analyses, both psychopathic traits and NDPs displayed significant positive associations with being screened positive for CD, though only the grandiose-deceitful dimension of CPTI-SV and the ADHD domain concentration and attention deficits remained significantly associated with CD in a multivariable regression model. The results are relevant to screening and assessment in child and youth psychiatry, as a grandiose and deceitful interpersonal style may also be a valid sign of children at risk of developing CD.

ADHD, CD, and ODD: Systematic review of genetic and environmental risk factors

This review aims to analyze the relationships between Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD), particularly regarding the relative importance of genetic and environmental factors in the development of these disorders. Studies that examined at least two of these disorders were obtained from multiple databases, following the procedures of the Cochrane Collaboration initiative. Of the 279 documents obtained, nine were retained for in-depth analysis and were considered eligible for inclusion. In addition, eight studies from the manual search were included. The objectives, methodological aspects (sample and instruments), and the main conclusions were extracted from each study. Overall, the results suggest that (a) the causes for the onset and maintenance of these disorders are more associated with genetic factors than environmental factors, although the importance of the latter is recognized, and (b) children with ADHD have a predisposition to manifest behaviors that are common to ODD and CD, including the antisocial behavior that these children often display.

Pediatric Referrals for Urgent Psychiatric Consultation: Clinical Characteristics, Diagnoses and Outcome of 4 to 12 Year Old Children

OBJECTIVES

1) To describe clinical characteristics and outcomes of children referred for urgent psychiatric consultation to a Child and Adolescent Mental Health Urgent Consult Clinic (CAMHUCC); and, 2) To study the association between referral source, clinical characteristics, and post assessment outcome.

METHOD

This is a 12-month retrospective cohort study of children aged 4 to 12-years referred to a CAMHUCC. The clinic's electronic data base contains demographic and clinical information including reason for referral, diagnosis, and consult outcome. Study data were extracted and analyzed using descriptive statistics and Mann-Whitney U tests.

RESULTS

The study sample consisted of 120 children, 41.5% male, average age 9.03 years (SD=2.2). Fifty-percent were referred by Children's Mental Health Agencies (CMHA) and 31.7% by Emergency Departments. The most frequent reason for referral was aggression (64.1%). Most common diagnoses were externalizing disorders (76.7%). Thirty-percent had an identified learning disorder, 80% were referred back to the community and 14.2% were referred to outpatient clinic. There was a significant association between referral from an Emergency Department and female gender (p=0.048) and brief follow-up with CAMHUCC (p=0.006).

CONCLUSION

Regardless of source of referral, the most common reason for urgent psychiatric referral was aggression and the majority of individuals did not require inpatient psychiatric care. Collaborative multiagency education in child and adolescent mental health disorders, including the role of learning disabilities in externalizing behaviors, may improve the capacity of CMHA and schools to identify and provide focused interventions that may, in turn, reduce behavioral crisis and visits to Emergency Departments and urgent clinics.

Discrepancies between self- and adult-perceptions of social competence in children with neuropsychiatric disorders

BACKGROUND

The present study examines discrepancies between self- and adult-perceptions of social competence in children with attention deficit-hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and possible co-morbid disruptive behaviour disorders (DBD).

METHOD

Self-reported questionnaires were collected from multiple informants at the baseline of a multi-systemic family intervention programme for children (aged 5-12) with ADHD, ASD and possible co-morbid DBD. In total, out of the 154 families eligible for the study, information was received concerning children from 124 families (children n = 121; mothers n = 117; fathers n = 86; teachers n = 97). In addition to this, a comparison community sample of 318 school-aged children (approximately 10 years old) was utilized to examine the perceptions of children's social competence across intervention and population groups in more detail.

RESULTS

Children's self-perceptions in the prosocial dimension of social competence (i.e. cooperating skills, empathy) did not differ between the intervention and comparison groups. Interestingly, the children in the intervention sample expressed more impulsivity and disruptiveness - the antisocial dimension of social competence - when compared with the children in the comparison sample. Adult ratings demonstrated that mothers, fathers and teachers reported decreased prosocial behaviour and increased antisocial behaviour across overall dimensions and sub-dimensions when compared with adults' ratings of elementary school children. Informant discrepancies between self-ratings and adult ratings across intervention groups yielded significant effect sizes (eta-squared) across all domains of social competence ranging from .09 to .25.

CONCLUSION

Children's positive self-ratings of social competence relative to adult ratings increased within intervention sample when compared with population sample. The intervention sample children appeared to acknowledge their social competence deficits, yet self-perceptions were inflated relative to adult ratings when focusing on peer relationship difficulties, particularly, aggression to peers.

The protective effect of character maturity in child aggressive antisocial behavior

BACKGROUND

Childhood aggressive antisocial behavior (CD) is one of the strongest predictors of mental health problems and criminal behavior in adulthood. The aims of this study were to describe personality profiles in children with CD, and to determine the strength of association between defined neurodevelopmental symptoms, dimensions of character maturity and CD.

METHODS

A sample of 1886 children with a close to equal distribution of age (9 or 12) and gender, enriched for neurodevelopmental and psychiatric problems were selected from the nationwide Child and Adolescent Twin Study in Sweden. Their parents rated them according to the Junior Temperament and Character Inventory following a telephone interview during which information about the children's development and mental health was assessed with the Autism-Tics, AD/HD and other Comorbidities inventory.

RESULT

Scores on the CD module significantly and positively correlated with scores on the Novelty Seeking temperament dimension and negatively with scores on character maturity (Self-Directedness and Cooperativeness). In the group of children with either neurodevelopmental or behavioral problems, the prevalence of low or very low character maturity was 50%, while when these two problems coexisted the prevalence of low or very low character maturity increased to 70%. Neurodevelopmental problems (such as: oppositional defiant disorder, symptoms of attention deficit/hyperactivity disorder and autism spectrum disorder) and low scores on character maturity emerged as independently significant predictors of CD; in a multivariable model, only oppositional defiant symptoms and impulsivity significantly increased the risk for coexisting CD while a mature self-agency in a child (Self-Directedness) remained a significant protective factor.

CONCLUSION

These results suggest that children's willpower, the capacity to achieve personally chosen goals may be an important protective factor - even in the presence of neurodevelopmental and psychiatric problems - against progressing into persistent negative outcomes, such as aggressive antisocial behaviors.

Neurodevelopmental disorders in young violent offenders: Overlap and background characteristics

Neurodevelopmental disorders (Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), tic disorder, intellectual disability (ID)), in prison populations have received increased attention but the focus has generally been on one single condition leaving out the global picture. This study assessed the prevalence and overlap of neurodevelopmental disorders (NDD) in a consecutive cohort (n=270) of young adult male offenders (age 18-25 years), sentenced for "hands-on" violent offences and serving prison time in Swedish prisons. Seventy-one percent of all who met inclusion criteria participated. Comprehensive clinical assessments were carried out including history of early antisocial behavior and maladjustment, self-report questionnaires and an intelligence test. Sixty-three percent of the study group met DSM-IV criteria for childhood ADHD, 43% for ADHD in adulthood, 10% met criteria for an ASD, 6% for Tourette syndrome, and 1% for ID. Twenty-two percent had borderline intellectual functioning. A substantial rate of overlap between the NDDs was found. The combined NDD group had an earlier onset of antisocial behavior, had more aggressive behavior and lower school achievements than the non-NDD group. The results highlight the need for prison and probation services to be attentive of and screen for neurodevelopmental disorders in young violent offenders.

Mental health among young adults in prison: the importance of childhood-onset conduct disorder

BACKGROUND

The psychiatric health burden of prisoners is substantial. However, there is a lack of high-quality studies of psychiatric disorders among young adults with a high risk of reoffending.

AIMS

To investigate the lifetime prevalence of psychiatric disorders and use of mental health services among young male violent offenders and the impact of childhood-onset conduct disorder (COCD).

METHOD

A nationally representative cohort (n = 270, age 18-25) of male offenders was followed back in medical records and clinically assessed by gold standard methods. Lifetime prevalences are presented together with odds ratios (ORs) as risk estimates in relation to COCD.

RESULTS

Previous use of psychiatric services among the participants was high but their lifetime psychiatric morbidity was even higher, with 93% meeting criteria for at least one Axis I disorder. The COCD group was overrepresented in most clinical categories and carried five times higher odds (OR = 5.1, 95% CI 2.0-12.8) of a psychotic disorder, three times higher odds (OR = 3.2, 95% CI 1.2-8.5) of a substance use disorder and two times higher odds of a mood disorder (OR = 2.3, 95% CI 1.3-4.0) or anxiety disorder (OR = 2.0, 95% CI 1.1-3.5).

CONCLUSIONS

The mental health burden is substantial among young violent offenders, and COCD is an important indicator of future mental health problems which must be a priority for public health efforts.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Mentally disordered offenders in Sweden: differentiating recidivists from non-recidivists in a 10-year follow-up study

BACKGROUND

Forensic psychiatric patients present a challenge as they manifest severe mental disorders together with criminal behaviour. There are well-known risk factors for criminal behaviour in the general population, yet knowledge of what predicts reconviction in the Swedish forensic population in the long-term perspective is still insufficient.

AIMS

The study aims to (1) describe background and clinical characteristics of forensic psychiatric patients in a 10-year follow-up, (2) analyse risk factors associated with recidivism, and (3) test the predictive validity of risk factors for general and violent criminality.

METHODS

Detailed information on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment from 1999-2005 (n = 125) was collected. Court decisions were collected up until the end of 2008 (median follow-up time = 6.2 years, range = 0.6-9.7 years).

RESULTS

Relapse in general crime (n = 30) was predicted by low educational attainment, mental disorder in a first degree relative, and low age at first sentenced crime. Relapse in violent crime (n = 16) was predicted by low educational attainment and low GAF scores. Patients with a restriction order were less likely to relapse in both crime categories.

CONCLUSIONS

Signs of childhood adversities together with early debut in criminality appeared as important risk factors for general and violent recidivism. Forensic psychiatric treatment combined with a restriction order was demonstrated as a protective factor against recidivism, suggesting that the risk of recidivism is strongly related to the level of supervision. Although the low number of recidivism cases is highly desirable, it unfortunately reduces the power of the analyses in this paper.

["Attention deficit hyperactivity disorder in forensic psychiatry: A review"]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is one of the most common and challenging childhood neurobehavioral disorders. ADHD may have behavioral consequences and involvements in minor and serious crimes. Our work aims to establish links between ADHD and forensic psychiatry.

METHODS

A review of international scientific literature concerning the relationship between ADHD and forensic psychiatry was conducted using the PudMed electronic database. We used the Mesh terms: "attention deficit hyperactivity disorder" and "forensic psychiatry". We also used the "related articles" function of PubMed, the bibliography of selected articles and the Google Scholar database to identify possible additional papers.

RESULTS

The prevalence of ADHD in prison populations may vary but remain higher than those found in the general population. Violence committed by a person with ADHD seems to be against other persons rather than property offences. Reactive-impulsive violence seems to be more prevalent than pro-active instrumental violence. The existence of ADHD does not appear as a risk factor of recidivism. The violence risk may be increased by the occurrence of comorbidities as conduct disorders and mental deficiency. There may exist a preferential association between ADHD and antisocial personality disorder or substance abuse which both increase the risk of violence.

DISCUSSION

To put in perspective forensic psychiatry and ADHD allowed us to identify typology of violence, epidemiological aspect of ADHD in a prison environment and comorbidities involved in the risk of violence. This research permits to precise elements of prevention, diagnosis and assistance in the management of violent behaviour in ADHD and in expert practice.

Genome-wide analyses of aggressiveness in attention-deficit hyperactivity disorder

Aggressiveness is a behavioral trait that has the potential to be harmful to individuals and society. With an estimated heritability of about 40%, genetics is important in its development. We performed an exploratory genome-wide association (GWA) analysis of childhood aggressiveness in attention deficit hyperactivity disorder (ADHD) to gain insight into the underlying biological processes associated with this trait. Our primary sample consisted of 1,060 adult ADHD patients (aADHD). To further explore the genetic architecture of childhood aggressiveness, we performed enrichment analyses of suggestive genome-wide associations observed in aADHD among GWA signals of dimensions of oppositionality (defiant/vindictive and irritable dimensions) in childhood ADHD (cADHD). No single polymorphism reached genome-wide significance (P < 5.00E-08). The strongest signal in aADHD was observed at rs10826548, within a long noncoding RNA gene (beta = -1.66, standard error (SE) = 0.34, P = 1.07E-06), closely followed by rs35974940 in the neurotrimin gene (beta = 3.23, SE = 0.67, P = 1.26E-06). The top GWA SNPs observed in aADHD showed significant enrichment of signals from both the defiant/vindictive dimension (Fisher's P-value = 2.28E-06) and the irritable dimension in cADHD (Fisher's P-value = 0.0061). In sum, our results identify a number of biologically interesting markers possibly underlying childhood aggressiveness and provide targets for further genetic exploration of aggressiveness across psychiatric disorders. © 2016 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics Published by Wiley Periodicals, Inc.

Aggressive Antisocial Behaviors Are Related to Character Maturity in Young Swedish Violent Offenders Independent of ADHD

BACKGROUND

Antisocial personality and psychopathic traits have constantly been found to accompany criminal and aggressive behaviors, but little attention has been given to aspects of character maturity and its relation to such behaviors. The present study investigated (1) whether level of character maturity (low, medium, and high) is associated with amount of aggressive antisocial behaviors (AABs) and psychopathic traits in young men imprisoned for violent criminality, and (2) whether such an association is independent of coexisting attention-deficit hyperactivity disorder (ADHD).

METHODS

Swedish males (N = 270, aged 18-25) sentenced to prison for violent and/or sexual criminality in the western region of the Swedish Prison and Probation Service underwent a thorough clinical examination during their incarceration. Data on character maturity, as measured by the character dimensions Self-Directedness and Cooperativeness of the Temperament and Character Inventory, were available for n = 148 subjects and were used to divide these offenders into three groups with low, medium, and high character maturity. These groups were then compared for variables reflecting criminal history, a DSM-IV diagnosis of ADHD, conduct disorder (CD) and substance use disorders (SUD), aggressive behaviors, and psychopathic traits.

RESULTS

Character maturity was consistently associated with less AABs and psychopathic personality traits; the group with the highest character maturity showed: (i) a later age at onset of criminality, (ii) a smaller number of prior violent criminal acts, (iii) lower prevalence of ADHD, CD, and SUD, (iv) less self-rated and expert-rated aggressive behaviors, and (v) less psychopathic traits. The association between character maturity and aggressive behaviors/psychopathic personality traits remained even when ADHD was controlled for. The only exception was sexual criminality, where the group with the highest character maturity contained the largest amount of sexual offenders.

CONCLUSION

Higher character maturity appeared to be a protective factor among young male violent offenders, associated with less AABs, suggesting that character maturity is a promising target for treatment interventions for this group of individuals.

The Return of Lombroso? Ethical Aspects of (Visions of) Preventive Forensic Screening

The vision of legendary criminologist Cesare Lombroso to use scientific theories of individual causes of crime as a basis for screening and prevention programmes targeting individuals at risk for future criminal behaviour has resurfaced, following advances in genetics, neuroscience and psychiatric epidemiology. This article analyses this idea and maps its ethical implications from a public health ethical standpoint. Twenty-seven variants of the new Lombrosian vision of forensic screening and prevention are distinguished, and some scientific and technical limitations are noted. Some lures, biases and structural factors, making the application of the Lombrosian idea likely in spite of weak evidence are pointed out and noted as a specific type of ethical aspect. Many classic and complex ethical challenges for health screening programmes are shown to apply to the identified variants and the choice between them, albeit with peculiar and often provoking variations. These variations are shown to actualize an underlying theoretical conundrum in need of further study, pertaining to the relationship between public health ethics and the ethics and values of criminal law policy.

Evolution of the Study of Methylphenidate and Its Actions on the Adult Versus Juvenile Brain

OBJECTIVE

Methylphenidate (MPH) is the most often prescribed medication for treatment of ADHD. However, many of its specific cellular and molecular mechanisms of action, as well as developmental consequences of treatment, are largely unknown. This review provides an overview of current understanding of MPH efficacy, safety, and dosage in adult and pediatric ADHD patients, as well as adult animal studies and pioneering studies in juvenile animals treated with MPH.

METHOD

A thorough review of the current literature on MPH efficacy and safety in children, adults, and animal models was included. Results of studies were compared and contrasted.

RESULTS

While MPH is currently considered safe, there is a lack of knowledge of potential developmental consequences of early treatment, as well as differences in drug actions in the developing versus mature brain system.

CONCLUSION

This review emphasizes the need for further research into the age-dependent activities and potency of MPH, and a need for tighter control and clinical relevance in future studies.

Prosocial skills may be necessary for better peer functioning in children with symptoms of disruptive behavior disorders

Children with disruptive behavior disorders experience substantial social challenges; however, the factors that account for (i.e., mediate), or influence (i.e., moderate), peer problems are not well understood. This study tested whether symptoms of Oppositional Defiant Disorder and Conduct Disorder were associated with peer impairment and whether prosocial skills mediated or moderated these associations. Teacher ratings were gathered for 149 children (Mage = 9.09, SD = 1.71, 26% female) referred for behavioral concerns to an urban child psychiatry clinic. Path-analytic linear regressions testing mediation and moderation effects showed that prosocial skills significantly moderated the negative effects of symptoms of Conduct Disorder on peer impairment. Children showed less peer impairment only when they had relatively few conduct symptoms and high prosocial skills. Measurement of prosocial skills, in addition to conduct problems, may best capture factors which contribute to peer problems of children with disruptive behaviors.

Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature

OBJECTIVE

To raise awareness of attention-deficit/hyperactivity disorder (ADHD) as an underdiagnosed, undertreated, often comorbid, and debilitating condition in adults.

DATA SOURCES

PubMed was searched using combinations of keywords, including ADHD, adult, diagnosis, identify, prevalence, and comorbid, to find articles published between 1976 and 2013.

STUDY SELECTION

In total, 99 articles were selected for inclusion on the basis of their relevance to the objective and importance to and representation of ADHD research, including international guidelines for adults with ADHD.

RESULTS

In a large proportion of children with ADHD, symptoms persist into adulthood. However, although adults with ADHD often experience chaotic lifestyles, with impaired educational and vocational achievement and higher risks of substance abuse and imprisonment, many remain undiagnosed and/or untreated. ADHD is usually accompanied by other psychiatric comorbidities (such as major depressive disorder, anxiety disorder, and alcohol abuse). Indeed, adults with ADHD are more likely to present to a psychiatric clinic for treatment of their comorbid disorders than for ADHD, and their ADHD symptoms are often mistaken for those of their comorbidities. Untreated ADHD in adults with psychiatric comorbidities leads to poor clinical and functional outcomes for the patient even if comorbidities are treated. Effective treatment of adults' ADHD improves symptoms, emotional lability, and patient functioning, often leading to favorable outcomes (eg, safer driving, reduced criminality). A few medications have now been approved for use in adults with ADHD, while a multimodal approach involving psychotherapy has also shown promising results. Conclusions General psychiatrists should familiarize themselves with the symptoms of ADHD in adults in order to diagnose and manage ADHD and comorbidities appropriately in these patients.

Executive functions and basic symptoms in adolescent antisocial behavior: a cross-sectional study on an Italian sample of late-onset offenders

Executive cognitive functions (ECFs) and other cognitive impairments, such as lower IQ and verbal deficits, have been associated with the pattern of antisocial and delinquent behavior starting in childhood (early-onset), but not with late-onset antisocial behavior. Beyond objective measures of ECF, basic symptoms are prodromal, subjectively experienced cognitive, perceptual, affective, and social disturbances, associated with a range of psychiatric disorders, mainly with psychosis. The goal of the present study was to examine ECF and basic symptoms in a sample of late-onset juvenile delinquents. Two-hundred nine male adolescents (aged 15-20 years) characterized by a pattern of late-onset delinquent behavior with no antecedents of Conduct Disorder, were consecutively recruited from the Social Services of the Department of Juvenile Justice of the city of Messina (Italy), and compared with nonantisocial controls matched for age, educational level, and socio-demographic features on measures for ECF dysfunction and basic symptoms. Significant differences between late-onset offenders (completers=147) and control group (n=150) were found on ECF and basic symptoms measures. Chi-square analysis showed that a significantly greater number of late-onset offending participants scored in the clinical range on several ECF measures. Executive cognitive impairment, even subtle and subclinical, along with subjective symptoms of cognitive dysfunction (basic symptom), may be contributing factor in the development and persistence of antisocial behaviors displayed by late-onset adolescent delinquents. The findings also suggest the need for additional research aimed to assess a broader range of cognitive abilities and specific vulnerability and risk factors for late-onset adolescent offenders.

Attention deficit hyperactivity disorder in offenders and the need for early intervention

Attention deficit hyperactivity disorder (ADHD) can be, for some people, a pathway to prison. Intervening at an early age may prevent delinquency. Generally, these interventions consist of a combination of medication, cognitive-behavioral therapy, family intervention, and educational support. Despite these interventions, some people with ADHD still develop antisocial and criminal behavior. This article examines the link between ADHD and delinquency, and reviews relevant treatments.

ADHD, autism spectrum disorder, temperament, and character: phenotypical associations and etiology in a Swedish childhood twin study

OBJECTIVE

To explore the links between neurodevelopmental disorders - attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) - and personality in a population-based, genetically sensitive study of children.

METHOD

A population-based sample of 1886 twins aged 9 and 12, enriched for childhood mental health problems, was recruited from the Child and Adolescent Twin Study in Sweden (CATSS). Parents were interviewed over the telephone using the Autism-Tics, AD/HD and other Comorbidities (A-TAC) inventory, and in a second step they rated their children according to the Junior Temperament and Character Inventory (JTCI).

RESULTS

ADHD was strongly correlated with novelty seeking, while ASD was correlated positively with harm avoidance and negatively with reward dependence. The strongest associations between personality traits and neurodevelopmental disorders were negative correlations between the character dimensions of self-directedness and cooperativeness and ADHD and ASD alike. Cross-twin cross-trait correlations between ADHD, ASD, and personality dimensions in monozygotic twins were more than double those in dizygotic twins, indicating a strong genetic effect behind the phenotypic covariation between neurodevelopmental disorders and personality.

CONCLUSIONS

Neurodevelopmental disorders are linked specifically to particular temperament profiles and generally to hampered development of the self-governing strategies referred to as "character." Poor self-agency and cooperation may be core functional outcomes in the separation of children with handicapping conditions from those with traits only reminiscent of neurodevelopmental disorders. The associations between neurodevelopmental disorders and personality are at least partly due to genetic effects influencing both conditions. As a consequence, personality must be broadly considered in neuropsychiatry, just as neuropsychiatric disorders and their genetic, neurodevelopmental, and cognitive susceptibilities have to be in personality research and clinical treatment.

Learning difficulties: a retrospective study of their co morbidity and continuity as indicators of adult criminal behaviour in 18-70-year-old prisoners

The development of learning difficulties is associated with problems in external (executive) and extensive behaviour in a co-occurrence with psycho-emotional problems beginning from pre-school, school age, and adolescence up to adulthood. Through the current survey, we aim to emphasise the early role of learning difficulties during the school age and adolescence of prisoners and their effects on the onset of offending behaviours in adulthood, such as criminal behaviour. Altogether, we studied 117 Greek adult prisoners from 18 to 70 years old who were accused of different types or degrees of offences. Through statistical analyses, the following factors were observed with high statistical significance as early indicators of criminal behaviour in the adult lives of the prisoners: (i) learning difficulties, (ii) family problems, (iii) behaviour disorders, (iv) developmental disorders, and (v) psycho-emotional disorders. As a result, the learning difficulties were assumed to be the most decisive factor in the developmental progression of prisoners because they manifested early in the prisoners' lives, weakened the prisoners to be competitive and robust, provoked a bad self-image and low self-esteem, and, in the frame of a weak or negative family and educational environment, they accompanied antisocial behaviour and psycho-emotional disorders even from adolescence, which continued into adulthood.

Predictive properties of the A-TAC inventory when screening for childhood-onset neurodevelopmental problems in a population-based sample

BACKGROUND

Identifying children with childhood-onset neurodevelopmental problems (NDPs, defined here as autism spectrum disorders [ASDs], attention-deficit/hyperactivity disorder [AD/HD], tic disorders [TDs], learning disorders [LDs] and development coordination disorder), using easily administered screening instruments, is a prerequisite for epidemiological research. Such instruments are also clinically useful to prioritize children for comprehensive assessments, to screen risk groups, and to follow controls.Autism-Tics, ADHD, and other Co-morbidities inventory (A-TAC) was developed to meet these requirements; here the A-TAC's prospective and psychometric properties are examined, when used in a population-based, epidemiological setting.

METHODS

Since 2004, parents of all Swedish twins have been asked to take part in an ongoing, nation-wide twin study (The Child and Adolescent Twin Study in Sweden). The study includes the A-TAC, carried out as a telephone interview with parents of twins aged 9 or 12. In the present study, screen-positive twins from three birth year cohorts (1993-1995) were invited to a comprehensive clinical follow-up (blinded for previous screening results) together with their co-twins and randomly selected, healthy controls at age 15 (Total N = 452).

RESULTS

Sensitivity and specificity of A-TAC scores for predicting later clinical diagnoses were good to excellent overall, with values of the area under the receiver operating characteristics curves ranging from 0.77 (AD/HD) to 0.91 (ASDs). Among children who were screen-positive for an ASD, 48% received a clinical diagnosis of ASDs. For AD/HD, the corresponding figure was also 48%, for LDs 16%, and for TDs 60%. Between 4% and 35% of screen-positive children did not receive any diagnosis at the clinical follow-up three years later. Among screen-negative controls, prevalence of ASDs, AD/HD, LDs, and TDs was 0%, 7%, 4%, and 2%, respectively.

CONCLUSIONS

The A-TAC appeared to be a valid instrument to assess NDPs in this population-based, longitudinal study. It has good-to-excellent psychometric properties, with an excellent ability to distinguish NDPs (mainly ASDs) from non-NDPs at least three years after the screening evaluations, although specific diagnoses did not correspond closely to actual clinical diagnoses.

Childhood trajectories of inattention, hyperactivity and oppositional behaviors and prediction of substance abuse/dependence: a 15-year longitudinal population-based study

Numerous prospective studies have shown that children diagnosed with attention deficit/hyperactivity disorder (ADHD) are at higher risk of long-term substance abuse/dependence. However, there are three important limits to these studies: (a) most did not differentiate the role of hyperactivity and inattention; (b) most did not control for associated behavioral problems; and (c) most did not consider females. Our aim was to clarify the unique and interactive contributions of childhood inattention and hyperactivity symptoms to early adulthood substance abuse/dependence. Behavioral problems of 1803 participants (814 males) in a population-based longitudinal study were assessed yearly between 6 and 12 years by mothers and teachers. The prevalence of substance abuse/dependence at age 21 years was 30.7% for nicotine, 13.4% for alcohol, 9.1% for cannabis and 2.0% for cocaine. The significant predictors of nicotine dependence were inattention (odds ratio (OR): 2.25; 95% confidence interval (CI): 1.63-3.11) and opposition (OR: 1.65; 95%: 1.20-2.28). Only opposition contributed to the prediction of cannabis dependence (OR: 2.33; 95% CI: 1.40-3.87) and cocaine dependence (OR: 2.97; 95% CI: 1.06-8.57). The best behavioral predictor of alcohol abuse/dependence (opposition) was only marginally significant (OR: 1.38; 95% CI: 0.98-1.95). Frequent oppositional behaviors during elementary school were clearly the most pervasive predictors of substance abuse/dependence in early adulthood. The association of childhood ADHD with substance abuse/dependence is largely attributable to its association with opposition problems during childhood. However, inattention remained an important predictor of nicotine dependence, in line with genetic and molecular commonalities between the two phenotypes suggested in the literature.

A Follow-up Study of Academic Functioning and Social Adjustment in Children with Attention Deficit Hyperactivity Disorder

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) persists in a majority of adolescents. It has been reported that ADHD patients have poor social functioning and risk for developing co-morbid psychiatric illnesses.

AIMS

To determine the retention of diagnosis of ADHD and to assess social adjustment, academic functioning and co-morbidities at follow-up.

DESIGN

Retrospective cohort study.

MATERIALS AND METHODS

ADHD patients of 5-14 years of age who came to the out-patient department from 2005 to 2008 were contacted telephonically. Fifty one patients could be contacted. Parents of patients were interviewed using Vanderbilt ADHD Diagnostic Parent Rating Scale for diagnosing ADHD and co-morbidities. Social Adjustment Inventory for Children and Adolescent was administered for assessing their academic and social functioning. Chi square test, Mann-Whitney Test, Kruskal-Wallis Test, and Pearson's product moment correlations were used for statistical analysis.

RESULTS

At current assessment, out of 51 patients, 38 were still fulfilling diagnosis of ADHD. Of these, 21 were of inattention type, 3 were hyperactive, and 14 were of combined type. Social functioning and academic functioning were significantly better in those who currently did not fulfill the criteria for ADHD (N=13). Twelve patients developed features of oppositional defiant disorder (ODD)/conduct disorder (CD) at follow-up.

CONCLUSIONS

ADHD persists in the majority of adolescents. Decline with age is seen more in hyperactive/impulsive symptoms than inattentive symptoms. Several adolescents also develop features of ODD/CD in addition to poorer functioning. Continuation of treatment is crucial to prevent such consequences.

Toward a theory of childhood learning disorders, hyperactivity, and aggression

Learning disorders are often associated with persistent hyperactivity and aggression and are part of a spectrum of neurodevelopmental disorders. A potential clue to understanding these linked phenomena is that physical exercise and passive forms of stimulation are calming, enhance cognitive functions and learning, and are recommended as complementary treatments for these problems. The theory is proposed that hyperactivity and aggression are intense stimulation-seeking behaviors (SSBs) driven by increased brain retinergic activity, and the stimulation thus obtained activates opposing nitrergic systems which inhibit retinergic activity, induce a state of calm, and enhance cognition and learning. In persons with cognitive deficits and associated behavioral disorders, the retinergic system may be chronically overactivated and the nitrergic system chronically underactivated due to environmental exposures occurring pre- and/or postnatally that affect retinoid metabolism or expression. For such individuals, the intensity of stimulation generated by SSB may be insufficient to activate the inhibitory nitrergic system. A multidisciplinary research program is needed to test the model and, in particular, to determine the extent to which applied physical treatments can activate the nitrergic system directly, providing the necessary level of intensity of sensory stimulation to substitute for that obtained in maladaptive and harmful ways by SSB, thereby reducing SSB and enhancing cognitive skills and performance.

Distress, defiance or adaptation? A review paper of at-risk mental health states in young offenders

AIM

This paper firstly aims to explore the prevalence of mental health problems in young offenders and secondly, to review the factors which mean a young offender is at risk of developing more serious and chronic mental health problems, including psychosis.

METHODS

The literature in this field will be reviewed, and the highlighted risk factors explored in detail.

RESULTS

Reviewing the evidence base highlights the complex needs of this population, as the prevalence of mental health problems in both detained and community-based young offenders is high, with the presence of at least one mental health problem found in up to 92%. There is much data to suggest that young offenders have many of the risk indicators that would place them at risk of significant mental health problems according to previously identified criteria. Factors such as intellectual level, difficulties in school, substance abuse problems, exposure to trauma and problems understood within an attachment framework are explored.

CONCLUSION

The main conclusion is that this population have many risk factors which increase the possibility of developing serious mental health problems, therefore highlighting the need for early intervention.

Facets of psychopathy among mentally disordered offenders: clinical comorbidity patterns and prediction of violent and criminal behavior

The complexity and consequences of psychopathy are still debated, and its relation to other mental disorders, pathological personality traits, and criminality needs to be further investigated by clinical, longitudinal studies using structured diagnostic instruments. The present study used two groups of mentally disordered offenders (N=153) investigated with in-depth clinical assessments and prospective long-term follow-up to identify the convergence between 1) the four facets of psychopathy defined by the Psychopathy Checklist-Revised (PCL-R; Interpersonal, Affective, Lifestyle, and Antisocial), 2) mental disorders according to SCID I and II interviews, 3) personality traits as measured by the Karolinska Scales of Personality, and 4) criminal recidivism. The Interpersonal facet differed substantially from the other three facets by not being significantly associated with substance use disorders, antisocial personality disorder (the other facets at P≤0.001 level), or personality traits involving impulsive and aggressive antisocial behaviors (the other facets at P<0.01 level). Furthermore, the interpersonal facet could not predict violent recidivism better than random. The Antisocial facet outperformed not only the other facets but also the total PCL-R score in the prediction of violent recidivism, P<0.001.The findings confirm psychopathy as a heterogeneous phenomenon and have clinical implications for assessments of psychopathy and violence risk assessments in clinical and forensic contexts.

The Child and Adolescent Twin Study in Sweden (CATSS)

The Child and Adolescent Twin Study in Sweden (CATSS) is an ongoing longitudinal twin study targeting all twins born in Sweden since July 1, 1992. Since 2004, parents of twins are interviewed regarding the children's somatic and mental health and social environment in connection with their 9th or 12th birthdays (CATSS-9/12). By January 2010, 8,610 parental interviews concerning 17,220 twins had been completed, with an overall response rate of 80%. At age 15 (CATSS-15) and 18 (CATSS-18), twins and parents complete questionnaires that, in addition to assessments of somatic and mental health, include measures of personality development and psychosocial adaptation. Twin pairs in CATSS-9/12 with one or both twins screening positive for autism spectrum disorders, attention deficit/hyperactivity disorder, tic disorders, developmental coordination disorder, learning disorders, oppositional defiant disorder, conduct disorder, obsessive-compulsive disorder, and/or eating problems have been followed with in-depth questionnaires on family, social environment and personality, and subsequently by clinical assessments at age 15 together with randomly selected population controls, including 195 clinically assessed twin pairs from the first 2 year cohorts (CATSS-15/DOGSS). This article describes the cohorts and study groups, data collection, and measures used. Prevalences, distributions, heritability estimates, ages at onset, and sex differences of mental health problems in the CATSS-9/12, that were analyzed and found to be overall comparable to those of other clinical and epidemiological studies. The CATSS study has the potential of answering important questions on the etiology of childhood mental health problems and their role in the development of later adjustment problems.

Callous-unemotional traits as a cross-disorders construct

PURPOSE

Callous-unemotional (CU) traits are currently viewed as the defining signs and symptoms of juvenile psychopathy. It is unclear, however, whether CU traits have validity only in the context of conduct disorder (CD) as proposed by Frick and Moffitt (A proposal to the DSM-V childhood disorders and the ADHD and disruptive behavior disorders work groups to include a specifier to the diagnosis of conduct disorder based on the presence of callous-unemotional traits, American Psychiatric Association, Washington, DC, 2010), or also outside CD, either in combination with other forms of psychopathology or as a stand-alone construct.

METHODS

The current review systematically studied the existent literature on CU traits in juveniles to examine their validity inside and outside CD according to the framework regarding the validity of a psychiatric diagnosis provided by Robins and Guze (Am J Psychiatry 126:983-987, 1970).

RESULTS

Inside youth with conduct problems, and CD specifically, it seems that CU traits meet the Robins and Guze criteria. As many of the reviewed studies included youth with ODD and ADHD as well, there are indications the same might be true for ODD and ADHD, although probably to a lesser extent. In other disorders, CU traits may be present as well, but their role is not firmly established. As stand-alone construct, data are lacking or are scarce on all of the above-mentioned criteria.

CONCLUSIONS

CU traits are a useful specifier in CD, and possibly also in disruptive behaviour disorders (DBDs) more generally. High CU traits outside DBDs exist but it is as yet unknown if there is a clinical need for defining CU traits as a stand-alone construct.

Attention deficit hyperactivity disorder does not predict criminal recidivism in young adult offenders: Results from a prospective study

As the state of research on the relationship between attention deficit hyperactivity disorder (ADHD) and recidivism can be considered controversial, our prospective study investigated whether ADHD predicts recidivism in a sample of 283 male, German, young adult prisoners. Currently existing ADHD symptoms and symptoms that were present in childhood were screened according to the DSM-IV checklist criteria. Information on general and violent recidivism was gathered using government records with a follow-up period of up to five years. The prevalence of adult ADHD was six times greater than in the general population, and the number of participants who retrospectively met the criteria for a diagnosis with ADHD in childhood was ten times greater than found in community samples. Survival analyses did not identify ADHD as a predictor of recidivism. Controlling for conduct disorder, substance dependence, and other relevant variables did not alter results. However, among individuals who were released from prison and then reconvicted for a new crime, offenders diagnosed with ADHD were found to reoffend sooner after release. These findings stress the necessity of differentiating between risk factors for delinquency and risk factors for recidivism.

Violent recidivism: a long-time follow-up study of mentally disordered offenders

Background

In this prospective study, mentally disordered perpetrators of severe violent and/or sexual crimes were followed through official registers for 59 (range 8 to 73) months. The relapse rate in criminality was assessed, compared between offenders sentenced to prison versus forensic psychiatric care, and the predictive ability of various risk factors (criminological, clinical, and of structured assessment instruments) was investigated.

Method

One hundred perpetrators were consecutively assessed between 1998 and 2001 by a clinical battery of established instruments covering DSM-IV diagnoses, psychosocial background factors, and structured assessment instruments (HCR-20, PCL-R, and life-time aggression (LHA)). Follow-up data was collected from official registers for: (i) recidivistic crimes, (ii) crimes during ongoing sanction.

Results

Twenty subjects relapsed in violent criminality during ongoing sanctions (n = 6) or after discharge/parole (n = 14). Individuals in forensic psychiatric care spent significantly more time at liberty after discharge compared to those in prison, but showed significantly fewer relapses. Criminological (age at first conviction), and clinical (conduct disorder and substance abuse/dependence) risk factors, as well as scores on structured assessment instruments, were moderately associated with violent recidivism. Logistic regression analyses showed that the predictive ability of criminological risk factors versus clinical risk factors combined with scores from assessment instruments was comparable, with each set of variables managing to correctly classify about 80% of all individuals, but the only predictors that remained significant in multiple models were criminological (age at first conviction, and a history of substance abuse among primary relatives).

Conclusions

Only one in five relapsed into serious criminality, with significantly more relapses among subjects sentenced to prison as compared to forensic psychiatric care. Criminological risk factors tended to be the best predictors of violent relapses, while few synergies were seen when the risk factors were combined. Overall, the predictive validity of common risk factors for violent criminality was rather weak.

Prenatal Cocaine Disrupts Serotonin Signaling-Dependent Behaviors: Implications for Sex Differences, Early Stress and Prenatal SSRI Exposure

Prenatal cocaine (PC) exposure negatively impacts the developing nervous system, including numerous changes in serotonergic signaling. Cocaine, a competitive antagonist of the serotonin transporter, similar to selective serotonin reuptake inhibitors (SSRIs), also blocks dopamine and norepinephrine transporters, leaving the direct mechanism through which cocaine disrupts the developing serotonin system unclear. In order to understand the role of the serotonin transporter in cocaine's effect on the serotonergic system, we compare reports concerning PC and prenatal antidepressant exposure and conclude that PC exposure affects many facets of serotonergic signaling (serotonin levels, receptors, transporters) and that these effects differ significantly from what is observed following prenatal SSRI exposure. Alterations in serotonergic signaling are dependent on timing of exposure, test regimens, and sex. Following PC exposure, behavioral disturbances are observed in attention, emotional behavior and stress response, aggression, social behavior, communication, and like changes in serotonergic signaling, these effects depend on sex, age and developmental exposure. Vulnerability to the effects of PC exposure can be mediated by several factors, including allelic variance in serotonergic signaling genes, being male (although fewer studies have investigated female offspring), and experiencing the adverse early environments that are commonly coincident with maternal drug use. Early environmental stress results in disruptions in serotonergic signaling analogous to those observed with PC exposure and these may interact to produce greater behavioral effects observed in children of drug-abusing mothers. We conclude that based on past evidence, future studies should put a greater emphasis on including females and monitoring environmental factors when studying the impact of PC exposure.

Juvenile offenders assessment

PURPOSE OF REVIEW

Evaluation of juveniles is an integral process that includes a broad bio-psycho-social clinical perspective together with the use of auxiliary instruments. The aim of this review is to report relevant issues for this process found in recent publications.

RECENT FINDINGS

Several evidences lead to broadening the assessment process of children and youngsters to include family functioning style. Mental health services allow the evaluation of multiple factors associated with antisocial behavior that may lead to devising preventive actions. In the Juvenile Justice System a wide-ranging evaluation must include the exploration of general personality characteristics and psychopathic traits in particular; attention deficit/hyperactivity disorder; intelligence; substance abuse and conduct disorder must be considered.

SUMMARY

A number of factors that have an impact on juvenile antisocial behavior have been identified and can be assessed using the appropriate methodology. The exploration of these factors at different developmental stages and in their various manifestations provide guidelines for devising preventive and therapeutic actions as well as for supporting judicial decisions. Though enriching the present state of the art is always a challenge, it is imperative to encourage the governments to utilize this knowledge to improve the care system of children and adolescents.

Life History of Aggression scores are predicted by childhood hyperactivity, conduct disorder, adult substance abuse, and low cooperativeness in adult psychiatric patients

The prevention of aggressive behaviours is a core priority for psychiatric clinical work, but the association between the diagnostic concepts used in psychiatry and aggression remains largely unknown. Outpatients referred for psychiatric evaluations of childhood-onset neuropsychiatric disorders (n=178) and perpetrators of violent crimes referred to pre-trial forensic psychiatric investigations (n=92) had comprehensive, instrument-based, psychiatric assessments, including the Life History of Aggression (LHA) scales. Total and subscale LHA scores were compared to the categorical and dimensional diagnoses of childhood and adult DSM-IV axis I and II mental disorders, general intelligence (IQ), Global Assessment of Functioning (GAF), and personality traits according to the Temperament and Character Inventory (TCI). Overall, the two groups had similar LHA scores, but the offender group scored higher on the Antisocial subscale. Higher total LHA scores were independently associated with the hyperactivity facet of attention-deficit/hyperactivity disorder (AD/HD), childhood conduct disorder, substance-related disorders, and low scores on the Cooperativeness character dimension according to the TCI. IQ and GAF-scores were negatively correlated with the LHA subscale Self-directed aggression. Autistic traits were inversely correlated with aggression among outpatients, while the opposite pattern was noted in the forensic group. The findings call for assessments of aggression-related behaviours in all psychiatric settings.

Zur Komorbidität von aggressivem Verhalten und ADHS

Bei Kindern und Jugendlichen treten aggressives Verhalten und ADHS häufig gemeinsam auf und führen vielfach zu erheblichen psychosozialen Belastungen. Durch eine Metaanalyse wird eine verlässliche Maßzahl zum komorbiden Auftreten von ADHS und aggressivem Verhalten bestimmt. Anhand der Datenbanken PsycINFO und Pubmed wurden Studien identifiziert, die neben den relevanten Suchbegriffen ausgewählte Einschlusskriterien erfüllten, unter anderem „Allgemeinbevölkerung“ und „strukturierte Interviewverfahren“. In die Berechnung gingen acht epidemiologische Studien ein (N = 29980). Die metaanalytische Betrachtung bestätigt die hohe Komorbidität von ADHS und aggressivem Verhalten mit einem mittleren Odds Ratio von 21. Dieses Ergebnis wird für die Ätiologie und den Krankheitsverlauf diskutiert. Relevante Schlussfolgerungen für Diagnostik und Therapie werden aufgezeigt.

Neuroanatomical correlates of attention-deficit-hyperactivity disorder accounting for comorbid oppositional defiant disorder and conduct disorder

AIM

An increasing number of neuroimaging studies have been conducted to uncover the pathophysiology of attention-deficit-hyperactivity disorder (ADHD). The findings are inconsistent, however, at least partially due to methodological differences. In the present study voxel-based morphometry (VBM) was used to evaluate brain morphology in ADHD subjects after taking into account the confounding effect of oppositional defiant disorder (ODD) and conduct disorder (CD) comorbidity.

METHODS

Eighteen children with ADHD and 17 age- and gender-matched typically developing subjects underwent high-spatial resolution magnetic resonance imaging. The regional gray matter volume differences between the children with ADHD and controls were examined with and without accounting for comorbid ODD and CD in a voxel-by-voxel manner throughout the entire brain.

RESULTS

The VBM indicated significantly smaller regional gray matter volume in regions including the bilateral temporal polar and occipital cortices and the left amygdala in subjects with ADHD compared with controls. Significantly smaller regional gray matter volumes were demonstrated in more extensive regions including the bilateral temporal polar cortices, bilateral amygdala, right occipital cortex, right superior temporal sulcus, and left middle frontal gyrus after controlling for the confounding effect of comorbid ODD and CD.

CONCLUSION

Morphological abnormalities in ADHD were seen not only in the regions associated with executive functioning but also in the regions associated with social cognition. When the effect of comorbid CD and ODD was taken into account, there were more extensive regions with significantly smaller volume in ADHD compared to controls.

The 'antisocial' person: an insight in to biology, classification and current evidence on treatment

BACKGROUND

This review analyses and summarises the recent advances in understanding the neurobiology of violence and empathy, taxonomical issues on defining personality disorders characterised by disregard for social norms, evidence for efficacy of different treatment modalities and ethical implications in defining 'at-risk' individuals for preventive interventions.

METHODS

PubMed was searched with the keywords 'antisocial personality disorder', 'dissocial personality disorder' and 'psychopathy'. The search was limited to articles published in English over the last 10 years (1999 to 2009)

RESULTS

Both diagnostic manuals used in modern psychiatry, the Diagnostic and Statistical Manual published by the American Psychiatric Association and the International Classification of Diseases published by the World Health Organization, identify a personality disorder sharing similar traits. It is termed antisocial personality disorder in the diagnostic and statistical manual and dissocial personality disorder in the International Classification of Diseases. However, some authors query the ability of the existing manuals to identify a special category termed 'psychopathy', which in their opinion deserves special attention. On treatment-related issues, many psychological and behavioural therapies have shown success rates ranging from 25% to 62% in different cohorts. Multisystemic therapy and cognitive behaviour therapy have been proven efficacious in many trials. There is no substantial evidence for the efficacy of pharmacological therapy. Currently, the emphasis is on early identification and prevention of antisocial behaviour despite the ethical implications of defining at-risk children.

CONCLUSIONS

Further research is needed in the areas of neuroendocrinological associations of violent behaviour, taxonomic existence of psychopathy and efficacy of treatment modalities.

Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications

Conforming to a medical disease model rooted in phenomenology and natural science, psychiatry classifies mental disorders according to signs and symptoms considered to be stable and homogeneous across individuals. Scientific studies addressing the validity of this classification are scarce. Following a seminal paper by Robins and Guze in 1970, validity of categories has been sought in specific criteria referring to symptoms and prognosis, aggregation in families, and "markers", preferentially laboratory tests. There is, however, a growing misfit between the model and empirical findings from studies putting it to the test. Diagnostic categories have not been shown to represent natural groups delineated from the normal variation or from each other. Aetiological factors (genetic and/or environmental), laboratory aberrations, and treatment effects do not respect categorical boundaries. A more adequate description of mental problems may be achieved by: 1) a clear definition of the epistemological frame in which psychiatry operates, 2) a basic rating of the severity of intra- and interpersonal dysfunctions, and 3) empirical comparisons to complementary rather than exclusive dimensions of inter-individual differences in context-specific mental functions, treatment effects, and laboratory findings. Such a pluralistic understanding of mental health problems would fit empirical models in the neurosciences and postmodern notions of subjectivity alike. It would also clarify the assessment of dysfunction and background factors in relation to the requisites for penal law exemptions or insurance policies and make them empirically testable rather than dependent on expert opinion on issues such as whether a specific dysfunction is "psychiatric", "medical", or ascribable to "personality".

Mental health problems in youths committed to juvenile institutions: prevalences and treatment needs

Many international studies show that adolescents in coercive institutional care display high prevalences of mental disorders, especially in the form of disruptive behavior disorders [including attention-deficit/hyperactivity disorder (AD/HD), oppositional defiant disorder, and conduct disorder], anxiety disorders, and mood disorders. High degrees of overlap across mental disorders have also been reported. In addition, institutionalized adolescents are often traumatized. Despite this well-documented psychiatric morbidity, the mental health care needs of detained adolescents are often overlooked. The main objective of this study is to assess prevalences of psychiatric disorders, results of intelligence tests, and previous contacts with child and adolescent psychiatric services among adolescents in institutional care. DSM-IV diagnoses, mental health contacts, substance abuse, neurocognitive abilities, and school performance were registered in 100 adolescents (92 boys, 8 girls) aged 12-19 years (mean age 16.0; SD ± 1.5) consecutively committed to Swedish juvenile institutions between 2004 and 2007. At least one psychiatric disorder was diagnosed in 73% of the subjects: 48% met DSM-IV diagnostic criteria for AD/HD, 17% for an autism spectrum disorder, and 10% for a mental retardation. The collapsed prevalence for psychiatric disorders requiring specialist attention was 63%. Our data indicate that systematic diagnostic procedures are crucial in the treatment planning for institutionalized adolescents. Adequate treatment strategies need to be designed and implemented to meet the extensive mental health care needs of this vulnerable population.

Genetics of attention-deficit hyperactivity disorder (ADHD)

Attention-deficit hyperactivity disorder (ADHD) is a clinically and genetically heterogeneous syndrome which is comorbid with childhood conduct disorder, alcoholism, substance abuse, dis-social personality disorder, and affective disorders. A small but consistent overlap with autistic symptoms has also been established. Twin and family studies of ADHD show a substantial genetic heritability with little or no family environmental effect. Linkage and association studies have conclusively implicated the dopamine transporter gene (DAT1). DAT1 has also been confirmed as being associated with bipolar disorder. Remarkably, and for the first time in psychiatry, genetic markers at the DAT1 locus appear to be able to predict clinical heterogeneity because the non-conduct disordered subgroup of ADHD is associated with DAT1 whereas other subgroups do not appear to be associated. The second most well replicated susceptibility gene encodes the DRD4 dopamine receptor and many other dopamine related genes appear to be implicated. It is becoming increasingly clear that genes causing bipolar mania overlap with genes for a subtype of ADHD. The key to understanding the genetics of ADHD is to accept very considerable heterogeneity with different genes having effects in different families and in different individuals. It is too early to interpret the new wave of genome-wide association and copy number variant studies but preliminary data support the overlap with affective disorder genes and also with CNS connectivity genes likely to be involved in autism and affective disorders.