DSM-IV Conduct Disorder symptoms in adolescents as markers of registered criminality

A nationwide sample of 1,079 Norwegian adolescent psychiatric in-patients, 581 males and 498 females, were followed up after 11–33 (mean 23.2) years. On the basis of detailed records from index hospitalisation they were re-diagnosed and retrospectively scored on 14 of the 15 behaviour items listed as diagnostic criteria for conduct disorder in DSM-IV. The patient list was linked to the national criminal registry, and 48 % were found to have a criminal record. The ability of the 14 behaviour items to identify overall and specific kinds of registered criminality was investigated. In males, “stealing” was the strongest marker for overall and violent crime. “Having forced someone into sexual activity” was a strong marker for later sex offences. In females, “running away from home” was strongly associated with overall and violent registered criminality. ROC curves were constructed to test the sensitivity and specificity of the sum of conduct disorder behaviour items fulfilled in the identification of individuals with registered criminality. The area under the curve was 0.81 (95 % c. i. = 0.78–0.85) in males and 0.75 (95 % c. i. = 0.71–0.80) in females. A cut-off at 3 criteria fulfilled seemed optimal in males and somewhat high in females. Accepted: 17 May 2001     

The temporal relationship between schizophrenia and crime

Background Little is known about the temporal relationship between illness onset and the possible beginning of a criminal career among people with schizophrenia, even though criminality, especially violent criminality, has been shown to be more common among people with schizophrenia than among people in general. Aim: The aim of this study was to analyse the temporal relationship between registered crime and contact to the psychiatric hospital system. Method: This is a register-based study merging data on the psychiatric career with criminal records. Results: Among the males with schizophrenia, 37% started a criminal career and 13% had committed first violent crime before first contact with the psychiatric hospital system. Conclusion: The criminality committed before first contact to the psychiatric hospital system is substantial, especially among males with schizophrenia. Accepted: 22 February 2003 Correspondence to Runa Munkner, MD     

Parental separation at birth and criminal behaviour in adulthood

Background: Parental absence has been connected with later criminality. We studied the association between very early separation and criminality in a unique data set. Methods: The index cohort consisted of 2,906 subjects born between 1945 and 1965 in Finland who were temporarily isolated from their family immediately after birth and sent to adequate nursing homes due to tuberculosis in the family. The average separation time was 7 months. For every index subject, two reference subjects (matched for sex, year of birth and place of birth) were gathered. Data on criminal offences were obtained from Statistics Finland arising from adolescence to middle age, between January 1, 1977 and December 31, 1998. The association between parental separation and subcategories of non-violent and violent criminality and violent recidivism, respectively, in male and female offspring was analysed. Subjects who had committed at least two violent crimes were defined as violent recidivists. Results: Of the male index subjects, 12.1% as compared with 7.1% of the reference cohort (estimated relative risk RR 1.73; 95% CI 1.42–2.11) had committed violent offences. Of the male index subjects 5.2% and of the male reference subjects 3.6% were violent recidivists (RR 1.47; 1.10–1.98). Of the male index subjects 26.3% and of the reference cohort 23.4% had committed nonviolent crimes (RR 1.14; 1.01–1.29). Among females, non-violent crimes were committed by 7.9% of the index subjects and by 5.0% of the reference subjects, respectively (RR 1.54; 1.18–2.00). Violent crimes were rare among female subjects. Conclusion: Criminal behaviour was more prevalent among both male and female subjects separated at birth from their families because of tuberculosis in the family than in the reference cohort. Especially violent crimes were prevalent in the male index cohort. Even so, the differences between the index and reference cohorts were rather modest. Very early separation may have some, although limited, influence on later criminality in the offspring. Accepted: 10 January 2003 Correspondence to P. M?ki, MD     

Adult mortality in the light of criminality,substance abuse,and behavioural and family-risk factors in adolescence

In their general theory of crime, Gottfredson and Hirschi (1990) advanced the argument that different aspects of antisocial behaviour and health-endangering forms of behaviour are derived from the same personality characteristic, namely low self-control. This raises expectations of high intercorrelations between antisocial behaviour, criminality and health-compromising activities. The objective of the present study was to examine mortality risk at an adult age (including sudden violent death and death due to accidents) as a consequence of adolescent behavioural problems and adverse home-upbringing conditions, and further to examine whether subjects who had a criminal conviction as an adult were over-represented among those who died prematurely. An alternative hypothesis was that disproportionately high future premature mortality among males with a record of early antisocial behaviour (and many family risk factors) is largely accounted for by a subgroup of antisocial subjects with strong alcohol and/or drug problems. In total, 7577 persons about to undertake compulsory military service, 18 years old in 1969–70, responded to questions about their family background and antisocial behaviour, and were followed up in registers of mortality, criminality and alcohol or drug abuse up to the age of 33. The results revealed that early contact with the police, truancy and school misconduct, and also the home-upbringing variables, divorce and parents' nervous disorders, were significant predictors of later premature mortality. When future registered abusers were excluded, the prognostic power of these variables was reduced; despite this, the same indicated risk factors still had a general impact on premature adult mortality. However, adolescent risk had less impact on deaths from accidents than on other types of death. It was also found that males had criminal convictions were over-represented among those who died prematurely. Excluding known cases of alcohol and drug abuse, there was a slight, almost negligible, increased risk of motality among males with criminal records. It is concluded that the higher likelihood of mortality among offenders can be attributed largely to the existence of a small group of alcohol and/or drug abusers who run a hight risk of dying prematurely. The generality of Gottfredson and Hirschi's theory with respect to mortality is called into question.     

Childhood psychiatric disorders and young adult crime: a prospective, population-based study

OBJECTIVE: While psychopathology is common in criminal populations, knowing more about what kinds of psychiatric disorders precede criminal behavior could be helpful in delineating at-risk children. The authors determined rates of juvenile psychiatric disorders in a sample of young adult offenders and then tested which childhood disorders best predicted young adult criminal status. METHOD: A representative sample of 1,420 children ages 9, 11, and 13 at intake were followed annually through age 16 for psychiatric disorders. Criminal offense status in young adulthood (ages 16 to 21) was ascertained through court records. RESULTS: Thirty-one percent of the sample had one or more adult criminal charges. Overall, 51.4% of male young adult offenders and 43.6% of female offenders had a child psychiatric history. The population-attributable risk of criminality from childhood disorders was 20.6% for young adult female participants and 15.3% for male participants. Childhood psychiatric profiles predicted all levels of criminality. Severe/violent offenses were predicted by comorbid diagnostic groups that included both emotional and behavioral disorders. CONCLUSIONS: The authors found that children with specific patterns of psychopathology with and without conduct disorder were at risk of later criminality. Effective identification and treatment of children with such patterns may reduce later crime.     

A long-term follow-up study of adolescent psychiatric in-patients. Part II. Predictors of delinquency

A total of 932 adolescent psychiatric in-patients were followed up 15-33 years after hospitalization by record linkage to the National Register of Criminality. On the basis of the hospital records the patients were rediagnosed according to DSM-IV and scored on data postulated to be predictors of later delinquency. The factors were investigated by Kaplan-Meyer survival analysis and Cox regression. Cox analysis showed that, in males, main diagnosis (relative risk (RR)=2.9, 95% confidence interval (CI)=2.0-4.2), verbal abuse at home (RR=1.5, CI=1.1-2.0), disciplinary problems at school (RR=1.7, CI=1.2-2.5), and violating ward rules during hospitalization (RR=1.6, CI=1.2-2.2) were strong and independent predictors of delinquency. In females, main diagnosis (RR=2.6, CI=1.6-4.2), concurrent psychoactive substance use disorder (RR=2.9, CI=1.9-4.2), verbal abuse at home (RR=1.5, CI=1.0-2.1), and disciplinary problems at school (RR=1.6, CI=1.1-2.5) were strong and independent predictors of delinquency. Among males who violated ward rules and received a diagnosis of disruptive behaviour disorder, psychoactive substance use disorder or personality disorder at index hospitalization, as many as 77.6% had a criminal record at follow-up.     

Low verbal ability predicts later violence in adolescent boys with serious conduct problems

Abstract

Background: Delinquent adolescents are a known high-risk group for later criminality. Cognitive deficits correlate with adult criminality, and specific cognitive deficits might predict later criminality in the high-risk adolescents. Aims: This study aimed to explore the neuropsychological performance and predictors of adult criminal offending in adolescents with severe behavioural problems. Methods: Fifty-three adolescents (33 boys and 20 girls), aged 15–18 years, residing in a reform school due to serious conduct problems, were examined for neuropsychological profile and psychiatric symptoms. Results were compared with a same-age general population control sample, and used for predicting criminality 5 years after the baseline testing. Results: The reform school adolescents’ neuropsychological performance was weak on many tasks, and especially on the verbal domain. Five years after the baseline testing, half of the reform school adolescents had obtained a criminal record. Males were overrepresented in both any criminality (75% vs. 10%) and in violent crime (50% vs. 5%). When cognitive variables, psychiatric symptoms and background factors were used as predictors for later offending, low verbal intellectual ability turned out to be the most significant predictor of a criminal record and especially a record of violent crime. Conclusions: Neurocognitive deficits, especially in the verbal and attention domains, are common among delinquent adolescents. Among males, verbal deficits are the best predictors for later criminal offending and violence. Clinical implications: Assessing verbal abilities among adolescent population with conduct problems might prove useful as a screening method for inclusion in specific therapies for aggression management.     

Use of holding,restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment

The aim of the study was to analyse the use of holding, restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment in Finland. The study included 504 child and adolescent psychiatric in-patients in the year 2000. Time-out had been used for 28 %, holding for 26 %, seclusion for 8 %, and mechanical restraints for 4 % of the in-patients. In multivariate analysis, aggressive acts were the strongest factor associated with all kinds of restraint practices. Psychosis, suicidal acts and older age (13–18 years) were associated with seclusion and mechanical restraints. Younger age (< 13 years), attachment disorder and autism were associated with holding. The longer children had been in treatment, the more likely they were to have been restrained. The high prevalence of restraint techniques used indicates a need for guidelines of restraint and seclusion which take into account the child's need for protection from his/her own impulses and the legal rights of the child. Accepted: 22 February 2002 Correspondence to: A. Sourander     

Do adolescent anorexia nervosa patients have deficits in emotional functioning?

Adult eating disorder patients have been characterised by alexithymia. We investigated whether adolescent eating disorder patients also show deficits in emotional functioning. To measure emotional functioning a questionnaire (the TAS) and an emotion recognition test were administered to 30 eating disorder (ED) adolescent girls and 31 healthy controls (HC), matched for age, education, and social status. Non-emotional, cognitive parallel tasks were administered on the same occasion to find out whether a possible deficit was emotion-specific or of a more general cognitive nature. The ED patients scored higher on the TAS and performed worse on the emotion recognition test, but no differences between the groups were found on the non-emotional cognitive instruments. It was concluded that adolescent eating disorder patients, just like adult eating disorder patients, are characterised by alexithymia and show specific deficits in emotional functioning. The implications of these findings are discussed. Accepted: 21 August 2001     

Psychopathology in adolescent and young adult criminal offenders (15–21 years) in Sweden

Background This study examined rates of psychopathology among adolescent and young adult serious offenders referred to pre-sentence forensic psychiatric services and compared patterns of psychiatric morbidity with adult forensic referrals and age-matched general psychiatric inpatients. Methods In Sweden, criminal offenders can be referred for an extensive court-ordered pre-sentence inpatient forensic psychiatric examination (FPE). Data on all 3,058 of these offenders (90% male, mean age = 35.3 years) during 1997–2001 were obtained from the National Board of Forensic Medicine. We compared DSM-IV psychiatric diagnoses across age bands 15–17 years (N = 60), 18–21 years (N = 300) and 22 years and older (N = 2,698). Comparative data by age bands were also obtained for inpatient diagnoses among individuals admitted to general psychiatric hospitals. Results Compared with the adult forensic psychiatric examinees, those aged 15–17 years and 18–21 years had higher rates of depression, and childhood and developmental disorders but lower rates of psychosis, bipolar disorder, and substance use disorders. Compared with general psychiatric inpatients, offenders aged 15–17 years had higher prevalences of depression and attention-deficit or disruptive disorders and lower ones of alcohol and drug misuse disorders. Conclusions There are significant differences in patterns of psychiatric morbidity in adolescent and young adult offenders that come into contact with psychiatric services compared with older offenders and adolescent psychiatric inpatients. This suggests that the development of health services addressing the psychiatric needs of younger offenders needs to draw on information on their specific mental health needs.     

Criminal and psychiatric histories of Finnish arsonists

We investigated psychiatric and demographic variables and lifetime criminality among arsonists referred for a pre-trial psychiatric assessment. The medical and criminal records of 282 arsonists were studied in order to compare first-time and repeat offenders with regard to diagnostic, demographic and biological variables. Alcohol dependence and antisocial personality disorder were common among recidivist offenders. This finding was especially prominent among offenders who committed violent crimes. Recidivist offenders commonly had a history of long-lasting enuresis during their childhood. They were younger at the time of their first offence, and were more often intoxicated with alcohol during the arson attempt. Among arsonists, lifetime criminal recidivism was primarily associated with alcohol dependence and antisocial personality disorder. Psychosis was a common diagnosis among subjects who had no record of recidivist criminal offences.     

Substance abuse in schizophrenia. A Singapore perspective

Background Most of the information on the prevalence and patterns of substance abuse in patients with schizophrenia has been from studies conducted in North America and Europe and data from Asian countries are conspicuously lacking. This study was undertaken with the aim to identify the prevalence and patterns of substance abuse among patients with first-episode schizophrenia in the city-state of Singapore. Methods All new patients with a diagnosis of first-episode schizophrenia or schizophreniform disorder who were seen in one calendar year in the only state mental institute in Singapore and its affiliated outpatient clinics were evaluated for a lifetime history of substance use. Results In a sample of 272 patients, 201 (73.6 %) were abstainers, 43 (15.8 %) had “mild” substance use and 28 (10.3 %) had “heavy” use patterns. Alcohol was the most frequently abused substance. The substance users were more likely to be males and were more likely to have a criminal record than abstainers. Conclusions To our knowledge, this is the first study that examines the co-morbidity of substance abuse in schizophrenia in an Asian population. Our findings once again highlight the fact that patients with schizophrenia are at a high risk for substance abuse. Accepted: 20 February 2002     

Incipient offending among schizophrenia patients after first contact to the psychiatric hospital system.

The study examines how age, sex and substance use disorder are associated with the risk of committing a criminal offence. The study explicitly examines the risk after the first contact to the psychiatric hospital system and after the diagnosis of schizophrenia for those with no previous criminal record; the association between previous non-violent criminality and later violent criminality is also analysed. The study sample comprised 4619 individuals ever diagnosed with schizophrenia. All solved offences were accessible. Data were analysed using Cox's regression. Schizophrenic men had twice the risk of schizophrenic women of committing both violent and non-violent offences. A registered substance use disorder increased the risk 1.9- to 3.7-fold, depending on the starting point for the analyses, while increasing age on first contact or when diagnosed with schizophrenia diminished the risk. Previous non-violent criminality increased the risk for later violent criminality 2.5- to 2.7-fold, depending on the starting point for the analyses. The results suggest that the psychiatric treatment system can play an active role in preventing criminality among individuals with schizophrenia. The preventive measures should be based on a thorough assessment including criminal history at intake and alertness toward young psychotic men with substance use disorders and especially if they also have a criminal history.     

The use of the ADI-R as a diagnostic tool in the differential diagnosis of children with infantile autism and children with a receptive language disorder

Children with infantile autism and children with a specific receptive language disorder often show similar behavioural problems, making the differentiation between these two diagnostic categories difficult. The purpose of this study is to evaluate the usefulness of parental information in the differential diagnosis of the two types of disorders mentioned above. Sixteen children with a receptive language disorder and 11 children with infantile autism participated in the study. All children had normal non-verbal IQs. The ADI-R (Autism Diagnostic Interview-Revised) was performed with all children. The results showed that the ADI-R items reflecting behavioural features at pre-school age (age range 4–5 years) were better suited to differentiate the groups than the items reflecting behavioural features at the time of the investigation (mean age: 9 years). The items on the dimension “Reciprocal social interaction” and “Communication and language” discriminated the groups better than the items of the dimension “Restricted interests”. According to the ICD-10 algorithm of the ADI-R one child with autism and one child with a receptive language disorder were falsely classified. These false classifications were mainly due to a distorted parental perception of the child's behaviour. The ADI-R is a useful tool in the differential diagnosis of developmental disorders. Accepted: 27 April 2001     

Who seeks treatment for alcohol dependence? Findings from the Australian National Survey of Mental Health and Wellbeing

Background: This paper presents findings from the Australian National Survey of Mental Health and Wellbeing (NSMHWB) regarding prevalence and treatment seeking for Australians with DSM-IV alcohol dependence and examines the influence of alcohol use variables on treatment seeking. Method: A standardised interview (including CIDI 2.1) was administered to a stratified random sample of 10,641 Australians aged 18 years and over. Demographic variables, common DSM-IV mental disorders, physical health status, perceived disability and treatment-seeking behaviour were assessed. Multiple logistic regression was used to ascertain the independent effects of all variables considered. Results: The prevalence of DSM-IV alcohol dependence was 4.1 % in this population, with 75 % being male and nearly 60 % in the 18–34 year age group. Variables that correlated independently with alcohol dependence were sex (male), age (young), not being in a married or de facto relationship and having any affective, anxiety or other substance use disorder. Functional disability did not correlate with a dependence diagnosis. Correlates of treatment seeking for those with dependence were sex (female) and having a comorbid affective disorder. Having a diagnosis of dependence and/or abuse and having more dependence symptoms did not predict treatment seeking. However, meeting either of two criteria assessing psychological, physical or social problems due to alcohol use tended to increase service use. Conclusions: People with alcohol dependence do not perceive themselves as disabled and do not seek treatment. However, having a comorbid affective disorder or other problems directly attributable to alcohol use increases the likelihood that such individuals will seek treatment. Efforts should be made at the primary care level to encourage those engaged in harmful drinking practices to recognise the risks of such drinking and reduce it or seek treatment. Similarly, it is recommended that integrated services are enhanced at both primary and specialist levels in order that those with multiple problems are appropriately treated. Further research is required to refine measurement of disability and diagnoses of alcohol use disorders and to examine the relationship between disability and alcohol use. Accepted: 29 April 2002     

Adult attachment style. I: Its relationship to clinical depression

Background Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002). Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into “Angry-dismissive” and “Withdrawn”. The degree to which attitudes and behaviour within such styles were dysfunctional (“non-standard”) was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder. Results The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the “non-standard” levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder. Conclusion The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance. Accepted: 21 September 2001     

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register-based study

Background   Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID.
Method   We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996–2006).
Results   One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure.
Conclusions   The offenders with so-called triple diagnosis – substance abuse, mental illness and ID – form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.     

Young cases of schizophrenia identified in a national inpatient register--are the diagnoses valid?

Background: Psychiatric inpatient registers are often used in research in the Nordic countries. We aimed to investigate the validity of recorded diagnoses of schizophrenia in the Swedish National Inpatient Register, in cases of early age at onset. We also wanted to describe the accuracy of the diagnoses in cities/university clinics and country hospitals as well as in child and adolescent psychiatric clinics and clinics for adults. Method: One hundred cases with a diagnosis of schizophrenia, born 1973–1977, were randomly selected. The psychiatric records were scrutinised according to the criteria of DSM-IV. Results: Eighty-six per cent (95 % CI 78–93 %) fulfilled the DSM-IV criteria of schizophrenia syndrome and 76 % (95 % CI 66–86 %) fulfilled the “narrow” definition. There were no large differences in the accuracy of the diagnoses between regions or clinics. Conclusion: The proportion of “true” cases of schizophrenia is high in the Swedish National Inpatient Register. In addition, the results did not support large differences between clinics or regions although a larger sample size would be needed to test this formally. In comparison with earlier studies from the Nordic countries the validity seems to be quite stable over time, between different ages at onset and between Nordic countries. Thus, the registers are well suited to be used in schizophrenia research. Accepted: 17 June 2002 Correspondence to Ch. Dalman     

Epidemiology and prognosis of specific disorders of language and scholastic skills

 Data from a prospective longitudinal study on the development of children born at biological and psychosocial risk were utilised to examine language and learning abilities of 320 children at ages 4.5 and 8 years. Following the research criteria of the ICD-10, specific developmental disorders of speech and language and specific developmental disorders of scholastic skills were diagnosed. Data were also provided for a clinical and general low achievement group according to less stringent criteria. Frequencies in the risk population were low for specific disorders (ICD-10) (0.6%–3.7% depending on age and type of disorder). Higher frequencies were found when a clinical definition (0.6%–13.6%) or overall low achievement score (0.6%–18.6%) was chosen. The impact of well-documented organic and psychosocial risks was analysed. Organic risk affected language abilities at 4.5 years of age but neither language nor learning abilities at 8 years of age. Psychosocial aspects of a child's environment proved to be associated with both specific language and learning abilities. Stability of language disorders, association between language and reading/spelling disorders as well as gender effects were investigated. Accepted: 17 December 1999