Decades-Long Study Points to Criminal-Behavior Risk Factors

Hyperactivity combined wit h conduct problems—but not hyperactivity alone—predicted later criminal behavior in adulthood in a 30-year prospective study of 179 boys in California who had been referred to a psychiatric outpatient clinic because of hyperactivity.

One conduct problem in particular, lying, predicted both adolescent and adult criminal behavior in this cohort, according to James Satterfield, M.D., now retired from the Department of Psychiatry at Oregon Health and Science University in Portland.

“This suggests that this behavioral variable should always be included in ADHD childhood evaluations,” wrote Satterfield and colleagues in the May Journal of the American Academy of Child and Adolescent Psychiatry. Socioeconomic status and IQ should also be included in such assessments, since they, too, had a strong influence on this cohort.

Up to three years of individualized treatment when the boys were preadolescents produced better school outcomes, improved attention, less antisocial behavior, and better adjustment at home. That effect extended into adolescence for those who were treated for more than two years, but not for those treated for shorter times. However, any beneficial effects of treatment disappeared by adulthood.

The 179 white boys were first evaluated at ages 6 to 12 and compared with 75 matched controls between 1970 and 1973. Seventy-six of the boys received multimodality treatment, and 103 got drug treatment alone. Satterfield and colleagues have published previous studies about this cohort over the past three decades. Their latest report comes as the subjects reached a mean age of 37 years. In the years since they entered the study, 79 (44.1 percent) of the hyperactive boys and 11 (14.7 percent) of the controls had been arrested, giving an odds ratio of 4.57 (p<0.001). Roughly similar odds ratios were recorded for convictions and imprisonment. Sixty-nine hyperactive boys had 228 arrests for felonies (the others were arrested for misdemeanors). The common reasons for arrest included battery/assault (39 arrests) and drug possession (49). The mean age after which they no longer were arrested was 30.

The effects held only for boys with both hyperactivity and conduct problems. Hyperactivity alone led to outcomes that were no different from those of controls.

Analysis showed that higher IQ and higher socioeconomic status (SES) were protective factors. Those with low SES were twice as likely to violate the law, compared with those from high-SES families.

The choice of treatment had no effect on outcomes. Nearly equal percentages of the multimodality and drug-only treatment groups had the same rates of arrest and imprisonment.

Satterfield and his colleagues believe that multimodality failed to prevent adult criminality because it was applied too late. “Serious behavioral problems tend to be established by the age of school entry and to remain stable thereafter,” they wrote. “From our study, we conclude that it is unlikely that a time-limited (three year) intensive [multimodality] clinical intervention for boys aged 6 to 12 years will either permanently eliminate existing antisocial behaviors or protect against their reemergence long after the intervention has ended.”

The authors noted that the study is limited by the ethnic homogeneity of the subjects and a lack of random assignment to treatment groups. Satterfield has received support from several pharmaceutical manufacturers.

A lot happens between youth and adulthood, said Edward Mulvey, Ph.D., a professor of psychiatry at Western Psychiatric Institute and Clinic of the University of Pittsburgh School of Medicine, in an interview. Hyperactivity may set the stage for adjustment problems, making it difficult for children to make friends, do well in school, or get along with parents, but it's not the only factor. “In the long run, the presence of hyperactivity does not doom a kid to criminality.”

Nor is he surprised at the lack of long-term benefits from treating these boys only when they were in elementary school.

“All treatments have a window of effectiveness that closes after a while,” said Mulvey. “It helps them but does not inoculate them against future problems forever. Any treatment should be expected to exert a positive influence for a limited time after implementation, to get the child under sufficient control and give him enough skills to deal with the next set of challenges.

“I'm surprised that there's not more in the literature on this subject. This is an important mechanism to investigate.”

The study was funded in part by a grant from the National Institute of Mental Health.

An abstract of “A 30-Year Prospective Follow-Up Study of Hyperactive Boys With Conduct Problems: Adult Criminality” is posted at<www.jaacap.com/pt/re/jaacap/currenttoc.htm>.▪