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A Prospective Study of Hyperactive Boys With Conduct Problems and Normal Boys: Adolescent and Adult Criminality
A Prospective Study of Hyperactive Boys With Conduct Problems and Normal Boys: Adolescent and Adult Criminality JAMES H. SATTERFIELD, M.D., AND ANNE SCHELL, PH.D.
ABSTRACT ObJective: To examine the relationship between attention deficit disorder with hyperactivity in childhood and criminality
in adolescence and adulthood in 89 hyperactive and 87 normal control subjects. Method: In this prospective study, adolescent follow-up intervals ranged from 13 to 21 years and adult follow-up ranged from 18 to 23 years. The official arrest records for all subjects were obtained. Results: Hyperactive subjects had significantly higher juvenile (46% versus 11%) and adult (21% versus 1%) arrest rates. Juvenile and adult incarceration rates were also significantly higher. Childhood conduct problems predicted later criminality, and serious antisocial behavior in adolescence predicted adult criminality. Conclusions: Hyperactive children are at risk for both juvenile and adult criminality. The risk for becoming an adult offender is associated with conduct problems in childhood and serious antisocial behavior (repeat offending) in adolescence. Hyperactive children who do not have conduct problems are not at increased risk for later criminality. J. Am. Acad. Child Ado/esc. Psychiatry. 1997,36(12):1726-1735. Key Words: hyperactivity, adult status. criminality, conduct
problems.
Long-term outcome studies of hyperactive children have found relatively high rates of antisocial behavior or conduct disorder in adolescence (Barkley et al., 1990; Hechtman et al., 1984; Klein and Mannuzza, 1991; Loeber et al., 1995; Mannuzza et al., 1989; Satterfield et al., 1982) and high rates of antisocial personality disorder in adults (Hechtman et al., 1984; Mannuzza et al., 1993; Loney er al., 1983; Weiss and Hechtman, 1986; Weiss et al., 1985). Although most studies of adults who were hyperactive as children have found high rates of antisocial disorders, the findings on criminality are inconsistent across studies, and it is not known whether teenage criminality predicts adult criminality in hyperactive subjects. The relationship berween criminality in later life and hyperactivity in childhood has been -studied using gen-
Acupud[une 16. 1997. Dr. Saturfitld is with the Division of Child Psychiatry. Department of Psychiatry. Ortgon Healsh Scimces Uniuersity; Portland;and Dr. Schell is with tbe Psychology Department, Occidental Colkgt. LosAngtlts. Reprint rtqutsts to Dr. Schtll. Psychology Department, Occidental Co/kgt. 1600 Campus Road. LosAngeles, 0190041. 0890-8567/97/3612-1726/$O.300/0© 1997 by the American Academy of Child and Adolescent Psychiatry.
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eral population studies and clinic samples of hyperactive children followed longitudinally. In a community study in New Zealand, Moffitt and Silva (1988) found that almost 60% of those with a childhood diagnosis of attention deficit disorder had become delinquent by age 13. In a long-term follow-up of a large sample of more than 2,000 child guidance cases from ages 9 to 29 in Stockholm, Nylander (1979) reported that one third of the hyperactive boys were officially registered for criminal acts. However, there was no control group in this study. Farrington et al. (1990), in a follow-up study of 4 II London boys, reported that among a subgroup of males with hyperactivity and conduct problems, 45% had juvenile convictions and 32% had adult convictions. There have been only rwo controlled prospective follow-up studies of clinically referred hyperactive children that evaluated subjects both during adolescence and again in adulthood. One study was carried out in Montreal (Weiss and Hechtman, 1986) and one in New York (Klein and Mannuzza, 1991). Our review of previous studies emphasizes these rwo studies because of their similarity to the present study. Mannuzza and coworkers (1989) reported arrest rates in 103 hyperactive males berween 16 and 23 years old
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(mean age 18) and 100 normal controls between 16 and 23 years old (mean age 18) at follow-up. Significantly more hyperactive than control subjects had been arrested for any offense (39% versus 20%), convicted for any offense (28% versus 11 %) , arrested for a felony offense (25% versus 7%) , and incarcerated (9% versus 1%). Mannuzza and colleagues carried out an interview study of 98% of subjects in the above study (Klein and Mannuzza, 1991; Mannuzza et al., 1993) when they were adults (mean age 26 years). Significantly more hyperactive subjects than controls had a diagnosis of antisocial personality disorder (18% versus 2%). Arrest and incarceration rates are not reported for either group; however, five hyperactive subjects were incarcerated for crimes that involved aggression and one died of a stab wound at the age of 22. The fact that 90% of both groups were gainfully employed at adult follow-up suggests a low incarceration rate at the time of followup but does not rule out incarceration or arrest during the 8 years since the earlier (at age 18 years) follow-up. Wei ss et al. (1979) and Hechtman et al. (1984) reported a 10-year prospective interview study of 75 subjects who were hyperactive as children (from an original cohort of 104) and 44 normal controls who were between 17 and 24 years old (an age range that includes both juveniles and adults) . The mean age of their subjects at follow-up was almost identical with that of the New York subjects. However, their results were quite different. There were no significant group differences in the number and seriousness of reported offenses during the preceding 5 years. Compared with controls, more former patients tended to report more court referrals during the 5 years preceding the followup (47% versus 32%. p < .07) but not during the year preceding the evaluation . Weiss and Hechtman (1986) reported a 15-year follow-up of 63 hyperactive subjects and 41 controls who were evaluated earlier (at age 19). In this study hyperactive subjects and normal controls were at an average age of 25 years (age range of 21 to 33 years). Similar to their earlier study, significantly more hyperactive subjects compared with control subjects appeared in court during 3 years preceding the follow-up (18% versus 5%). However, most of the hyperact ive subjects had appeared in court for highway offenses that fell under the criminal code (speeding). A small minority of subjects (three or four) were involved with criminal offenses such as theft , drug possession, or dealing. Significantly more
hyperactive than control subjects had a diagnosis of antisocial personality disorder (23% versus 2.5%; p < .01). Loney and coworkers (1983) interviewed 22 subjects who had been hyperactive as boys and their brothers (aged 21 to 23 years). The patients were found to have a greater incidence of antisocial personality disorder (45% versus 18%) and significantly more incarcerations than their brothers (41% versus 5%). However, there was no significant difference between groups on reponed number of police contacts. Conclusions are limited, however, because Loney er aI. identified hyperactive children retrospectively from clinic charts . We previously reported a prospective evaluation of 110male adolescents who had been diagnosed as hyperactive in childhood and 89 normal controls who were still residing in Los Angeles County at the time of the follow-up (Satterfield et al., 1982). Official records of arrests from ages 10 to 18 years indicated that the juvenile arrest rates for hyperactive subjects in the lower, middle, and upper socioeconomic classes were 58%, 36%, and 52%, compared with 11 %,9%, and 2% ·for the controls. Thus the juvenile arrest rates for hyperactive subjects were from 5 to 26 times higher than those of controls depending on social class. and they had a 25 times higher institutionalization rate (25% versus 1%). Arrest rates were not significantly related to social class in either group. The present study extends the follow-up of most of these subjects into adulthood. METHOD Methods, diagnostic criteria, proband characteristics, and data on the Satterfield rating scales have been described elsewhere (Satterfield er aI., 1982, 1987; Satterfield and Schell, 1984) and are reviewed only briefly, Juvenile criminality was measured by examining th e official arrest records as recorded in the Los Angeles County Probation Department's automated juvenile index . Adult crim inality was measured by examining the adult crim inal records for the state of California. Only felony crimes are considered in this study of juvenile and adult criminality.
Subjects Probands were 19- to 25 -year-old males who had been d iagnosed as hyperactive between the ages of 6 and 12 years. All had been of normal intelligence and without a history of psychoses or neurological disorder. No attempt was made to exclude subjects with conduct disorder. Control subjects were white males selected from publ ic school classes and were matched to the hyperactive subjects as closely as possible for age, IQ (WISC), and social class. Controls were not evaluated psychiatrically but were evaluated using the Satterfield Teacher Rating Scale and th e Satterfield Parent Rating Scale (Satterfield et al., 1982). When hyperactive subjects were selected for this stud y, the diagnostic categoty of attention deficit dis-
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order was not in use. Nevertheless, the hyperactive subjects in this study were selected by criteria that are similar to DSM-Ill criteria for attention deficit disorder with hyperactivity. As used here. "hyperactive" is a diagnostic term referring to the entire group of probands. Although DSM-IIl, DSM-I/I-R, and DSM-IV differ on the exact symptoms and how they are grouped . they are globally quite consistent (Cantwell, 1996). All patients received stimulant drugs for a mean treatment period of 2 years (Satterfield et al., 1987). The current study is an evaluation of adolescent and adult official arrest records for 89 of the 110 hyperactive and 87 of the 89 control subjects previously evaluated at adolescence (Satterfield et aI., 1982). This former adolescent study included 21 hyperactive and 2 normal Mrican-Americans who are not included in the current study. The rationale for excluding this subgroup is that arrest rates tended to be higher among African-Americans compared with the other subjects. Therefore, limiting the study to Anglo subjects makes this hyperactive group more comparable with the control group and to the only two other adult follow-up studies of hyperactive children (which also did not include African-Americans) . At the time of our former adolescent follow-up, many of our subjects had not passed through the age of risk for committing a juvenile offense (had not reached their 18th birthday). The 5 years of additional follow-up time in the current study allows an examination of the arrest rates for subjects, all of whom have passed through the age of risk (from childhood to age 18 years) for juvenile offend ing. It also provides us with the opportunity to examine the adult arrest rates in these same two groups .
Data Analysis Group contrasts such as age were subjected to t test analyses. For contrasts of dichotomous variables, such as arrested/not arrested, Xl or Fisher's Exact Test values were computed. All probabilities reported are two-tailed.
11%; X2 = 24.5, df= l,p < .001) and incarcerated (22% versus 1%; X2 = 19.0, df= l,p < .001). Seventeen of the 19 incarcerated hyperactive subjects spent time in juvenile hall (many while awaiting trial), and two were sentenced to the California Youth Authority. There were more recidivists among the hyperactive than among the control subjects (29% versus 1%; X2 = 26.7, df = 1, P < .001). However, there was no significant between-group difference in the number of single-offense subjects (17% versus 12%; X2 = 1.5, df = 1, not significant). Among those arrested, more hyperactive than control subjects had been arrested for violent crimes (34% versus 9%; p < .10, Fisher's Exact Test). Assault/battery was the most frequent crime against persons, and burglary was the most frequent property crime for both groups. The hyperactive subjects' assault/battery category included charges of battery on person/peace/fire officer, assault with a deadly weapon, kidnapping, and assault to commit rape. The mean number of arrests for the 41 arrested hyperactive subjects and for the 11 arrested controls was 2.80 and 1.09, respectively (p < .001, Mann-Whitney U test). Age of first arrest ranged from 10 to 18 years for hyperactive subjects and from 13 to 18 years for controls. Of those who had been arrested, more hyperactive than control subjects had been arrested before 15 years of age (61% versus 18%; X2 = 6.36. df = 1, P < .02) .
RESULTS
Adult Criminality
Juvenile Criminality
Demographics and Arrest History. Hyperactive and control subjects did not differ in age at the time when the follow-up records were obtained (Table 1). Child-
Significantly more adolescent hyperactive subjects than control subjects had been arrested (46% versus
TABLE 1 Age, IQ, Socioeconomic Status (SES), and Family Type for All Hyperactive Subjects, All Controls, and Two Adult Hyperactive Subgroups (Arrested and Nonarrested)
Variable Age at follow-up. yr Mean (SO) Range SES, No. (0/0) Lower Middle Upper WISC Full Scale, Mean (SO) Family type," No. (%) One parent Two parents Other
Hyperactives (n = 89)
Controls (n = 87)
22.3 (1.4) 19-25 20 50 19 101
22.4 (1.4) 19-25
(23) (56) (21) (14)
17 26 44 115
24 (27) 41 (46) 24 (27)
(19) (30) (51) (14)
13 (16) 62 (76) 6 (8)
Yes (n
Hyperactives Arrested No tn
= 19)
22.5 (1.3) 20-25 5 9 5 102
(26) (48) (26) (14)
5 (26) 10 (53) 4 (21)
= 70)
22 .2 (1.5) 18-25 11 41 18 101
(16) (58) (26) (14)
22 (32) 41 (58) 7 (10)
"Family types by number of biological parents with whom the child lived.
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TABLE 2 Juvenile and Adult Arrest History for 18 Chronic Offender Hyperactive Subjects Juvenile Arrest History Category of Arrests Violenr crimes Assault/batrery Robbery Weapons Any violenr crime Properry crimes Theft Grand theft Unlawful raking of vehicle Burglary Any properry crime Drug-related crime
Offenders
Arrests
Adult Arrest History Offenders
6 2 2 9
(33) (II) (II) (50)
10 (13) 3 (4) 2 (3) 15 (19)
3 2 2 7
(16) (II) (11) (39)
7 5 7 16 17 1
(39) (28) (38) (89) (94) (6)
20 (25) 6 (7) 7 (9) 27 (34) 60 (75) 2 (3)
I 5 3 7 13 0
(6) (28) (16) (39) (72) (0)
Arrests
3 (10) 2 (7) 2 (7) 7 (23) I 10 3 9 23 0
(3) (33) (10) (30) (77) (0)
Note: Values represenr No. (0/0).
hood evaluations found that controls had higher IQs (t = 6.48, df= l,p < .001), came from families with higher socioeconomic status (X 2 = 17.7, df = 2, P < .001), and were more likely to live in families with two biological parents (X 2 = 18, df = 2, P < .001). However, socioeconomic status, biological parents in family, and IQ scores for the arrested and the nonarrested adult hyperactive subjects were not significantly different (Table 1). Since only one control subject was arrested as an adult, similar analyses could not be carried out for the control group. Adult hyperactive arrestees' ages ranged from 18 to 23 years. Forty-seven percent were arrested at age 18 years, and 79% had been arrested before age 21 years. Arrestand Incarceration Rates. The felony arrest rate for hyperactive subjects was 21 times that of the controls (21% versus 1%; X2 = 18.25, df = 1, P < .001). Eight hyperactive and no control subjects (9% versus 0%; p < .004, Fisher's Exact Test) had been arrested more than once for a felony offense. Eleven hyperactive and no control subjects (12% versus 0%; X2 = 8.94, df = 1, P < .01) had been incarcerated as adults. Of the 11 incarcerated hyperactive subjects, 3 were incarcerated in local jails, 4 in the county jail, 2 in the California Youth Authority, and 2 in state prisons. These 11 hyperactive subjects had served or had been sentenced to serve a total of 10.2 years adult time. Eighteen (95%) of the 19 hyperactive adult offenders became official offenders early in life and had been arrested more than once prior to age 18 years. These 18 subjects accounted for 77 juvenile and 30 adult arrests for a total of 108 felony arrests (a mean of 6 arrests per subject). Furthermore,
this 21 % of the 89 hyperactive subjects accounted for 74% of all juvenile and adult offenses. We will call this group our chronic offender hyperactive group. Table 2 shows the types of offenses for which these chronic offender hyperactive subjects were arrested, both as juveniles and later as adults. Property crime was the most frequent type of crime for which these hyperactive subjects were arrested, both as juveniles and as adults. The mean number of arrests for these chronic offenders was two times greater in their adolescence than in their adulthood (4.3 versus 1.7; t = 4.49, df = 17, P < . 001). Adolescent Predictors of Adult Criminality in Hyperactive Subjects
Arrest for felony crimes in adolescence predicted criminality in later life. Forty-eight hyperactive youths had no juvenile arrests, 15 had only one, 8 had two, and 18 had three or more juvenile arrests. The adult arrest rates for the adolescents with none, one, two, and three or more juvenile arrests were 2%, 0%, 38%, and 83% respectively. Eighteen of the 26 juvenile recidivists were arrested as adults for felony offenses versus 1 of the 63 nontecidivists (69% versus 1.6%; X2 = 50, df= 1, P < .0001). Incarceration as a juvenile also predicted adult criminality. Ten of the 19 hyperactive adolescents incarcerated were later arrested as adults compared with 9 of the 70 hyperactive subjects who were not incarcerated as juveniles (58% versus 22%; X2 = 14.08, df = 1, P < .001). The younger the hyperactive subject at the time of the first felony arrest, the more likely he
}. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:12, DECEMBER 1997
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SATTERFIELD AND SC HE LL
would become a chronic juvenile offender and eventually be arrested in adulthood. Twenty-five hyperactive youths were first arrested before age 15 years (earlyarrest group) and 16 hyperactive youths were 15 to 18 years of age when first arrested (late-arrest group). Of those in the early-arrest group, 15 became adult offenders compared with 3 of the late-arrest group (60% versus 19%; X2 = 6.74, df= l,p < .01). Of the 41 hyperactive subjects arrested for felony crimes as juveniles, 18 (43%) continued (persisters) and 23 (57%) discontinued (desisters) their criminal activity (as reflected by their adult arrest histories). We were unable to determine any differences between these two groups other than number of juvenile arrests and age of first felony arrest. The specific type of juvenile arrest did not predict type of adult arrest. For example, of the 14 hyperactive youths arrested for a violent juvenile crime, only 3 (21 %) were arrested as an adult for a violent crime, and of the 7 hyperactive subjects arrested for a violent adult crime, only 3 had been arrested for a violent crime as a juvenile. Childhood Predictors of Juvenile and Adult Criminality in Hyperactive Boys
The Satterfield Teacher Rating Scale and the Satterfield Parent Rating Scale were administered to most subjects . The rating scales consisted of items arranged in checklist form so that the teacher or parent could
indicate the degree to which each item of behavior was present (not at all = 0, just a little = 1, pretty much = 2, very much = 3). Four conduct problems (CPs) items and two factor scores from both teacher and parent rating scales were selected to be examined as predictors of juvenile and adult criminality. Items selected from both parent and teacher rating scales were "often gets into fights with other children," "lies to get out of trouble," and "takes things from other children" (i.e., steals). One additional item, "takes money from members of his family" (i.e., steals), was selected from the parent rating scale. Item scores were dichotomized as either low (not at all or just a little) or high (pretty much or very much). The factor scores selected were the antisocial and hyperactive factors (Satterfield and Schell, 1984); these were dichotomized (high and low) using a median split. Several of the selected parent rating scale items predicted juvenile criminality. Hyperactive subjects who were rated high on lying had a juvenile recidivist rate that was five times higher than those rated low on lying (p < .02, Fisher's Exact Test) (Fig. 1). Hyperactive subjects who were rated high on "takes things from children" were four times more likely to be juvenile recidivists than those rated low on this item (p < .0002, Fisher's Exact Test). Hyperactive subjects who were rated high on "takes money from members of his family" were twice as likely to become juvenile recidi-
60
50
10
o Fights
Lies
Stesls from Steals from Children Family Parent Ratings
Antisocial Factor
Hyperactive Factor
Fig. 1 Relation ship between ch ildho od parent ratings and juvenile recidivism.
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CRIMINALITY AND HYPERACTIVE BOYS
40
- ---
.--- .- --- - - -..- - - -- .-- .------ ....-
-.-.--.--.-
- -- -.-
- - -- ..- .
35
5
o Fights
Lies
Steals from Children
Steals from Family
Antisocial Factor
Hyperactive Factor
Parent Ratings Fig. 2 Relationship between childhood parent ratings and adult offending.
vists as were those rated low on this item (p < .005, Fisher's Exact Test). Hyperactive subjects who were rated high on the antisocial factor were three times more likely to become juvenile recidivists than were those rated low on this factor (p < .0003, Fisher's Exact Test). Although hyperactive subjects rated high on "fights" and on the hyperactive factor were somewhat more likely to become juvenile recidivists, compared with those rated low, these differences were not statistically significant. None of the teacher ratings or factor scores were predictive of juvenile recidivism. Parent ratings also predicted adult criminality (Fig. 2) . Hyperactive subjects rated high on "lies," "takes things from other children," and "takes money from members of his family" had significantly higher adult arrest rates compared with those rated low on these items (p < .01, P < .004, P < .05, respectively, Fisher's Exact Test). Hyperactive subjects rated high on an antisocial factor from the parent rating scale had a higher arrest rate compared with those rated low on this antisocial factor (p < .008, Fisher's Exact Test). Thus, three parent rating scale items ("lies," "takes things from other children," and "takes money from members of his family") and one factor (antisocial) significantly predicted both juvenile recidivism and adult arrest (Figs. 1 and 2) . However, two identical items ("lies," "takes things from other children") and the antisocial factor
J.
from the teacher rating scale did not predict juvenile recidivism or adult arrest, nor were these items or factors from the teacher and parent rating scales significantly correlated (r = .01 to .10). Neither the hyperactive factor nor the item "often gets into fights with other children" on either the parent or teacher scale predicted juvenile recidivist rates or adult criminality (Figs. 1 and 2). Other childhood attributes that did not predict juvenile recidivism or adult criminality were Full Scale IQ,. Verbal IQ, social class, and family type (with whom the child lived). Among the 16 hyperactive boys rated "low" on both lying and stealing, none became juvenile recidivists or adult offenders (Fig. 3). This is consistent with the finding that children who are not antisocial almost never become antisocial adults (Robins and Ratcliff, 1979). All 18 of the chronic offenders had high childhood ratings on lying, and most (94%) had high ratings on both lying and stealing. DISCUSSION
We have previously reported that hyperactive children are at an increased risk for criminal behaviors resulting in multiple arrests and incarceration in adolescence (Satterfield et al., 1982). The present study confirms our previous report and extends the findings so that we now conclude that hyperactive children are also at an increased risk for arrest and incarceration in adulthood.
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SATTERFIELD AND SCHELL
It is difficult to compare our arrest rates with those of either the New York or Montreal follow-up studies because of differences in methods of reporting arrest rates. In their adolescent follow-up studies, neither center reported juvenile and adult arrest rates separately, nor have they reported, as we have, juvenile arrest rates for subjects, all of whom have passed through the age of risk for juvenile offending (18 years). In their adult follow-up study, adult arrest and incarceration rates are not reported by Mannuzza and colleagues . Differences in selection criteria may also have contributed to differences in outcome. For example, the New York group concluded that they were probably successful in screening out most subjects with conduct disorder (Mannuzza et al., 1993), whereas we did not exclude this group and, in fact, most of our subjects were found to have CPs (Fig. 3) . Weiss and coworkers, in their IS-year follow-up of 64 of 104 hyperactive subjects, reported that only a small minority (3 or 4 subjects) were involved in criminal offenses such as theft, drug possession, or drug dealing. Their low rate of adult offenders may be due in part to their attrition rate of 38%, since groups most at risk for delinquency usually have the highest attrition rate (Polk and Ruby, 1978). We found that adolescent arrest history in hyperactive boys was a good predictor of adult arrest . As far as we know, this is the first study to report this finding. The arrest rate for our hyperactive subjects in adulthood Childhood
16 Boys without Conduct Problems
was less than half of their adolescent arrest rate (20% versus 46%). This could be due in part to the fact that the number of years at risk for adult offending was not as great as for juvenile offending. However, Farrington (1992) found that offending and aggressiveness decline with age (18 to 32 years). Among our 63 hyperactive subjects who did not have serious antisocial behavior in their adolescence (as reflected by two or more arrests), only 1 (1.5%) was later arrested in adulthood. The adult arrest rate for this group was no higher than the 1.1 % rate of the normal controls. This result is consistent with Farrington and West's study (1990) that found that very few of the hyperactive/non-CP boys began criminal careers in adulthood. The present study suggests that the association between childhood hyperactivity and adult criminality is almost always med iated by the presence of childhood CPs and by serious antisocial behavior in adolescence. This latter conclusion is in agreement with Mannuzza et al. (1989) , who concluded that the association between arrest history and childhood hyperactivity is almost entirely mediated by the occurrence of antisocial disorders in young adulthood. Relationship Between Number of Offenses, Age of First Arrest. and Remission
We found that hyperactive subjects with a history of early arrest were more likely than those with a history of
Adolescence
~
2 Single Offenders
~
'i
14 Non-Offenders
r---
~
13 Single Offenders
/ 73 Boys with Conduct Problems
Adulthood
1/ ~ 1\
26 Multiple Offenders
,
\
34 Non-Offenders
l*
r- H ~
KM K Hil
16 Non-Offenders
I
13 Non-Offenders
I
18 Offenders
I
8 Non-Offenders
I
I Offender
I I
33 Non-Offenders
Fig. 3 Relationship between childhood conduct problems . adolescent offending, and adult offending in 89 hyperactive males.
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AM. AC AD . C H IL D A DOLES C. PS YC H IAT RY, 36: 12 , D ECEMB ER 19 9 7
CRIMINALITY AND HYPERACTIVE BOYS
100 90
~ 80
~
E ;:
..
0
70 60
:i 50 'l:I
<
.E 40 GI
U
c
S 30
.!!
!'"
20
fI. 10 0 Under 11
12-13
14
15-16
17
Fig. 4 Relationship between age of first arrest and desistance in adult criminality in 89 hyperact ive boys.
late arrest to continue their offending into adulthood. We found a low desistance or remission rate for those first arrested before 15 years of age compared with a much greater desistance for those first arrested at age 15 years and older (Fig. 4). This finding is consistent with Farrington et al. (1990), who found early onset of delinquency to be an excellent predictor of later serious recidivism and with Loeber (1982), who found that early age of onset of CPs is predictive of chronic offending. We also found that hyperactive adolescents with multiple arrests were more likely than those with few arrests to continue offending into adulthood. Our study may have implications for "one strike and you're out" laws which mandate prison sentencing for a single violent crime (presumably to prevent later violent offending). Our finding that juvenile arrest for a violent offense was a poor predictor of adult arrest for violent offenses suggest that mandatory sentencing for a single violent offense may be neither wise nor cost-effective for this population. This study has a number of limitations. Because it is based on a overwhelmingly white, clinically referred, inner-city population, it may not be generalizable to other populations. The arrest records were obtained in 1985 and may not be representative of current arrest trends . Conduct disorder was not diagnosed and the N's are quite small. The adult arrest rates of the two groups may have been affected by subjects moving out of state during the 5 years between our earlier follow-up
J.
(Satterfield et al., 1982) and the current follow-up. This could lead to an underreporting of adult arrest rates that could affect one group more than the other. However, it seems unlikely that controls, who were more likely to live in families with two biological parents, would have moved out of state at a greater rate than our hyperactive subjects. who came from less stable families (Table 1). Thus lower arrest rates due to subjects moving out of state would have affected the hyperactive group more than the controls. Such a selective reduction in arrest rates would make our reponed between-group differences smaller than the real between-group differences. Strengths of this study are that this was a prospective controlled study and that official arrest records were obtained for 100% of both groups. As far as we know, this is the first prospective study of hyperactive children to examine not only offending in general. but juvenile offending in subjects who have passed the age of risk for juvenile offending, adult offending of the same subjects, juvenile offending as a predictor of adult offending, chronic offending versus occasional juvenile offending, and early versus late juvenile offending. Results of this study suggest that the pathway to crime for hyperactive children is mediated first by childhood CPs, which leads to serious juvenile antisocial behavior, which leads to adult criminality. However, most hyperactive boys with CPs do not become juvenile recidivists and not all (only 69%) juvenile recidivists become adult offenders (Fig. 3). All of our
AM . ACAD. CHILD ADOLE SC . PSY CHIATRY, 36:12. DECEMBER 199 7
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SATTERFIELD AND SCHELL
chronic offender hyperactive subjects had CPs in childhood, and none of those hyperactive subjects who did not have CPs in childhood later became chronic offenders. Thus childhood CPs may be a necessary but insufficient precursor of chronic offending (Fig. 3). Our childhood and adolescent data suggest that hyperactivity in the absence of antisocial behavior does not indicate an increased risk for serious antisocial behavior in later life. Hyperactive children are nevertheless at increased risk (five times normal) for developing conduct disorder (Loeber et al., 1995), thus making them at increased risk for serious antisocial behavior in later life. Clinical Implications
Our findings suggest that there are at least two important subgroups of hyperactive children: those with and without CPs. That only one CP was needed to identify an increased risk for serious antisocial behavior in adolescence and adulthood suggests that the threshold set to identify clinically significant conduct disorder in DSM-IV (American Psychiatric Association, 1994) (three or more CPs) may be too high for this age group of hyperactive boys. Furthermore, the CPs described here (takes things from other children, lies to get out of trouble) would not be considered serious enough to fit the DSM-IV criteria for conduct disorder. DSM-IV criteria (stealing while confronting a victim [e.g., mugging, purse snatching, extortion , armed robbery); often lies to obtain goods or favors or to ovoid obligations [i.e., "cons" others]') are more appropriate for older (teenage) children. Our CPs would fit ICD-9CM (World Health Organization, 1994) criteria ("lies"; "solitary stealing") for conduct disorder. Since these less serious CPs occur earlier in development, they offer an opportunity to intervene with treatments designed to prevent the later-occurring, more serious antisocial behavior. Our findings suggest that every hyperactive child should be evaluated for these early CPs and specific treatments should be targeted to treat these CPs during childhood when behavior is more malleable. Our findings also suggest that certain behaviors (felony arrest before age 15 years and multiple teenage felony arrests) of older hyperactive youths should alert professionals and parents to the presence of a serious problem that presagesserious adult antisocial behaviors. There is evidence that antisocial behaviors "crystallize" and become more stable as children grow older (Loeber, 1991). However, this behavior is also change-
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able, especially during preadolescence. Intervention efforts should be undertaken within this period. Very few intervention studies of hyperactive children who were then followed up to ascertain effects on adolescent antisocial behavior have been reported (see Weiss and Hechtman, 1986, for a review of stimulant drug interventions), We have reported a multimodality treatment of hyperactive boys which resulted in less antisocial behavior, improved academic performance, and better social adjustment at home and at school after 3 years of treatment (Satterfield et al., 1981). When followed up as adolescents, these mulrirnodaliry-treated boys were found to have a 50% reduction in juvenile arrest rates compared with a drug-treated-only group of hyperactive boys (Satterfield et al., 1987). Our studies suggest that childhood interventions with hyperactive children can be effective.
REFERENCES American Psychiatric Association (1994), Diagnostic and StatisticalManual of Mental Disorders, 4th edition (DSM-IV). Washington. DC: American Psychiatric Association, pp 85-91 Barkley RA, Fisher M. Edelbrock CS. Smallish L (1990). The adolescent outcome of hyperactive children diagnosed by research criteria. I: an 8year prospective follow-up study. JAm Acad Child Adolac Psychiatry 29:546-557 Cantwell DP (1996). Attention deficit disorder: a review of the past 10 years. JAm Acaa Child Adolac Psychiatry 35:978-987 Farrington DP (1992). The development of offending and antisocial behavior from childhood to adulthood. Paper presented at Congress on Rethinking Delinquency at the University of Minho, Braga. Portugal Farrington DP, Loeber R. Van Kammen WB (1990). Long-term criminal outcomes of hyperactive-impulsivity-attention deficit and conduct problems in childhood. In: Straight and Devious Pathways From Childhood to Adulthood. Rob ins L, Rutter M, eds. New York: Cambridge University Press. pp 62-81 Farrington Dp, West OJ (1990), The Cambridge study in delinquent development: a long term follow-up of 411 London males. In: Kriminalitat, Personlichkeit, Lrbmsgrschichu und Vrrhaltm (Criminality Personality. Behavior and Life History) , Kerner HJ. Kaiser G. eds. Heidelberg. Germany: Springer-Verlag Hechtman L. Weiss G. Perlman T (1984), Hyperacrives as young adults: past and current substance abuse and antisocial behavior. Am J Orthopsychiatry 54:415-425 Klein RG. Mannuzza S (1991). Long-term outcome of hyperactive children: a review. JAm Acaa Child Adole« Psychiatry 30:383-387 Loeber R (1982). The stability of antisocial and delinquent child behavior. Child Drv 53:1431-1446 Loeber R (1991). Antisocial behavior: more enduring than changeable? J Am Acad ChildAdolesc Psychiatry 30:393-397 Loeber R. Green SM. Keenan K. Lahey BB (1995), Which boys will fare worse? Early predictors of the onset of conduct disorder in a six-year longitudinal study. JAm Acad ChildAdalesc Psychiatry 34:499-509 Loney J. Whaley-Klahn T. Conboy J (l983). Hyperactive boys and their brothers at 2 J: predictors of aggressive and antisocial outcomes. In: Prospective Studirs of Crime and Delinqumcy, Van Dusen KT, Mednick SA. eds. Boston: Kluwer/Nijhoff, pp 181-206 Mannuzza S. Klein RG, BesslerA. Malloy P, Lapadula M (1993), Adult outcome of hyperactive boys. Arch Gen Psychiatry 50:565-576
] . AM. ACAD. C H I LD ADOLESC . PSYCHIATRY, 36 :12, DE CEMBER 1997
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Mannuzza S. Klein RG. Konig PH. Giampino TL (1989), Hyperactive boys almost grown up. IV: criminality and its relationship ro psychiatric status. Arch Gen Psychiatry 46: 1073-1079 Moffitt TE, Silva PA (1988), Self-reported delinquency. neuropsychological deficit, and history of attention deficit disorder.] Abnorm Child Psychol 16:553-569 Nylander I (1979). A 20-year prospective follow-up study of 2,164 cases at child guidance clinics in Stockholm. Acta Paediatr ScandSupp1276:1-45 Polk K. Ruby C (1978). Respondent loss in the longitudinal study of deviant behavior. National Council on Crime and Delinquency. San Francisco Robins LN. Ratcliff KS (1979). Risk facrors in the continuation of childhood antisocial behavior into adulthood . Int] Ment Health 7 :96-116 Satterfield J. Hoppe C. Schell A (1982), A prospective study of delinquency in 110 adolescent boys with attention-deficit disorder and 88 normal adolescent boys. Am] Psychiatry 139:795-798 Satterfield J. Satterfield B. Cantwell D (1981). Three-year treatment study of 100 hyperactive boys.] Pediatr98:650-655
J.
Satterfield J. Satterfield B. Schell A (1987) , Therapeutic interventions to prevent delinquency in hyperactive boys.] Am Acad Child AdolescPsychiatry 26:56-64 Satterfield J, Schell A (1984), Childhood brain function differences in delinquent and non-delinquent hyperactive boys. Electoencephalogr Clin N~rophysioI57: 199-207
Weiss G. Hechtman L (1986). Hyp~ractiv~ Children Grown Up. New York: Guilford Weiss G. Hechtman L. Milroy T. Perlman T (1985). Psychiatric status of hyperactives as adults: a controlled prospective IS-year follow-up of 63 hyperactive children.] Am Acad Child Psychiatry 24:2 I1-220 Weiss G. Hechtman L, Perlman T, Hopkins J, Wener A (1979) , Hyperacrives as young adults: a controlled prospective ten-year follow-up of 75 children . Arch Gen Psychiatry 36:675-681 World Health Organization (1994). International Classification of Diseases, 9th Revision, Clinical Modification (lCD-9-CM). Los Angeles: Practice Management Information Corp
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ABSTRACT ObJective: To examine the relationship between attention deficit disorder with hyperactivity in childhood and criminality
in adolescence and adulthood in 89 hyperactive and 87 normal control subjects. Method: In this prospective study, adolescent follow-up intervals ranged from 13 to 21 years and adult follow-up ranged from 18 to 23 years. The official arrest records for all subjects were obtained. Results: Hyperactive subjects had significantly higher juvenile (46% versus 11%) and adult (21% versus 1%) arrest rates. Juvenile and adult incarceration rates were also significantly higher. Childhood conduct problems predicted later criminality, and serious antisocial behavior in adolescence predicted adult criminality. Conclusions: Hyperactive children are at risk for both juvenile and adult criminality. The risk for becoming an adult offender is associated with conduct problems in childhood and serious antisocial behavior (repeat offending) in adolescence. Hyperactive children who do not have conduct problems are not at increased risk for later criminality. J. Am. Acad. Child Ado/esc. Psychiatry. 1997,36(12):1726-1735. Key Words: hyperactivity, adult status. criminality, conduct
problems.
Long-term outcome studies of hyperactive children have found relatively high rates of antisocial behavior or conduct disorder in adolescence (Barkley et al., 1990; Hechtman et al., 1984; Klein and Mannuzza, 1991; Loeber et al., 1995; Mannuzza et al., 1989; Satterfield et al., 1982) and high rates of antisocial personality disorder in adults (Hechtman et al., 1984; Mannuzza et al., 1993; Loney er al., 1983; Weiss and Hechtman, 1986; Weiss et al., 1985). Although most studies of adults who were hyperactive as children have found high rates of antisocial disorders, the findings on criminality are inconsistent across studies, and it is not known whether teenage criminality predicts adult criminality in hyperactive subjects. The relationship berween criminality in later life and hyperactivity in childhood has been -studied using gen-
Acupud[une 16. 1997. Dr. Saturfitld is with the Division of Child Psychiatry. Department of Psychiatry. Ortgon Healsh Scimces Uniuersity; Portland;and Dr. Schell is with tbe Psychology Department, Occidental Colkgt. LosAngtlts. Reprint rtqutsts to Dr. Schtll. Psychology Department, Occidental Co/kgt. 1600 Campus Road. LosAngeles, 0190041. 0890-8567/97/3612-1726/$O.300/0© 1997 by the American Academy of Child and Adolescent Psychiatry.
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J.
eral population studies and clinic samples of hyperactive children followed longitudinally. In a community study in New Zealand, Moffitt and Silva (1988) found that almost 60% of those with a childhood diagnosis of attention deficit disorder had become delinquent by age 13. In a long-term follow-up of a large sample of more than 2,000 child guidance cases from ages 9 to 29 in Stockholm, Nylander (1979) reported that one third of the hyperactive boys were officially registered for criminal acts. However, there was no control group in this study. Farrington et al. (1990), in a follow-up study of 4 II London boys, reported that among a subgroup of males with hyperactivity and conduct problems, 45% had juvenile convictions and 32% had adult convictions. There have been only rwo controlled prospective follow-up studies of clinically referred hyperactive children that evaluated subjects both during adolescence and again in adulthood. One study was carried out in Montreal (Weiss and Hechtman, 1986) and one in New York (Klein and Mannuzza, 1991). Our review of previous studies emphasizes these rwo studies because of their similarity to the present study. Mannuzza and coworkers (1989) reported arrest rates in 103 hyperactive males berween 16 and 23 years old
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:12, DECEMBER 1997
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(mean age 18) and 100 normal controls between 16 and 23 years old (mean age 18) at follow-up. Significantly more hyperactive than control subjects had been arrested for any offense (39% versus 20%), convicted for any offense (28% versus 11 %) , arrested for a felony offense (25% versus 7%) , and incarcerated (9% versus 1%). Mannuzza and colleagues carried out an interview study of 98% of subjects in the above study (Klein and Mannuzza, 1991; Mannuzza et al., 1993) when they were adults (mean age 26 years). Significantly more hyperactive subjects than controls had a diagnosis of antisocial personality disorder (18% versus 2%). Arrest and incarceration rates are not reported for either group; however, five hyperactive subjects were incarcerated for crimes that involved aggression and one died of a stab wound at the age of 22. The fact that 90% of both groups were gainfully employed at adult follow-up suggests a low incarceration rate at the time of followup but does not rule out incarceration or arrest during the 8 years since the earlier (at age 18 years) follow-up. Wei ss et al. (1979) and Hechtman et al. (1984) reported a 10-year prospective interview study of 75 subjects who were hyperactive as children (from an original cohort of 104) and 44 normal controls who were between 17 and 24 years old (an age range that includes both juveniles and adults) . The mean age of their subjects at follow-up was almost identical with that of the New York subjects. However, their results were quite different. There were no significant group differences in the number and seriousness of reported offenses during the preceding 5 years. Compared with controls, more former patients tended to report more court referrals during the 5 years preceding the followup (47% versus 32%. p < .07) but not during the year preceding the evaluation . Weiss and Hechtman (1986) reported a 15-year follow-up of 63 hyperactive subjects and 41 controls who were evaluated earlier (at age 19). In this study hyperactive subjects and normal controls were at an average age of 25 years (age range of 21 to 33 years). Similar to their earlier study, significantly more hyperactive subjects compared with control subjects appeared in court during 3 years preceding the follow-up (18% versus 5%). However, most of the hyperact ive subjects had appeared in court for highway offenses that fell under the criminal code (speeding). A small minority of subjects (three or four) were involved with criminal offenses such as theft , drug possession, or dealing. Significantly more
hyperactive than control subjects had a diagnosis of antisocial personality disorder (23% versus 2.5%; p < .01). Loney and coworkers (1983) interviewed 22 subjects who had been hyperactive as boys and their brothers (aged 21 to 23 years). The patients were found to have a greater incidence of antisocial personality disorder (45% versus 18%) and significantly more incarcerations than their brothers (41% versus 5%). However, there was no significant difference between groups on reponed number of police contacts. Conclusions are limited, however, because Loney er aI. identified hyperactive children retrospectively from clinic charts . We previously reported a prospective evaluation of 110male adolescents who had been diagnosed as hyperactive in childhood and 89 normal controls who were still residing in Los Angeles County at the time of the follow-up (Satterfield et al., 1982). Official records of arrests from ages 10 to 18 years indicated that the juvenile arrest rates for hyperactive subjects in the lower, middle, and upper socioeconomic classes were 58%, 36%, and 52%, compared with 11 %,9%, and 2% ·for the controls. Thus the juvenile arrest rates for hyperactive subjects were from 5 to 26 times higher than those of controls depending on social class. and they had a 25 times higher institutionalization rate (25% versus 1%). Arrest rates were not significantly related to social class in either group. The present study extends the follow-up of most of these subjects into adulthood. METHOD Methods, diagnostic criteria, proband characteristics, and data on the Satterfield rating scales have been described elsewhere (Satterfield er aI., 1982, 1987; Satterfield and Schell, 1984) and are reviewed only briefly, Juvenile criminality was measured by examining th e official arrest records as recorded in the Los Angeles County Probation Department's automated juvenile index . Adult crim inality was measured by examining the adult crim inal records for the state of California. Only felony crimes are considered in this study of juvenile and adult criminality.
Subjects Probands were 19- to 25 -year-old males who had been d iagnosed as hyperactive between the ages of 6 and 12 years. All had been of normal intelligence and without a history of psychoses or neurological disorder. No attempt was made to exclude subjects with conduct disorder. Control subjects were white males selected from publ ic school classes and were matched to the hyperactive subjects as closely as possible for age, IQ (WISC), and social class. Controls were not evaluated psychiatrically but were evaluated using the Satterfield Teacher Rating Scale and th e Satterfield Parent Rating Scale (Satterfield et al., 1982). When hyperactive subjects were selected for this stud y, the diagnostic categoty of attention deficit dis-
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order was not in use. Nevertheless, the hyperactive subjects in this study were selected by criteria that are similar to DSM-Ill criteria for attention deficit disorder with hyperactivity. As used here. "hyperactive" is a diagnostic term referring to the entire group of probands. Although DSM-IIl, DSM-I/I-R, and DSM-IV differ on the exact symptoms and how they are grouped . they are globally quite consistent (Cantwell, 1996). All patients received stimulant drugs for a mean treatment period of 2 years (Satterfield et al., 1987). The current study is an evaluation of adolescent and adult official arrest records for 89 of the 110 hyperactive and 87 of the 89 control subjects previously evaluated at adolescence (Satterfield et aI., 1982). This former adolescent study included 21 hyperactive and 2 normal Mrican-Americans who are not included in the current study. The rationale for excluding this subgroup is that arrest rates tended to be higher among African-Americans compared with the other subjects. Therefore, limiting the study to Anglo subjects makes this hyperactive group more comparable with the control group and to the only two other adult follow-up studies of hyperactive children (which also did not include African-Americans) . At the time of our former adolescent follow-up, many of our subjects had not passed through the age of risk for committing a juvenile offense (had not reached their 18th birthday). The 5 years of additional follow-up time in the current study allows an examination of the arrest rates for subjects, all of whom have passed through the age of risk (from childhood to age 18 years) for juvenile offend ing. It also provides us with the opportunity to examine the adult arrest rates in these same two groups .
Data Analysis Group contrasts such as age were subjected to t test analyses. For contrasts of dichotomous variables, such as arrested/not arrested, Xl or Fisher's Exact Test values were computed. All probabilities reported are two-tailed.
11%; X2 = 24.5, df= l,p < .001) and incarcerated (22% versus 1%; X2 = 19.0, df= l,p < .001). Seventeen of the 19 incarcerated hyperactive subjects spent time in juvenile hall (many while awaiting trial), and two were sentenced to the California Youth Authority. There were more recidivists among the hyperactive than among the control subjects (29% versus 1%; X2 = 26.7, df = 1, P < .001). However, there was no significant between-group difference in the number of single-offense subjects (17% versus 12%; X2 = 1.5, df = 1, not significant). Among those arrested, more hyperactive than control subjects had been arrested for violent crimes (34% versus 9%; p < .10, Fisher's Exact Test). Assault/battery was the most frequent crime against persons, and burglary was the most frequent property crime for both groups. The hyperactive subjects' assault/battery category included charges of battery on person/peace/fire officer, assault with a deadly weapon, kidnapping, and assault to commit rape. The mean number of arrests for the 41 arrested hyperactive subjects and for the 11 arrested controls was 2.80 and 1.09, respectively (p < .001, Mann-Whitney U test). Age of first arrest ranged from 10 to 18 years for hyperactive subjects and from 13 to 18 years for controls. Of those who had been arrested, more hyperactive than control subjects had been arrested before 15 years of age (61% versus 18%; X2 = 6.36. df = 1, P < .02) .
RESULTS
Adult Criminality
Juvenile Criminality
Demographics and Arrest History. Hyperactive and control subjects did not differ in age at the time when the follow-up records were obtained (Table 1). Child-
Significantly more adolescent hyperactive subjects than control subjects had been arrested (46% versus
TABLE 1 Age, IQ, Socioeconomic Status (SES), and Family Type for All Hyperactive Subjects, All Controls, and Two Adult Hyperactive Subgroups (Arrested and Nonarrested)
Variable Age at follow-up. yr Mean (SO) Range SES, No. (0/0) Lower Middle Upper WISC Full Scale, Mean (SO) Family type," No. (%) One parent Two parents Other
Hyperactives (n = 89)
Controls (n = 87)
22.3 (1.4) 19-25 20 50 19 101
22.4 (1.4) 19-25
(23) (56) (21) (14)
17 26 44 115
24 (27) 41 (46) 24 (27)
(19) (30) (51) (14)
13 (16) 62 (76) 6 (8)
Yes (n
Hyperactives Arrested No tn
= 19)
22.5 (1.3) 20-25 5 9 5 102
(26) (48) (26) (14)
5 (26) 10 (53) 4 (21)
= 70)
22 .2 (1.5) 18-25 11 41 18 101
(16) (58) (26) (14)
22 (32) 41 (58) 7 (10)
"Family types by number of biological parents with whom the child lived.
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TABLE 2 Juvenile and Adult Arrest History for 18 Chronic Offender Hyperactive Subjects Juvenile Arrest History Category of Arrests Violenr crimes Assault/batrery Robbery Weapons Any violenr crime Properry crimes Theft Grand theft Unlawful raking of vehicle Burglary Any properry crime Drug-related crime
Offenders
Arrests
Adult Arrest History Offenders
6 2 2 9
(33) (II) (II) (50)
10 (13) 3 (4) 2 (3) 15 (19)
3 2 2 7
(16) (II) (11) (39)
7 5 7 16 17 1
(39) (28) (38) (89) (94) (6)
20 (25) 6 (7) 7 (9) 27 (34) 60 (75) 2 (3)
I 5 3 7 13 0
(6) (28) (16) (39) (72) (0)
Arrests
3 (10) 2 (7) 2 (7) 7 (23) I 10 3 9 23 0
(3) (33) (10) (30) (77) (0)
Note: Values represenr No. (0/0).
hood evaluations found that controls had higher IQs (t = 6.48, df= l,p < .001), came from families with higher socioeconomic status (X 2 = 17.7, df = 2, P < .001), and were more likely to live in families with two biological parents (X 2 = 18, df = 2, P < .001). However, socioeconomic status, biological parents in family, and IQ scores for the arrested and the nonarrested adult hyperactive subjects were not significantly different (Table 1). Since only one control subject was arrested as an adult, similar analyses could not be carried out for the control group. Adult hyperactive arrestees' ages ranged from 18 to 23 years. Forty-seven percent were arrested at age 18 years, and 79% had been arrested before age 21 years. Arrestand Incarceration Rates. The felony arrest rate for hyperactive subjects was 21 times that of the controls (21% versus 1%; X2 = 18.25, df = 1, P < .001). Eight hyperactive and no control subjects (9% versus 0%; p < .004, Fisher's Exact Test) had been arrested more than once for a felony offense. Eleven hyperactive and no control subjects (12% versus 0%; X2 = 8.94, df = 1, P < .01) had been incarcerated as adults. Of the 11 incarcerated hyperactive subjects, 3 were incarcerated in local jails, 4 in the county jail, 2 in the California Youth Authority, and 2 in state prisons. These 11 hyperactive subjects had served or had been sentenced to serve a total of 10.2 years adult time. Eighteen (95%) of the 19 hyperactive adult offenders became official offenders early in life and had been arrested more than once prior to age 18 years. These 18 subjects accounted for 77 juvenile and 30 adult arrests for a total of 108 felony arrests (a mean of 6 arrests per subject). Furthermore,
this 21 % of the 89 hyperactive subjects accounted for 74% of all juvenile and adult offenses. We will call this group our chronic offender hyperactive group. Table 2 shows the types of offenses for which these chronic offender hyperactive subjects were arrested, both as juveniles and later as adults. Property crime was the most frequent type of crime for which these hyperactive subjects were arrested, both as juveniles and as adults. The mean number of arrests for these chronic offenders was two times greater in their adolescence than in their adulthood (4.3 versus 1.7; t = 4.49, df = 17, P < . 001). Adolescent Predictors of Adult Criminality in Hyperactive Subjects
Arrest for felony crimes in adolescence predicted criminality in later life. Forty-eight hyperactive youths had no juvenile arrests, 15 had only one, 8 had two, and 18 had three or more juvenile arrests. The adult arrest rates for the adolescents with none, one, two, and three or more juvenile arrests were 2%, 0%, 38%, and 83% respectively. Eighteen of the 26 juvenile recidivists were arrested as adults for felony offenses versus 1 of the 63 nontecidivists (69% versus 1.6%; X2 = 50, df= 1, P < .0001). Incarceration as a juvenile also predicted adult criminality. Ten of the 19 hyperactive adolescents incarcerated were later arrested as adults compared with 9 of the 70 hyperactive subjects who were not incarcerated as juveniles (58% versus 22%; X2 = 14.08, df = 1, P < .001). The younger the hyperactive subject at the time of the first felony arrest, the more likely he
}. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:12, DECEMBER 1997
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SATTERFIELD AND SC HE LL
would become a chronic juvenile offender and eventually be arrested in adulthood. Twenty-five hyperactive youths were first arrested before age 15 years (earlyarrest group) and 16 hyperactive youths were 15 to 18 years of age when first arrested (late-arrest group). Of those in the early-arrest group, 15 became adult offenders compared with 3 of the late-arrest group (60% versus 19%; X2 = 6.74, df= l,p < .01). Of the 41 hyperactive subjects arrested for felony crimes as juveniles, 18 (43%) continued (persisters) and 23 (57%) discontinued (desisters) their criminal activity (as reflected by their adult arrest histories). We were unable to determine any differences between these two groups other than number of juvenile arrests and age of first felony arrest. The specific type of juvenile arrest did not predict type of adult arrest. For example, of the 14 hyperactive youths arrested for a violent juvenile crime, only 3 (21 %) were arrested as an adult for a violent crime, and of the 7 hyperactive subjects arrested for a violent adult crime, only 3 had been arrested for a violent crime as a juvenile. Childhood Predictors of Juvenile and Adult Criminality in Hyperactive Boys
The Satterfield Teacher Rating Scale and the Satterfield Parent Rating Scale were administered to most subjects . The rating scales consisted of items arranged in checklist form so that the teacher or parent could
indicate the degree to which each item of behavior was present (not at all = 0, just a little = 1, pretty much = 2, very much = 3). Four conduct problems (CPs) items and two factor scores from both teacher and parent rating scales were selected to be examined as predictors of juvenile and adult criminality. Items selected from both parent and teacher rating scales were "often gets into fights with other children," "lies to get out of trouble," and "takes things from other children" (i.e., steals). One additional item, "takes money from members of his family" (i.e., steals), was selected from the parent rating scale. Item scores were dichotomized as either low (not at all or just a little) or high (pretty much or very much). The factor scores selected were the antisocial and hyperactive factors (Satterfield and Schell, 1984); these were dichotomized (high and low) using a median split. Several of the selected parent rating scale items predicted juvenile criminality. Hyperactive subjects who were rated high on lying had a juvenile recidivist rate that was five times higher than those rated low on lying (p < .02, Fisher's Exact Test) (Fig. 1). Hyperactive subjects who were rated high on "takes things from children" were four times more likely to be juvenile recidivists than those rated low on this item (p < .0002, Fisher's Exact Test). Hyperactive subjects who were rated high on "takes money from members of his family" were twice as likely to become juvenile recidi-
60
50
10
o Fights
Lies
Stesls from Steals from Children Family Parent Ratings
Antisocial Factor
Hyperactive Factor
Fig. 1 Relation ship between ch ildho od parent ratings and juvenile recidivism.
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}. AM . ACAD . C H IL D ADOL ESC . PSY CHIATRY. %:12. D ECEMBER 1997
CRIMINALITY AND HYPERACTIVE BOYS
40
- ---
.--- .- --- - - -..- - - -- .-- .------ ....-
-.-.--.--.-
- -- -.-
- - -- ..- .
35
5
o Fights
Lies
Steals from Children
Steals from Family
Antisocial Factor
Hyperactive Factor
Parent Ratings Fig. 2 Relationship between childhood parent ratings and adult offending.
vists as were those rated low on this item (p < .005, Fisher's Exact Test). Hyperactive subjects who were rated high on the antisocial factor were three times more likely to become juvenile recidivists than were those rated low on this factor (p < .0003, Fisher's Exact Test). Although hyperactive subjects rated high on "fights" and on the hyperactive factor were somewhat more likely to become juvenile recidivists, compared with those rated low, these differences were not statistically significant. None of the teacher ratings or factor scores were predictive of juvenile recidivism. Parent ratings also predicted adult criminality (Fig. 2) . Hyperactive subjects rated high on "lies," "takes things from other children," and "takes money from members of his family" had significantly higher adult arrest rates compared with those rated low on these items (p < .01, P < .004, P < .05, respectively, Fisher's Exact Test). Hyperactive subjects rated high on an antisocial factor from the parent rating scale had a higher arrest rate compared with those rated low on this antisocial factor (p < .008, Fisher's Exact Test). Thus, three parent rating scale items ("lies," "takes things from other children," and "takes money from members of his family") and one factor (antisocial) significantly predicted both juvenile recidivism and adult arrest (Figs. 1 and 2) . However, two identical items ("lies," "takes things from other children") and the antisocial factor
J.
from the teacher rating scale did not predict juvenile recidivism or adult arrest, nor were these items or factors from the teacher and parent rating scales significantly correlated (r = .01 to .10). Neither the hyperactive factor nor the item "often gets into fights with other children" on either the parent or teacher scale predicted juvenile recidivist rates or adult criminality (Figs. 1 and 2). Other childhood attributes that did not predict juvenile recidivism or adult criminality were Full Scale IQ,. Verbal IQ, social class, and family type (with whom the child lived). Among the 16 hyperactive boys rated "low" on both lying and stealing, none became juvenile recidivists or adult offenders (Fig. 3). This is consistent with the finding that children who are not antisocial almost never become antisocial adults (Robins and Ratcliff, 1979). All 18 of the chronic offenders had high childhood ratings on lying, and most (94%) had high ratings on both lying and stealing. DISCUSSION
We have previously reported that hyperactive children are at an increased risk for criminal behaviors resulting in multiple arrests and incarceration in adolescence (Satterfield et al., 1982). The present study confirms our previous report and extends the findings so that we now conclude that hyperactive children are also at an increased risk for arrest and incarceration in adulthood.
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It is difficult to compare our arrest rates with those of either the New York or Montreal follow-up studies because of differences in methods of reporting arrest rates. In their adolescent follow-up studies, neither center reported juvenile and adult arrest rates separately, nor have they reported, as we have, juvenile arrest rates for subjects, all of whom have passed through the age of risk for juvenile offending (18 years). In their adult follow-up study, adult arrest and incarceration rates are not reported by Mannuzza and colleagues . Differences in selection criteria may also have contributed to differences in outcome. For example, the New York group concluded that they were probably successful in screening out most subjects with conduct disorder (Mannuzza et al., 1993), whereas we did not exclude this group and, in fact, most of our subjects were found to have CPs (Fig. 3) . Weiss and coworkers, in their IS-year follow-up of 64 of 104 hyperactive subjects, reported that only a small minority (3 or 4 subjects) were involved in criminal offenses such as theft, drug possession, or drug dealing. Their low rate of adult offenders may be due in part to their attrition rate of 38%, since groups most at risk for delinquency usually have the highest attrition rate (Polk and Ruby, 1978). We found that adolescent arrest history in hyperactive boys was a good predictor of adult arrest . As far as we know, this is the first study to report this finding. The arrest rate for our hyperactive subjects in adulthood Childhood
16 Boys without Conduct Problems
was less than half of their adolescent arrest rate (20% versus 46%). This could be due in part to the fact that the number of years at risk for adult offending was not as great as for juvenile offending. However, Farrington (1992) found that offending and aggressiveness decline with age (18 to 32 years). Among our 63 hyperactive subjects who did not have serious antisocial behavior in their adolescence (as reflected by two or more arrests), only 1 (1.5%) was later arrested in adulthood. The adult arrest rate for this group was no higher than the 1.1 % rate of the normal controls. This result is consistent with Farrington and West's study (1990) that found that very few of the hyperactive/non-CP boys began criminal careers in adulthood. The present study suggests that the association between childhood hyperactivity and adult criminality is almost always med iated by the presence of childhood CPs and by serious antisocial behavior in adolescence. This latter conclusion is in agreement with Mannuzza et al. (1989) , who concluded that the association between arrest history and childhood hyperactivity is almost entirely mediated by the occurrence of antisocial disorders in young adulthood. Relationship Between Number of Offenses, Age of First Arrest. and Remission
We found that hyperactive subjects with a history of early arrest were more likely than those with a history of
Adolescence
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/ 73 Boys with Conduct Problems
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,
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Fig. 3 Relationship between childhood conduct problems . adolescent offending, and adult offending in 89 hyperactive males.
1732
J.
AM. AC AD . C H IL D A DOLES C. PS YC H IAT RY, 36: 12 , D ECEMB ER 19 9 7
CRIMINALITY AND HYPERACTIVE BOYS
100 90
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Fig. 4 Relationship between age of first arrest and desistance in adult criminality in 89 hyperact ive boys.
late arrest to continue their offending into adulthood. We found a low desistance or remission rate for those first arrested before 15 years of age compared with a much greater desistance for those first arrested at age 15 years and older (Fig. 4). This finding is consistent with Farrington et al. (1990), who found early onset of delinquency to be an excellent predictor of later serious recidivism and with Loeber (1982), who found that early age of onset of CPs is predictive of chronic offending. We also found that hyperactive adolescents with multiple arrests were more likely than those with few arrests to continue offending into adulthood. Our study may have implications for "one strike and you're out" laws which mandate prison sentencing for a single violent crime (presumably to prevent later violent offending). Our finding that juvenile arrest for a violent offense was a poor predictor of adult arrest for violent offenses suggest that mandatory sentencing for a single violent offense may be neither wise nor cost-effective for this population. This study has a number of limitations. Because it is based on a overwhelmingly white, clinically referred, inner-city population, it may not be generalizable to other populations. The arrest records were obtained in 1985 and may not be representative of current arrest trends . Conduct disorder was not diagnosed and the N's are quite small. The adult arrest rates of the two groups may have been affected by subjects moving out of state during the 5 years between our earlier follow-up
J.
(Satterfield et al., 1982) and the current follow-up. This could lead to an underreporting of adult arrest rates that could affect one group more than the other. However, it seems unlikely that controls, who were more likely to live in families with two biological parents, would have moved out of state at a greater rate than our hyperactive subjects. who came from less stable families (Table 1). Thus lower arrest rates due to subjects moving out of state would have affected the hyperactive group more than the controls. Such a selective reduction in arrest rates would make our reponed between-group differences smaller than the real between-group differences. Strengths of this study are that this was a prospective controlled study and that official arrest records were obtained for 100% of both groups. As far as we know, this is the first prospective study of hyperactive children to examine not only offending in general. but juvenile offending in subjects who have passed the age of risk for juvenile offending, adult offending of the same subjects, juvenile offending as a predictor of adult offending, chronic offending versus occasional juvenile offending, and early versus late juvenile offending. Results of this study suggest that the pathway to crime for hyperactive children is mediated first by childhood CPs, which leads to serious juvenile antisocial behavior, which leads to adult criminality. However, most hyperactive boys with CPs do not become juvenile recidivists and not all (only 69%) juvenile recidivists become adult offenders (Fig. 3). All of our
AM . ACAD. CHILD ADOLE SC . PSY CHIATRY, 36:12. DECEMBER 199 7
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SATTERFIELD AND SCHELL
chronic offender hyperactive subjects had CPs in childhood, and none of those hyperactive subjects who did not have CPs in childhood later became chronic offenders. Thus childhood CPs may be a necessary but insufficient precursor of chronic offending (Fig. 3). Our childhood and adolescent data suggest that hyperactivity in the absence of antisocial behavior does not indicate an increased risk for serious antisocial behavior in later life. Hyperactive children are nevertheless at increased risk (five times normal) for developing conduct disorder (Loeber et al., 1995), thus making them at increased risk for serious antisocial behavior in later life. Clinical Implications
Our findings suggest that there are at least two important subgroups of hyperactive children: those with and without CPs. That only one CP was needed to identify an increased risk for serious antisocial behavior in adolescence and adulthood suggests that the threshold set to identify clinically significant conduct disorder in DSM-IV (American Psychiatric Association, 1994) (three or more CPs) may be too high for this age group of hyperactive boys. Furthermore, the CPs described here (takes things from other children, lies to get out of trouble) would not be considered serious enough to fit the DSM-IV criteria for conduct disorder. DSM-IV criteria (stealing while confronting a victim [e.g., mugging, purse snatching, extortion , armed robbery); often lies to obtain goods or favors or to ovoid obligations [i.e., "cons" others]') are more appropriate for older (teenage) children. Our CPs would fit ICD-9CM (World Health Organization, 1994) criteria ("lies"; "solitary stealing") for conduct disorder. Since these less serious CPs occur earlier in development, they offer an opportunity to intervene with treatments designed to prevent the later-occurring, more serious antisocial behavior. Our findings suggest that every hyperactive child should be evaluated for these early CPs and specific treatments should be targeted to treat these CPs during childhood when behavior is more malleable. Our findings also suggest that certain behaviors (felony arrest before age 15 years and multiple teenage felony arrests) of older hyperactive youths should alert professionals and parents to the presence of a serious problem that presagesserious adult antisocial behaviors. There is evidence that antisocial behaviors "crystallize" and become more stable as children grow older (Loeber, 1991). However, this behavior is also change-
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able, especially during preadolescence. Intervention efforts should be undertaken within this period. Very few intervention studies of hyperactive children who were then followed up to ascertain effects on adolescent antisocial behavior have been reported (see Weiss and Hechtman, 1986, for a review of stimulant drug interventions), We have reported a multimodality treatment of hyperactive boys which resulted in less antisocial behavior, improved academic performance, and better social adjustment at home and at school after 3 years of treatment (Satterfield et al., 1981). When followed up as adolescents, these mulrirnodaliry-treated boys were found to have a 50% reduction in juvenile arrest rates compared with a drug-treated-only group of hyperactive boys (Satterfield et al., 1987). Our studies suggest that childhood interventions with hyperactive children can be effective.
REFERENCES American Psychiatric Association (1994), Diagnostic and StatisticalManual of Mental Disorders, 4th edition (DSM-IV). Washington. DC: American Psychiatric Association, pp 85-91 Barkley RA, Fisher M. Edelbrock CS. Smallish L (1990). The adolescent outcome of hyperactive children diagnosed by research criteria. I: an 8year prospective follow-up study. JAm Acad Child Adolac Psychiatry 29:546-557 Cantwell DP (1996). Attention deficit disorder: a review of the past 10 years. JAm Acaa Child Adolac Psychiatry 35:978-987 Farrington DP (1992). The development of offending and antisocial behavior from childhood to adulthood. Paper presented at Congress on Rethinking Delinquency at the University of Minho, Braga. Portugal Farrington DP, Loeber R. Van Kammen WB (1990). Long-term criminal outcomes of hyperactive-impulsivity-attention deficit and conduct problems in childhood. In: Straight and Devious Pathways From Childhood to Adulthood. Rob ins L, Rutter M, eds. New York: Cambridge University Press. pp 62-81 Farrington Dp, West OJ (1990), The Cambridge study in delinquent development: a long term follow-up of 411 London males. In: Kriminalitat, Personlichkeit, Lrbmsgrschichu und Vrrhaltm (Criminality Personality. Behavior and Life History) , Kerner HJ. Kaiser G. eds. Heidelberg. Germany: Springer-Verlag Hechtman L. Weiss G. Perlman T (1984), Hyperacrives as young adults: past and current substance abuse and antisocial behavior. Am J Orthopsychiatry 54:415-425 Klein RG. Mannuzza S (1991). Long-term outcome of hyperactive children: a review. JAm Acaa Child Adole« Psychiatry 30:383-387 Loeber R (1982). The stability of antisocial and delinquent child behavior. Child Drv 53:1431-1446 Loeber R (1991). Antisocial behavior: more enduring than changeable? J Am Acad ChildAdolesc Psychiatry 30:393-397 Loeber R. Green SM. Keenan K. Lahey BB (1995), Which boys will fare worse? Early predictors of the onset of conduct disorder in a six-year longitudinal study. JAm Acad ChildAdalesc Psychiatry 34:499-509 Loney J. Whaley-Klahn T. Conboy J (l983). Hyperactive boys and their brothers at 2 J: predictors of aggressive and antisocial outcomes. In: Prospective Studirs of Crime and Delinqumcy, Van Dusen KT, Mednick SA. eds. Boston: Kluwer/Nijhoff, pp 181-206 Mannuzza S. Klein RG, BesslerA. Malloy P, Lapadula M (1993), Adult outcome of hyperactive boys. Arch Gen Psychiatry 50:565-576
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Mannuzza S. Klein RG. Konig PH. Giampino TL (1989), Hyperactive boys almost grown up. IV: criminality and its relationship ro psychiatric status. Arch Gen Psychiatry 46: 1073-1079 Moffitt TE, Silva PA (1988), Self-reported delinquency. neuropsychological deficit, and history of attention deficit disorder.] Abnorm Child Psychol 16:553-569 Nylander I (1979). A 20-year prospective follow-up study of 2,164 cases at child guidance clinics in Stockholm. Acta Paediatr ScandSupp1276:1-45 Polk K. Ruby C (1978). Respondent loss in the longitudinal study of deviant behavior. National Council on Crime and Delinquency. San Francisco Robins LN. Ratcliff KS (1979). Risk facrors in the continuation of childhood antisocial behavior into adulthood . Int] Ment Health 7 :96-116 Satterfield J. Hoppe C. Schell A (1982), A prospective study of delinquency in 110 adolescent boys with attention-deficit disorder and 88 normal adolescent boys. Am] Psychiatry 139:795-798 Satterfield J. Satterfield B. Cantwell D (1981). Three-year treatment study of 100 hyperactive boys.] Pediatr98:650-655
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Satterfield J. Satterfield B. Schell A (1987) , Therapeutic interventions to prevent delinquency in hyperactive boys.] Am Acad Child AdolescPsychiatry 26:56-64 Satterfield J, Schell A (1984), Childhood brain function differences in delinquent and non-delinquent hyperactive boys. Electoencephalogr Clin N~rophysioI57: 199-207
Weiss G. Hechtman L (1986). Hyp~ractiv~ Children Grown Up. New York: Guilford Weiss G. Hechtman L. Milroy T. Perlman T (1985). Psychiatric status of hyperactives as adults: a controlled prospective IS-year follow-up of 63 hyperactive children.] Am Acad Child Psychiatry 24:2 I1-220 Weiss G. Hechtman L, Perlman T, Hopkins J, Wener A (1979) , Hyperacrives as young adults: a controlled prospective ten-year follow-up of 75 children . Arch Gen Psychiatry 36:675-681 World Health Organization (1994). International Classification of Diseases, 9th Revision, Clinical Modification (lCD-9-CM). Los Angeles: Practice Management Information Corp
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