Special Risk Factor

There seems to be an important subgroup of the childhood-onset cohort that are at special risk for developing adult problems. Although the theoretical underpinnings of why ADHD, ODD, CD in childhood, and APD in adulthood are related is yet unclear, there is substantial empirical support to suggest that they are. Lahey and Loeber (1997), drawing on 30 years of empirical literature exploring these relationships, cite several lines of research that help explicate the connections between these childhood disorders and adult antisocial behavior. The first is the well-supported finding that children with ADHD are more likely to display antisocial behavior as adolescents and adults than are children without ADHD. A second involves the relatively poor prognosis for children who have concurrent ADHD and CD. Those who meet criteria for both have higher rates of CD over time than for those with CD alone. Less is known about the ways that ODD is linked to CD and later adult antisocial behavior, but there is some preliminary evidence to suggest that it is even more strongly linked than ADHD.

However, further conclusions are much muddier. For example, Lahey and Loeber cite two studies that do not support the hypothesis that children with ADHD in the absence of CD are at risk for later developing antisocial behavior (Loeber, 1988; Magnusson & Bergman, 1990) and three studies that did (Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Lambert, 1988; Mannuzza et al., 1991). Loeber, Burke, Lahey, Winters, and Zera (2000) propose that while ODD and CD appear to place adolescents at risk for several subsequent disorders, there seems to be a modal sequence; namely, ODD is often a precursor for CD, which may be a precursor to APD. To confuse matters more, ADHD is often a comorbid condition with ODD and CD but may not affect the course of CD without prior ODD.

Much of this research is plagued with methodological issues that make clear interpretations of the findings difficult. You can imagine the problems that arise in developmental research. One is an issue of longitudinal versus cross-sectional samples. If you are trying to determine the developmental nature of a disorder (i.e., Does a child with ADHD and CD develop into an adult with antisocial personality disorder?), it makes sense to follow the same people from childhood, through adolescence, and into adulthood. Research of this sort is very costly and is confounded by ever-evolving diagnostic criteria. Throughout the various incarnations of the DSM, criteria for all of these diagnoses have changed considerably with an accompanying change in the prevalence of each disorder. So, a child with a set of symptoms may meet criteria for ODD one year, but because criteria changed with a new edition of the DSM, three years later, with the same constellation of symptoms, he or she no longer meets criteria for ODD. This renders interpreting results both within and between studies a tricky business.

to those in which they were first learned. In certain cases, however, these experiences may give rise to a chain of reactions and events that establish pervasive pathological trends. In the next section, we see that the conditions of early experience, whatever their nature, may persist long after the event that prompted them has passed.

Comment: We have taken the liberty in this section of bringing together many of the diverse notions and findings that theorists have used to identify the principal psychogenic sources of personality pathology; only briefly have we commented on the adequacy of these data or the methods employed in obtaining them. Our presentation would be amiss if we failed to appraise, albeit briefly, the soundness of the evidence.

The view that the particular setting and events of early experience play a decisive part in determining personality is assumed by psychologists of all theoretical persuasions. But where, in fact, are the hard data, the unequivocal evidence derived from well-designed and well-executed research? Such data, unfortunately, are sorely lacking. Most of the research in the field can be faulted on methodological grounds, biased populations, poor assessment techniques, unreliable diagnostic categories, and, most significantly, failures to include appropriate control groups by which comparative evaluations can be made. Without controls, for example, it is impossible to determine whether the specific parental attitude, training procedure, or traumatic event under investigation can be assigned the significance attributed to it.

Disconcerting findings show us that there may be no substantial difference in deleterious childhood experiences between normal men and psychiatric patients. It is known, furthermore, that many adults who have been reared in seemingly devastating childhood environments not only survive but thrive, whereas adults raised under idealistic conditions often deteriorate into severe pathological patterns. The combination of factors and the sequence of events involved in producing pathology are awesomely complex and difficult to unravel. Unless future lines of research are based on sound premises and executed with the utmost of methodological care, investigators will continue to go around in circles, confirming only what their naive prejudices incline them to find.

The importance of well-reasoned and well-designed studies is nowhere more evident than in the investigation of psychogenic sources of personality pathology; few studies of the past have met the basic criteria of good research. We minimized reference to specific studies in this section lest we lead you to believe that there are data from well-designed research to support the notions presented. You should view these notions as propositions that will be confirmed or disconfirmed as a result offuture research.

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