Antisocial behaviour in clinically referred boys : early identification and assessment procedures in child psychiatry

Background: Oppositional and aggressive behaviour in children below twelve years of age is a frequent cause of concern for parents and teachers, and a common reason for referral to child and adolescent psychiatry. Whereas most children outgrow these behaviours, a small subgroup is at risk for developing a persistent antisocial lifestyle. Successfully identifying children at risk could prevent potential human and economic suffering of the child, his/her family, potential victim(s) and society. However, predicting which children are at higher risk for future antisocial behaviours is intricate and associated with the perils of mislabelling. Recently, promising approaches for early identification of boys at risk for future antisocial behaviour have been formulated. These include assessments of risk factors (risk assessments) and evaluation of certain personality traits callous-unemotional (CU) traits. CU-traits are defined as patterns of emotional dysregulation, such as a pronounced lack of empathy, remorselessness and shallow affects. The main aim of this thesis was to investigate whether these structured approaches might improve early identification of clinic-referred boys at risk for future antisocial behaviour and to explore clinical child psychiatric work with these children and their families.

Method: A combination of quantitative and qualitative methodologies was used. A prospective longitudinal multicentre project was initiated in mid-Sweden during 2001. Parents of clinic-referred boys (n = 76) completed questionnaires and participated in a semi-structured researcher-led interview at baseline, yielding information to evaluate the risk for future antisocial behaviour. Parents were then interviewed again after six and thirty months. At the thirty-month follow-up we also included teachers as informants. Child clinicians at each clinic were asked to fill in separate evaluations of the boys risk. Furthermore, a qualitative study was conducted in which narrative interviews with 16 clinicians from seven child psychiatric teams enabled exploration of clinical work with conduct-disordered boys.

Results: Assessments of risk for future antisocial behaviour, based on the risk assessment tool Early Assessment Risk List for Boys (EARL-20B), demonstrated acceptable interrater reliability (Paper I). EARL-20B-based assessments were associated with concurrent and prospective estimates of antisocial behaviour (Paper I-II). Combinations of EARL-20B risk factors were tentatively identified through cluster analysis, distinguishing between boys with high and low levels of antisocial behaviour (Paper I). Comparing the EARL-20B-based baseline evaluations with unstructured clinical baseline evaluations of risk and baseline DSM-IV Conduct Disorder (CD) indicated incremental predictive validity of the EARL-20B. The AUC estimate of CD-diagnosis at the thirty-month follow-up was of good accuracy (.87) for the EARL-20B. Further, conduct problem boys (n = 41) high on CU-traits had significantly more pervasive, varied and aggressive disruptive behavioural problems than boys low on these traits. This finding was not explained by the presence of DSM-IV AD/HD and Oppositional Defiant Disorder (ODD)/CD symptoms. Boys with CU-traits experienced poorer household circumstances, lived in families under high stress and received less help in school from special teachers than boys low in CU-traits (Paper III). The qualitative study suggested that child psychiatry clinicians consider a multitude of case characteristics when working with antisocial boys (Paper IV). The behaviour of the boys sometimes evoked feelings of fear among caregivers, signalling the need for instant interventions. The teams described a lack of consent and collaboration with other agencies, with unclear responsibilities across organisations.

Conclusions: The results suggest that structured assessments of risk and the evaluation of CU-traits can be valuable for identifying severe antisocial behaviour in boys. Early identification procedures touch upon the delicate balance between discerning children at risk to prevent them from repeated violent and norm-breaking behaviours, and the dangers of labelling. When addressing either risk for violence or CU-traits in boys, the purpose, due to ethical considerations, should therefore be to prevent serious antisocial behaviours from occurring through the provision of treatment and other interventions. Over the years, researchers and clinicians have pointed to a need for improved management of antisocial behaviour in child psychiatric services. Improved collaboration and clearer responsibilities among agencies still seem necessary to enable good care and management.

List of scientific papers

I. Enebrink P, Langstrom N, Hulten A, Gumpert CH (2005). Swedish validation of the early assessment risk list for boys (EARL-20B), a decision-aid for use with children presenting with conduct-disordered behaviour. Nordic Journal of Psychiatry. [Accepted]
https://doi.org/10.1080/08039480601021795

II. Enebrink P, Langstrom N, Gumpert CH (2004). Predicting aggressive and disruptive behaviour in referred 6-12 year-old boys: Prospective validation of the EARL-20B risk/needs checklist. [Submitted]

III. Enebrink P, Andershed H, Langstrom N (2005). Callous-unemotional traits are associated with clinical severity in referred boys with conduct problems. Nordic Journal of Psychiatry. [Accepted]
https://doi.org/10.1080/08039480500360690

IV. Enebrink P, Cederborg AC, Ryd Carlqvist M, Gumpert CH (2004). Clinical work with antisocial behaviour in boys: Narrative interviews with clinical teams in Swedish child and adolescent psychiatry. [Submitted]