The Relationship Between Oppositional Defiant Disorder, Conduct Disorder, Antisocial Personality Disorder and Psychopathy: a Proposed Trajectory

Home , Conduct disorder, Psychopathy Checklist

Taylor Salisbury*

This review paper critically examines the literature on oppositional defiant disorder (ODD), conduct disorder (CD), antisocial personality disorder (APD) and psychopathy. Through examining diagnostic criteria laid out in the DSM-IV along with statistics related to diagnosis and prognosis, the idea that ODD, CD, and APD may fall on a developmental trajectory as opposed to being distinct, categorical entities is proposed. Additionally, the notion that these three disorders may represent narrow, behavioural indicators of a general psychopathic personality is suggested using comparisons to Hare’s Psychopathy Checklist Revised (PCL-R). Several implications related to child development, family instability and violence, as well as labeling and stigma are discussed and the importance of family intervention and involvement is highlighted. Finally, a number of implications related to the criminal justice system, including the prediction of conviction and recidivism rates, are explored.

The construct of psychopathy has had a measured instead of relying on the often long history within the literature of clinical and ambiguous interpersonal and affective forensic psychopathology, constantly evolving personality characteristics used to infer through revisions of the Diagnostic and diagnoses in the past (Coid & Ullrich, 2010). Statistical Manual of Mental Disorders (DSM) This improvement helped distinguish between used extensively by psychologists. It was APD and general psychopathy, with the former identified by clinical psychologists as one of the construct focusing on the overt antisocial first acknowledged personality disorders, called behaviours of such individuals and the latter ‘Psychopathic Personalities’ and was published characterizing a more overarching personality in the first edition of the DSM as ‘Sociopathic style involving interpersonal, affective, and Personality Disorders’ (Ogloff, 2006). The behavioural dimensions (Ogloff). Drawing this DSM-II changed this label to ‘Personality distinction between behavioural and personality Disorder, Antisocial Type’ in 1968 (Ogloff, factors undoubtedly helped resolve some of the 2006), which has ultimately progressed to the inter-rater reliability criticisms from the past. current title ‘Antisocial Personality Disorder However, in doing so, it has generated the (APD)’ in the most recent version, the DSM-IV- notion that overt behaviours can actually be TR (American Psychological Association, separated from personality factors, and that 2000). Historically, the terms asocial, sociopath, mental disorders and personality disorders are psychopath, and APD have been used real and distinct categorical entities with interchangeably; however, recent improvements independent characteristics. That being said, a in nosology have helped to clarify the large body of literature supports the idea that distinction between them. The largely case APD, and several other disorders diagnosed in study/clinical description-based format of the childhood and adolescence, are actually on a DSM-II evoked criticisms of poor inter-rater continuum with psychopathy and may be reliability which led to the development of the specific points along a developmental trajectory specific-criteria approach used in current rather than distinct diagnostic categories (Burke, versions of the DSM today (Ogloff, 2006). Waldman, & Lahey, 2010; Coid & Ullrich). A Now, criteria in the DSM are based on overt diagnosis of Oppositional Defiant Disorder behavioural traits that can be observed and (ODD) and/or Conduct Disorder (CD) in childhood or adolescence often precedes the

*Initially submitted for Psychology 3310F at the University of Western Ontario. For inquiries regarding the article, please email the author at [email protected]. ODD.CD.APD development of APD in adulthood, all of which with CD meeting diagnostic criteria for ODD may serve as narrow, behavioural indicators of a directly before, or at the same time as the CD general psychopathic personality. Examining diagnosis. Other longitudinal evidence confirms these behavioural disorders from a that ODD typically has an earlier onset and is developmental standpoint is important as more prevalent than CD, with ODD children several implications related to child being at greater risk of being diagnosed with CD development and the criminal justice system can later in life (Burke et al., 2010). be drawn. It is important to note that in order to be The DSM-IV-TR describes ODD as a diagnosed with ODD, the child must not meet pattern of “negativistic, defiant, disobedient, and criteria for CD (American Psychiatric hostile behaviour towards authority figures” Association, 2000). However, clinical studies (Rowe, Costello, Angold, Copeland, & have demonstrated that 60 to 95% of CD cases Maughan, 2010, p. 726) lasting at least six include a comorbid ODD diagnosis (Rowe et months and causing significant distress or al., 2010). Such a high rate of comorbidity in impairment in the child’s life. Some typical CD patients suggests that CD may be a more behaviours include irritability, frequently losing serious form of ODD along the same his or her temper, arguing with adults, behavioural trajectory. It is also significant to deliberately provoking people, and blaming note that ODD has been shown to predict later others for his or her own misbehaviour onset of CD, but there has been no confirming (American Psychiatric Association, 2000). This evidence of a reciprocal relationship (i.e., CD behavioural disorder usually onsets early in leading to ODD), thereby lending more support childhood, around two to four years of age, and to the developmental pathway of these is characterized by a display of oppositional disruptive behavioural disorders. behaviours and emotions in contexts involving Since CD is often seen as a more serious other people, particularly those in positions of form of ODD, it is not surprising that many, if authority (Hofvander, Ossowwki, Lundstrom, & not all, of the features of ODD are usually Anckarsater, 2009). There has been some present in cases of CD. CD is characterized by speculation as to whether these behaviours are general violation of the basic rights of others, indicative of an actual disorder or are merely with other defining features including typical childhood acts of rebellion (Hofvander et aggression towards people and animals, al., 2009). However, it is the persistence of destruction of property, deceitfulness, theft, these behaviours (i.e., lasting at least six rule-breaking, and serious violation of societal months) and their ability to cause significant norms (American Psychiatric Association, distress in a child’s life that distinguishes 2000). CD has an age of onset similar to ODD, between such normal acts of rebellion and with symptoms emerging as young as four to clinically-disordered behaviour (American five years old, and can be diagnosed in Psychiatric Association, 2000). Additionally, childhood, adolescence, or adulthood several longitudinal studies have noted striking (Hofvander et al., 2009). Of course, not all similarities between ODD and other childhood children diagnosed with ODD go on to develop disruptive behaviour disorders (e.g., ADHD, CD (American Psychiatric Association, 2000); CD) and have proposed that they may reflect however, child-onset cases of CD are typically manifestations of the same behavioural disorder preceded by ODD and patterns of physical at different stages in development (Burke et al., violence and family instability appear to be 2010). important factors in the transition (American Rowe et al. (2010) assessed cohorts of Psychiatric Association, 2000; Rowe et al., children aged three to seven to examine the 2010). predictive validity of ODD to CD. They found Milan and Pinderhughes (2006) that ODD was a significant predictor of child- examined the relationship between family onset CD with 79% of the children diagnosed instability and child development and suggested

ODD.CD.APD that early patterns of instability are related to criminality are two defining features of this externalizing behaviour problems (e.g., disorder, with a significant proportion of people outwardly defiant behaviour). The authors also with APD engaging in a criminal lifestyle (Coid found that: & Ullrich, 2010). The main theme underlying “high levels of family instability APD is a general disregard for the rights of increased the likelihood that a child would meet others, often to the extent of manipulation for criteria for diagnosis [of a disorder in the DSM- personal benefit. Both CD and APD are IV] in third grade, beyond the predictive characterized by disruptive behaviour violating accuracy attained through early measures of the rights of others, with APD being behaviour problems from teachers and mothers distinguished by a more encompassing (p. 53)”. antisocial lifestyle. Furthermore, Campbell, Shaw, and Not all cases of CD progress to a Gilliom (2000) found that an early childhood diagnosis of APD; however, numerous environment with negative parenting and family empirical studies have demonstrated a strong stress combined with patterns of hyperactivity link between the two. Gelhorn, Sakai, Price, and and aggression may exacerbate the progression Crowley (2007) noted that generally, around of externalizing behaviour problems. Finally, 40% of people with CD move on to develop Skodol et al. (2007) determined that positive APD. They tested this figure by examining a childhood experiences (e.g., achievements, sample from the National Epidemiologic Survey positive relationships, and competent on Alcohol and Related Conditions (NESARC) caretakers) were associated with better and found the percentage to be significantly prognoses and remission from certain higher, with 75% of their sample of CD patients personality disorders. The results of these also meeting diagnostic criteria for APD at the studies lend support to the notion that an age of 18 (Gelhorn et al.). Hofvander et al. unstable family environment may be a (2009) suggested that approximately half of contributing factor in the progression from ODD children with CD develop APD in adulthood, to child-onset CD. However, the relationship while another longitudinal study demonstrated between ODD and adolescent-onset CD is less that around one third of their sample of CD clear and further research is necessary to cases progressed to APD, which was understand how they are related (Burke et al., interestingly around the same percentage of 2010). children with ODD that went on to develop CD The relationship between CD and APD, (Burke et al., 2010). however, is quite well understood in Although many children and adolescents psychopathological literature. In fact, one of the with ODD or CD outgrow their disorder and diagnostic criteria for APD, as laid out in the have symptoms that persist only at a subclinical DSM-IV-TR, is evidence of conduct disorder level, the relationship of these two childhood before the age of 15 (American Psychiatric disorders to APD is pronounced. The significant Association, 2000). The fact that the DSM overlap in behavioural criteria needed to arranged these disorders in a hierarchical diagnose these three disorders and the fact that fashion suggests that they are at the very least they are arranged hierarchically in the DSM-IV- related, if not variations of the same underlying TR suggests that they may be age-dependent disorder. Similar to the way ODD and CD are manifestations of the same behavioural disorder related, all of the behavioural manifestations of along distinct points of a developmental CD are present in APD on a more extreme scale. trajectory ending in APD. Other diagnostic criteria of APD include That being said, as previously discussed, violations of social norms with respect to the the DSM-IV-TR utilizes a behavioural approach law, persistent deceitfulness, impulsivity, in developing diagnostic criteria to eliminate recklessness, irresponsibility, and lack of confusion and improve reliability of diagnosis remorse (Ogloff, 2006). Violence and between clinicians (Coid & Ullrich, 2010).

ODD.CD.APD Since diagnoses of ODD, CD, or APD are beginning before age 13 years’ directly restricted to observing only the behavioural correspond to ‘early behavioural problems’ and manifestations of the disorder, it is plausible to ‘juvenile delinquency’ in the PCL-R (i.e., items suggest that all three of these disorders are 4 and 8 on the social deviance dimension; related to the construct of psychopathy which American Psychiatric Association, 2000; Hare, encompasses behavioural, interpersonal, and 2003). affective characteristics of the antisocial Coid and Ullrich (2010) also found a personality not otherwise taken into account by significant correlation between severity of APD clinicians using the DSM-IV-TR. and severity of psychopathy as measured by The Psychopathy Checklist Revised scores on the PCL-R, thereby supporting the (PCL-R) developed by Robert Hare is a notion that the two constructs are on a validated 20- item measurement tool used to continuum. They noted that some of the criteria assess a person’s level of psychopathy based on used to diagnose APD in the DSM-IV-TR (e.g., these behavioural, interpersonal and affective deceitfulness, irritability, aggressiveness, and traits. Many of the behavioural dimensions recklessness) are essentially measuring the same assessed in the PCL-R are consistent with the things assessed in the PCL-R (e.g., being diagnostic criteria laid out for APD (e.g., conning, manipulation, poor behavioural irresponsibility, impulsivity, violation of social controls, and irresponsibility). Despite the norms). Interpersonally, psychopathic significant correlation, not all individuals with individuals come off as “grandiose, arrogant, APD are considered psychopathic. Because of callous, dominant, superficial, deceptive, and the DSM-IV- TR’s focus on overt behaviours, manipulative. Affectively, they are short- all individuals with APD would satisfy at least tempered, unable to form strong emotional some of the criteria laid out in the PCL-R, with bonds with others, and lacking in empathy, the interpersonal and affective dimensions guilt, remorse, or deep-seated emotions.” (Hare, distinguishing the psychopathic vs. Clark, Grann, & Thornton, 2000, p. 624). It has nonpsychopathic APD individuals. These been noted that certain items on the PCL-R also findings suggest that APD may be a moderate relate directly to ODD and CD (Coid & Ullrich, form of psychopathy based upon a narrow 2010). For example, criteria for diagnosing subset of behavioural traits. Those individuals ODD in the DSM-IV, such as ‘often loses with APD also possessing the interpersonal and temper’, ‘argues with adults’, and ‘blames affective characteristics would score higher on others for his or her mistakes or misbehaviour’ the PCL-R and be considered psychopathic if a are directly related to ‘poor behavioural score of 25 or more was obtained (Coid & controls’ (item 3 on the social deviance factor) Ullrich, 2010). and ‘failure to accept responsibility for own These findings have several implications actions’ (item 8 on the interpersonal/affective within the criminal justice system. As factor) on the PCL-R (American Psychiatric previously discussed, violence and criminality Association, 2000; Hare, 2003). Similarly, the are two defining features of APD and therefore criteria ‘deceitfulness or theft’ and ‘often lies to psychopathy (Coid & Ullrich, 2010). Heinzen, obtain goods or favours or to avoid obligations Kohler, Godt, Geiger, and Huchzermeier (2011) (i.e., “cons” others)’ necessary for a CD noted that IQ was an important factor in diagnosis are directly related to items 3 and 4 on predicting conviction rates of antisocial the interpersonal/affective dimension of Hare’s individuals. They found that “individuals PCL-R: ‘pathological lying’ and scoring high on interpersonal features of ‘conning/manipulative’ (American Psychiatric psychopathy are more intelligent than those Association, 2000; Hare, 2003). Finally, CD scoring high on antisocial features” (Heinzen et criteria such as ‘often stays out at night, despite al., 2011, p. 336). Applying this finding could parental prohibitions, beginning before age 13 help predict conviction and recidivism rates of years’ and ‘is often truant from school, antisocial offenders. Those individuals

ODD.CD.APD achieving higher interpersonal scores on the psychopathy, a construct encompassing PCL-R would be more intelligent, more behavioural but also interpersonal and affective manipulative, and be better at planning their antisocial characteristics (Coid & Ullrich). criminal endeavors (Heinzen et al., 2011). Generally speaking, many children meet Individuals scoring high on the antisocial diagnostic criteria for ODD as young as age 3, features component, however, would probably with only a small percentage progressing to CD offend more impulsively and have a greater in childhood or adolescence and an even smaller chance of getting caught. proportion going on to develop APD in A number of researchers have adulthood (American Psychological demonstrated a significant correlation between Association, 2000). With the three disorders recidivism rates and psychopathy as measured having overlapping behavioural criteria by the PCL-R. The DSM-IV-TR recognizes in necessary for diagnosis, and a significant the associated features section of APD that the proportion of APD and CD cases containing a construct of psychopathy has greater predictive comorbid CD or ODD diagnosis respectively, it validity in relation to recidivism, especially in becomes clear that ODD, CD, and APD may be prison settings (American Psychiatric age-dependent manifestations of the same Association, 2000). Laurell and Daderman underlying disorder. (2005) also demonstrated this by looking at a Understanding this pathway is important sample of convicted homicide offenders to for children diagnosed at a young age since assess their psychopathy level and rates of family education and therapy efforts can be used recidivism after getting out of prison. They to control disruptive behaviours and potentially found that individuals scoring higher on the intervene the developmental progression. PCL-R reoffended more frequently than those Roberts (1984) highlighted the importance of achieving lower scores (Laurell & Daderman). parental involvement in treatment outcomes and Understanding how ODD, CD, APD, and suggested that the “effect of the parents’ psychopathy are related is very important in deployment of action positions has been detailed terms of predicting developmental pathways of both in terms of effective management of the disruptive children, as well as conviction and problems in the patient and in the production of recidivism rates of antisocial adults. an emotional crisis in the adolescent” (Roberts, The extensive body of literature p. 74). Wells and Egan (1988) found that a attempting to describe, understand, and predict social learning- based parent training therapy the lives of individuals with a psychopathic was more effective at decreasing some of the personality has been ongoing and constantly main disruptive behaviours that characterize changing within the last century (Ogloff, 2006). ODD than a traditional systems family therapy Although the shift to a behaviourally-based approach. Elias (1997) went on to suggest that classification system of mental disorders has treatment approaches in which parents are improved the reliability of diagnosis between trained to be ‘primary agents of change’ may clinicians using the DSM- IV-TR (Coid & contribute to this greater efficacy through Ullrich, 2010), it has arguably also created the education about the nature of their child’s perception that the diagnostic categories laid out problems, clarifying responsibility, and are real and distinct. Many have suggested that facilitating the transition of knowledge into APD may actually be on developmental effective action. Finally, he found that trajectory with childhood disruptive behavioural emphasizing work with parents as the main disorders ODD and CD, rather than being focus of social learning family therapy may discrete categorical entities (Burke et al., 2010). have positive effects on the treatment of CD as Since DSM-IV-TR personality disorder criteria well. are based solely on overt behaviours, many have That being said, it is important to also suggested that the three disorders being highlight the interaction of environmental and discussed are developmental indicators of genetic factors in the manifestation of

ODD.CD.APD behavioural disorders such as ODD and CD. reoffend due to boredom and poor behavioural Inasmuch as patterns of family instability may controls than those scoring higher on the contribute to the progression of a mental ‘personality aggressive narcissism’ dimension. disorder, the initial development is more likely This kind of information may be helpful during to occur in someone with a genetic conviction or after an offender is released on predisposition to that behaviour. The reverse is parole. also true. For example, Foley et al. (2004) The DSM-IV-TR has supported this examined a gene-environment interaction notion that APD may be related to psychopathy. involving the monoamine oxidase A genotype in The American Psychiatric Association has even order to predict risk of conduct disorder in suggested the addition of an antisocial boys. They found that the mere “Antisocial/Psychopathic Type” category in the presence of the monoamine oxidase A genotype personality disorders section of the DSM-V with only slightly increased the risk of development an emphasis on personality and character of CD; however, being exposed to an adverse (American Psychiatric Association, 2000). childhood environment (such as family Additionally, researchers have also noted that adversity, inter-parental violence, parental the inhibitory control deficits and patterns of neglect, and inconsistent discipline) brain activity observed in individuals with significantly increased the risk of a CD Attention Deficit Hyperactivity Disorder diagnosis. Complicating the effects even more, (ADHD) are similar to those deficits present in many behavioural disorders (i.e., ADHD, CD, individuals with CD, ODD, and APD. This and ODD) are inherited through a combination finding has allowed some to speculate that of multiple genes, not just a single one ADHD may be another behavioural disorder (Comings, 2000). This means that genes may falling somewhere along this spectrum (Barkley, exert their combined effects on various 1997), which may prove to be another exciting neurotransmitter systems and receptor sites avenue of future research. (e.g., dopamine, serotonin, monoamine oxidase, As this paper presents, it is very and gamma-aminobutyric acid) and interact to important to be critical of psychological characterize the behavioural patterns of ODD, classification efforts and the implications that CD, or APD. Separating out the effects may be they may have on individuals. As our difficult; however, it is important to understanding of mental disorders changes over acknowledge the interaction of both genetic and time, the corresponding nosology must also be environmental factors in the development of updated and improved. It is this kind of analysis behavioural disorders and their treatment. that has ultimately moved the DSM forward to Understanding this developmental the more reliable and valid classification system pathway is also important in terms of labeling. that it is today. The possibility of incorrect diagnoses at a young age is dangerous in terms of the negative First Received: 1/13/2013 implications that such a label may have on a Final Revision Received: 3/1/2013 child’s self-identity and development. However, ISBN: 978-0-7714-3036-7 there are potential benefits of diagnosis and labeling that can be applied to the criminal justice system. Understanding how these behavioural disorders relate to psychopathy, as measured by scores on Hare’s PCL-R can help to predict conviction and recidivism rates of antisocial offenders (Laurell & Daderman, 2005). As previously mentioned, those offenders scoring higher on the ‘socially deviant lifestyle’ dimension may be more likely to

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