Article The Impact of ADHD and Autism Spectrum Disorders on Temperament, Character, and Personality Development Henrik Anckarsäter, M.D., Ph.D. Stefan Westergren, M.D. Results: Patients with ADHD reported high novelty seeking and high harm Ola Stahlberg, Psychol., M.Sc. C. Robert Cloninger, M.D. avoidance. Patients with autism spectrum disorders reported low novelty seeking, low reward dependence, and high harm Tomas Larson, B.A. Christopher Gillberg, M.D., Ph.D. avoidance. Character scores (self-directed- ness and cooperativeness) were ex- Catrin Hakansson, B.A. Maria Rastam, M.D., Ph.D. tremely low among subjects with neurop- sychiatric disorders, indicating a high Sig-Britt Jutblad, Psychol., M.Sc. Objective: The authors describe person- overall prevalence of personality disor- ality development and disorders in rela- ders, which was confirmed with the SCID- Lena Niklasson, Psychol., M.Sc. tion to symptoms of attention deficit hy- II. Cluster B personality disorders were peractivity disorder (ADHD) and autism more common in subjects with ADHD, Agneta Nydén, Psychol., Ph.D. spectrum disorders. while cluster A and C disorders were more common in those with autism spectrum Method: Consecutive adults referred for disorders. The overlap between DSM-IV Elisabet Wentz, M.D., Ph.D. neuropsychiatric investigation (N=240) personality disorder categories was high, were assessed for current and lifetime and they seem less clinically useful in this ADHD and autism spectrum disorders context. and completed the Temperament and Character Inventory. In a subgroup of sub- Conclusions: ADHD and autism spec- jects (N=174), presence of axis II personal- trum disorders are associated with spe- ity disorders was also assessed with the cific temperament configurations and an Structured Clinical Interview for DSM-IV increased risk of personality disorders Personality Disorders (SCID-II). and deficits in character maturation. (Am J Psychiatry 2006; 163:1239–1244) Childhood-onset neuropsychiatric disorders—which ies of subjects with neuropsychiatric disorders (17, 18). include attention deficit hyperactivity disorder (ADHD), These observations suggest that deficits in neurocognitive autism spectrum disorders, tic disorders, and learning dis- development during childhood may often lead to person- abilities—are defined by operational criteria targeting be- ality disorders during adulthood. In other words, certain haviors and deficits in abilities such as attention, empathy, childhood temperament profiles may impair healthy communication, flexibility, and IQ (1). Research during character development, producing personality disorders the 1990s showed that these disorders are more frequent in adulthood. than previously assumed (2–5), with severe variants affect- In the DSM system, personality disorders are assessed ing at least 5% of all children and milder phenotypal ex- on a separate axis from the “major mental disorders” and, pressions or “shadow syndromes” frequent in relatives of analogous with the ICD system, are defined categorically. affected children (6–11). Hypothetically, neuropsychiatric Both principles are controversial and disputed by most ex- diagnoses designate dysfunctional extremes of normally perts, since empirical data lend no support for a sharp de- distributed abilities, such as attention and impulse con- lineation of personality disorders from other mental disor- trol; adaptive decision-making strategies; adequate per- ders or for a categorical structure for personality traits ception and control of voice, posture, mimicry, and inter- (19). Although the validity of DSM-IV personality disor- personal skills; and mentalizing. The variation in such ders seems weak, reliability in assessments by means of abilities is partly constitutional and may influence per- structured interviews such as the Structured Clinical In- sonality development to a greater extent than recognized terview for DSM-IV Axis II Personality Disorders (SCID-II) in current personality theory. Patients afflicted by such has been demonstrated (20). dysfunctions describe themselves in terms applicable to Cloninger’s biopsychosocial theory of personality (21) is personality disorders (12, 13). Subjects with personality based on the assumption that personality involves four disorders demonstrate neurocognitive problems (14–16), temperament dimensions and three character dimen- and personality disorders are common in follow-up stud- sions. The four dimensions of temperament measure indi- Am J Psychiatry 163:7, July 2006 ajp.psychiatryonline.org 1239 ADHD, AUTISM, AND PERSONALITY DEVELOPMENT TABLE 1. Diagnostic Overlap Between ADHD and Autism Spectrum Disorder Diagnoses in 240 Adults Referred for Neurop- sychiatric Investigation ADHD Diagnosis No ADHD Combined Type Inattentive Type Hyperactive Type ADHD in Remission Autism Spectrum Disorder Diagnosis (N=93) (N=69) (N=44) (N=16) (N=18) No autism spectrum disorders (N=127) 27 51 27 12 10 Autistic disorder (N=6)3020 1 Asperger syndrome (N=46) 33 5 3 1 4 Atypical autism (N=61) 30 13 12 3 3 vidual differences in basic emotional drives: harm avoid- Method ance (i.e., pessimistic and anxious versus optimistic and risk-taking); novelty seeking (i.e., impulsive and irritable The Göteborg Child Neuropsychiatric Clinic is the only diag- nostic center specifically focused on neuropsychiatric assess- versus rigid and stoical); reward dependence (i.e., sociable ments of childhood-onset disorders in the city of Göteborg and and warm versus aloof and cold); and persistence (i.e., per- has a nationwide responsibility for assessment of autism and re- severing and ambitious versus easily discouraged and lated disorders. Between January 2001 and April 2003, an “Adults lazy). The three character dimensions measure individual Project” was carried out at the clinic, offering specialized assess- ments of adult patients with possible childhood-onset neuropsy- differences in higher cognitive processes that define a per- chiatric disorders (ADHD, autism spectrum disorders, tic disor- son’s style of mental self-government: self-directedness ders, and various kinds of learning disorders). Many of these (i.e., responsible and resourceful versus blaming and in- patients were self-referred or came from general practitioners, ept), cooperativeness (i.e., helpful and principled versus but 59% were secondary or tertiary referrals from specialists in adult psychiatry dealing with “hard-to-diagnose” in- and outpa- hostile and opportunistic), and self-transcendence (i.e., in- tients attending psychiatric clinics. Only a minority of the pa- tuitive and insightful versus concrete and conventional). tients had been diagnosed in childhood. Thus, in most cases This model can serve as a tool for disentangling personality childhood developmental problems were assessed retrospec- tively. All assessments for the project were on an outpatient basis. problems or disorders in subjects with neuropsychiatric Subjects provided clinical data and blood for genetic analyses disorders (12). A 238-item self-rating instrument, the Tem- within the Göteborg Neuro-Psychiatry Genetics Project, which perament and Character Inventory (21) has been devel- aimed to establish large, well-characterized, clinical cohorts for oped to measure the model’s seven personality dimen- genetic studies. The present study group consists of all subjects who gave informed consent to participate in the Neuro-Psychia- sions. Presence of a personality disorder is indicated by try Genetics Project (N=273) and completed the Temperament presence of character immaturity (especially by low self- and Character Inventory within the stipulated time frame (N= directedness and/or cooperativeness) and type of disorder 240; 131 men, 109 women; median age=31.0 years, range=19–60). by the temperament configuration (22, 23). The least fre- DSM-IV diagnoses (including ADHD and autism spectrum dis- quent answers from each Temperament and Character In- orders) were assigned in each case by two authors (H.A., M.R.) af- ter consensus discussions. The individual diagnoses were based ventory dimension form a rarity scale, generally used for on all available information including clinical status of the pa- validation purposes. In this study, rarity is also used as a re- tient, the Structured Clinical Interview for DSM-IV Axis I Disor- flection of mental health problems and distorted ideas, ders (SCID), the Yale-Brown Obsessive Compulsive Scale, the As- since rarity scores have been shown to differ considerably perger Syndrome and High-Functioning Autism Screening Questionnaire (25), the Asperger Syndrome Diagnostic Interview between subjects in the general population (who generally (26), and DSM-IV criteria checklists, current and lifetime, for au- have very low rarity scores) and subjects with mental disor- tism spectrum disorders, ADHD, tic disorders, impulse control ders (who have much higher scores) (24). disorders, and all other relevant axis I disorders not covered by the SCID. Reliability and validity for all these scales are good to ex- This article presents patterns of self-rated personality cellent. In 209 of the 240 cases (87%), a semistructured collateral traits measured by the Temperament and Character In- interview was performed with a relative who had known the index ventory and current personality disorder symptoms mea- subject as a child. Clinical records were collected from pediatric sured according to DSM-IV in a relatively large group of and child psychiatry services and from school health services. For