2013. Vol.4, No.10, 782-786
Published Online October 2013 in SciRes (
Copyright © 2013 SciRes.
Can Youth Health Care Scans at the Age of Five Discriminate
between Adolescent Psychiatric Inpatients with Severe Disruptive
Behavior and a Non-Treatment Group?
Sjoukje Berdina Beike de Boer1,2*, Albert Eduard Boon1,2,3, Anna Marte de Haan2
1De Fjord, Center of Orthopsychiatry and Forensic Youth Psychiatry, Lucertis, Capelle aan den I Jssel,
The Netherlands
2De Jutters, Center of Yo u th Mental Healthcare Haaglanden, The Hague, The Netherlands
3Department of Child and Ado l es ce n t Ps ychiatry, Curium-Leiden University Medical Center, Leiden, The
Email: *
Received August 13th, 2013; r evised September 12th, 2013; accepted October 15th, 2013
Copyright © 2013 Sjoukje Berdina Beike de Boer et al. This is an open access article distributed under the Crea-
tive Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any me-
dium, provided the origi nal work is properly cited.
The aim of the study was to examine whether adolescent psychiatric inpatients (n = 24) with severe dis-
ruptive behavior could be discriminated from a control sample (n = 41) based on information about dis-
ruptive behavior recorded early in their lives. Remarks by teachers and health professionals made in youth
health care files when the respondents were five years of age were used. Both teachers and professionals
made significantly more remarks regarding disruptive behavior in the files of the future patients. The files
of the patients also contained more remarks about other behavior. The sensitivity and specificity of be-
havior at the age of five to predict future treatment was satisfactory. The majority of the inpatients be-
longed to the prototypical life-course-persistent group that is known from epidemiological studies.
Keywords: Adolescent Psychiatry; Life-Course-Persistent; Antisocial Behavior; Youth Health Care Files
Epidemiological research (Moffitt, 1993, 2003) has shown
that a relatively small part of the population (6.2%) was en-
gaged in antisocial behavior at a very young age which per-
sisted at every stage in their life. This group was labeled
life-course-persistent (LCP). A larger group (23.6%) was found
to be involved in antisocial behavior during adolescence only
and therefore their behavior was labeled adolescence-limited
(AL). Although during adolescence both groups did not differ
in frequency and seriousness of offending, Moffitt (Moffitt,
1993, 2003; Moffitt & Caspi, 2001) argued that they differed in
etiology, developmental course, prognosis and classification of
their behavior as either pathological (LCP) or normative (AL).
Extensive support for these prototypes and their relevance for
etiology, developmental processes, and prevention priorities
was found (Odgers et al., 2008). By labeling children with early
onset of antisocial behavior as “life-course-persistent”, the epi-
demiological researchers implied that this group would hardly
benefit from treatment or at least are in need of more intensive
treatment. However, thus far this consequence has barely been
tested in treatment research, nor have findings from epidemiol-
ogical research been put to practical use for inpatient or foren-
sic settings.
Present study concerned adolescents with antisocial behavior
that were treated in a residential orthopsychiatric treatment
facility for severe disruptive behavior combined with psychiat-
ric disorders. For prognostic purposes it would be relevant to
know whether these inpatients belonged to the LCP or the AL
group. Therefore the question arose whether it was possible to
determine if the patients’ disruptive behaviors were present in
early life based on retrospective data. At the moment of treat-
ment, no reliable data about their disruptive behavior earlier in
life or about the age of onset of this behavior were available.
Anamnestic information gathered at admission is often subjec-
tive and unreliable: patients themselves are no reliable source
on their early history and the parents’ view on their child’s
development is often biased by their child’s current condition.
Therefore more objective sources of information on the child’s
early behavior were required. For the present study the informa-
tion about the childhood disruptive behavior was drawn from
youth health care files to examine its use for diagnostic pur-
poses. The information in these files was gathered at fixed
points in the child’s life by youth health care professionals. In
the Netherlands, Youth Health Care (YHC) offers basic care to
all children from birth until the age of nineteen. This system
already exists for over a hundred years and is unique in the
world. The care is offered free of charge and 95% of all chil-
dren is reached. YHC is aimed at the growth and development
of the child and monitors the physical, mental, social and cog-
nitive development of children. Traditionally, the emphasis was
on the physical development of the child, but in recent years,
educational and psychosocial problems were also taken into
account (AJN, 2009). From age five on, the schoolteacher of
the second grade is asked which children need extra attention.
*Corresponding author.
If a child is in need of extra attention, the remarks of the teacher
are recorded in the YHC files.
Aim of the Study
The question addressed in this paper was whether the distinc-
tion between subjects who received residential treatment for
disruptive behavior during adolescence and a non-treatment
control group could be made on the basis of information in the
YHC files gathered at an early age. Remarks indicating disrup-
tive behaviors at the age of five of the patients and a control
group were compared to determine whether the patients already
displayed more disruptive behavior in early childhood. It was
hypothesized that at the age of five more signs of disruptive
behavior would have been reported by the YHC workers as
well as the teachers in the YHC files of the inpatients compared
to the non-treatment group.
Currently some research has been conducted to determine
whether the epidemiological findings regarding LCP antisocial
behavior apply within a clinical sample (De Boer, Boon, Ver-
heij, & Donker, 2013; De Boer, Van Oort, Donker, Verheij, &
Boon, 2012; De Boer, Verheij, & Donker, 2007). The question
arose whether the distinction between individuals on the LCP
and AL trajectories of antisocial behavior could be made in an
inpatient sample of adolescents treated in an orthopsychiatric
facility, based on retrospective data of youth health care files.
This is relevant because in orthopsychiatric settings adolescents
are treated who are contraindicated for regular psychiatric treat-
ment because of their severe disruptive behavior. During ado-
lescence these inpatients meet the broad criteria that are used in
epidemiological studies on antisocial behavior. Therefore, if
this behavior started early in life, they meet the criteria of the
LCP group. It has been demonstrated that orthopsychiatric
treatment is effective (Boon & De Boer, 2007), so when inpa-
tients could be assigned to the LCP group, this would indicate
that they are treatable and for that reason the term life-course-
persistent is too pessimistic. The information about disruptive
behaviors used to assign the patients to the LCP group is taken
from notes written down in their YHC files when the children
were about five years of age. Due to the complexity of the dis-
ruptive behaviors and psychiatric disorders of the sample, it was
expected that a relatively high prevalence of LCP would be found.
Present study was conducted at De Fjord, an orthopsychiatric
and forensic psychiatric youth facility near Rotterdam. In The
Netherlands, orthopsychiatric facilities offer treatment to ado-
lescents and young adults who have psychiatric disorders com-
bined with severe disruptive behavior. Besides day treatment
and outpatient treatment, De Fjord offers a specialized treat-
ment program to 32 adolescent inpatients. The treatment pro-
gram consists of various therapies and training activities, for
instance, cognitive behavioral therapy, psycho-motor therapy,
art therapy, drama therapy, family therapy, social skills training,
aggression regulation training, job training, and education. A
cognitive-behavioral treatment model is applied with an em-
phasis on enhancement of social competence (Bartels, 2001)
extended by elements of the scheme-based therapy (Young,
Klosko, & Weishaar, 2004), as developed by Young (Young,
1990). The facility offers treatment to both boys and girls, but
boys are the majority.
The Orthopsychiatric Sample
Of the 49 inpatients that agreed to participate, only 24 health
care files could be used. Of 13 patients (27%) the files could
not be traced and of 12 patients (24%) the information about
the examination in the second grade was missing. In present
study, the orthopsychiatric sample of which the YHC informa-
tion could be used was comprised of 10 female and 14 male
inpatients, born between 1983 and 1992 that were admitted to
De Fjord between 2001 and 2008. The average age at admis-
sion was 17.3 year (SD = 1.13 year; range 15 - 19 year). They
were referred to the orthopsychiatric residential treatment facil-
ity by child and adolescent psychiatric institutions, youth care
or judicial institutions. About a third was judicially imposed.
The patients had an average 2.6 clinical diagnoses (axis I; range
1 - 5, SD 1.24). Patients were diagnosed with conduct disorders,
oppositional defiant disorder, schizophrenia and related disor-
ders, mood disorders, pervasive developmental disorders and
Attention Deficit Hyperactivity Disorder (APA, 2001). Al-
though the level of intelligence (mostly measured at the institu-
tions that requested the admission) of the sample was about
average, compared to the general population the educational
attainment was relatively low.
The Control Sample
The control group was selected from the general population
and was matched to the inpatient sample based on gender and
year of birth (between 1983 and 1992). Only respondents with
no reported history of behavioral or psychiatric disorders were
selected. It was attempted to trace 55 files, of those 7 (13%)
could not be traced and of 7 files (13%) the information about
the examination in the second grade was missing. The control
group used in present study consisted of 25 males and 16 fe-
After a verbal description of the study to the subjects, written
informed consent was obtained to gather information from their
YHC files. Respondents of the patient group were informed that
they could refuse cooperation without any consequence for
their treatment. The YHC files, in which all information was
recorded, were usually stored at the Municipal Public Health
Service (MPHS) of the district where the child resided at the
age of twelve. Every MPHS used the same file format, with
standard (sub) headings to register notes (e.g. length, weight,
illnesses, speech, hearing, temper tantrums). Of both samples,
the YHC files were requested at the designated MPHS. The
tracked files were viewed by the researchers at the office of the
MPHS, and screened on remarks on behavior problems. Be-
cause many of the obtained files were incomplete on a later age,
it was decided to focus the study on the information of the
health scans at the second grade (the nursery school part) of the
Dutch school system. In the YHC procedure this was the first
time that teachers were asked which children needed extra at-
tention because of concerns about their health or behavior.
Children were also examined by a doctor or nurse. In present
study the remarks of teachers and the amnesic information from
Copyright © 2013 SciRes. 783
the health care doctor or nurse were used. The YHC profess-
sionals had to use a format with defined headings: “Appetite”,
“Sleep”, “Toilet training”, “Playing solo”, “Playing with other s”,
“General impression”, “Pathology” and “Psychosocial function-
ing”. Apart from the remarks written under these headings, the
files also contained additional remarks on developmental issues
that were considered relevant by the teachers and the health
care professionals. All of these, often sketchy written, remarks
were categorized by the researchers in four categories: “Re-
marks indicating disruptive behavior”, “Positive remarks”,
“Neutral remarks” and “No remarks”. Examples of remarks
indicating disruptive behavior were: “Bad concentration,
doesn’t listen”, “Motivation and behavior problems”, “Black
sheep because of aggression”, “Needs a lot of attention”, “Has
many conflicts”, “Very noisy child”. All remarks like “Does
very well”, “She likes school”, “Has many friends” were la-
beled positive. All other remarks like: “Wears glasses”, “Does
often have a cold”, “Sight of left eye needs attention” were seen
as neutral from the perspective of this study. The remarks were
categorized without knowledge of the background (patient or
control) of the respondent. The categorized remarks from teach-
ers and health care practitioners concerning the inpatients and
the controls were compared. Children with one or more “re-
marks indicating disruptive behavior” before or at age five were
considered as possibly belonging to the LCP group.
Statistical Analysis
All analyses were performed using the Statistical Package for
the Social Sciences, version 17.01 (SPSS, 2008). Chi-square
tests were used to examine differences in categorical variables.
ROC-curves were calculated to investigate the sensitivity and
specificity of the remarks from teachers and YHC professionals
in discriminating the inpatient and the control group.
Both the number (X2 (1,65) = 15.1, p = .000) and the nature
(X2 (3,65) = 19.2, p = .000) of remarks made by teachers (see
Table 1) on the patients and on the control group differed sig-
nificantly. The remarks made by the health care professionals
(see Table 1) only differed in nature (X2 (3,65) = 17.1, p = .001)
between patients and controls.
Subsequently, the remarks of the teachers and the health care
professionals were compared (X2) and although there were large
differences in the number of times any remarks were given, no
differences were found between the two groups of evaluators.
Table 1.
Comparison of health care professionals’ remarks about inpatients and
control group.
Inpatients Controls Total
n % n % n %
Positive remarks 7 29 22 54 29 45
Remarks disruptive
behavior 12 50 3 7 15 23
Neutral remarks 5 21 11 27 16 25
No remarks 0 0 5 12 5 8
Total 24 100 41 100 65 100
Table 2.
Comparison of teachers’ remarks about inpatients and control group.
Inpatients Controls Total
n % n % n %
Positive remarks 6 25 7 17 13 20
Remarks disruptive
behavior 10 42 2 5 12 19
Neutral remarks 3 12 3 7 6 9
No remarks 5 21 29 71 34 52
Total 24 100 41 100 65 100
Less than thirty percent of the files of the control group con-
tained remarks from the teachers, opposed to about eighty per-
cent of the inpatients files (see Table 2).
The percentage of teachers’ remarks indicating disruptive
behavior of the patients was eight times higher than that of the
control group. Of the patient group, ten individuals (42%) had a
remark indicating disruptive behavior, in the control group this
was the case for two children (5%). For the health care profes-
sionals the difference in the number of remarks between the
inpatient group and the control group was much smaller. This
was probably due to the fact that the professionals had to fill in
prearranged categories, while the teachers’ remarks were only
recorded when something was considered wrong with the child.
The percentage remarks given by the YHC professional indi-
cating disruptive behavior of the inpatients was almost seven
times higher than that of the control group. Of the inpatient
group twelve individuals (50%) had a remark indicating disrup-
tive behavior, while for the control group this was the case for
three children (7%).
To examine whether information from YHC files could be
used as a predictor for orthopsychiatric treatment later in life, a
ROC curve analysis was made (see Figure 1).
The remarks of both teachers and YHC professionals were
allocated to the following values: 1 “No remarks”, 2 “Neutral
remarks”, 3 “Positive remarks”, 4 “Remarks indicating disrupt-
tive behavior”. Belonging to the inpatient group was the state
variable. The area’s under the curve (AUC), indicating sensitiv-
ity (the probability that a child with disruptive behavior at the
age of five will belong to the orthopsychiatric sample) and
specificity (the probability that a child without disruptive be-
havior at the age of five will belong to the control group) was
significant. For the teachers’ remarks the AUC was .79 (p
= .000, 95% CI = .67 - .91), for the YHC professionals’ re-
marks the AUC was .73 (p = .001, 95% CI = .59 - .86). The
sensitivity of the teachers remarks was .42 and the specific-
ity .70 when “remarks about disruptive behavior” was taken as
a criterion. When “any remark of the teacher” was taken as the
criterion, sensitivity was .79 and specificity .95. The sensitivity
of the YHC professionals remarks was .50 and the specific-
ity .92 when “remarks about disruptive behavior” was taken as
a criterion. When “any remark of the doctor or nurse” was
taken as the criterion, sensitivity was 1.00 and specificity .12.
The theoretical framework of present study concerned the
distinction between individuals with life-course-persistent and
adolescence-limited antisocial behavior. In this light, the main
Copyright © 2013 SciRes.
Figure 1.
ROC curves of the predictive value for residential treatment during
adolescence of teachers’ and health care professionals’ observations of
disruptive behaviour a t age 5.
goal of this paper was to examine whether an adolescent inpa-
tient group differed from a matched, non-treatment control
group on information about early disruptive behavior registered
in youth health care (YHC) files. These files contained infor-
mation that had been gathered at fixed times from birth to age
nineteen, and were therefore considered usable to determine
early onset of disruptive behavior reliably. Because much in-
formation of a later age was missing in the files, the study fo-
cused on information of health scans at the second grade, when
the infant was about fiv e years of age.
The first finding was that of the inpatient group over half of
the files could not be used, because either the files were un-
traceable or the information about the examination in the sec-
ond grade was missing. Of the control group, the percentages of
untraceable or unusable data were about half as high. There
may be several reasons why files were missing or incomplete.
Parents may have refused to cooperate with the youth health
care examination, or files can be untraceable because of fre-
quent rehousing of the family or the child. It was unclear what
happened to a file if a child was not at school, for instance in
case of institutionalization. Although the exact reasons for un-
traceability of the files remained unknown, it should be consid-
ered as a first indication that the early lives of the children that
would be institutionalized during adolescence were more tur-
bulent and complicated than those of the controls.
Because the remarks of the teachers were only registered
when he or she thought the child needed extra attention, the fact
that majority of the inpatient group had a remark of any kind,
compared to about only one third of the control group, is an
indication that the inpatients already differed from their peers at
a very young age. The fact that special attention had been asked
for some children, but the remarks in the YHC file were posi-
tive or neutral, indicates that the files probably did not always
adequately ref lect the reason for extra at te ntion.
For the inpatient group, both teachers and health care profes-
sionals have reported much more disruptive behavior. This
indicates that, based on the observations at the age of five and
the fact that the inpatients displayed severe disruptive behavior
in adolescence, at least about half of the inpatients probably
belonged to the LCP group. Only a minority (7%) of the control
group displayed disruptive behavior at age five, and because the
controls were selected on their absence of behavioral problems
in adolescence, the problems mentioned at the age of five were
probably temporarily. The data do not allow conclusions re-
garding children who did not display disruptive behavior in the
second grade. Although the literature is inconclusive about the
upper limit in the age of onset of LCP disruptive behavior (e.g.
age 8, age 10, age 12), the possibility exists that the group that
showed no signs of disruptive behavior at the second grade, did
develop this behavior later on during primary school.
It is concluded that within the group that would eventually be
treated in the orthopsychiatric residential setting, signs of dis-
ruptive behavior were already observed at the age of five by
teachers or health care professionals for about half of the re-
spondents. In this aspect, they differed significantly from the
control group. More attention should be paid to children that
show signs of disruptive behavior at this early age. Although
epidemiological researchers labeled this group as life-course-
persistent, ergo untreatable (Moffitt, 2003; Moffitt & Caspi,
2001; Moffitt, Caspi, Harrington, & Milne, 2002), they can
profit from early interventions. Children with untreated behav-
ioral problems are more likely to drop out from school, engage
in delinquent activities, drug and alcohol abuse and unemploy-
ment (Lochman & Salekin, 2003; Odgers et al., 2008).
Recently the storage of information of the youth health care
files in The Netherlands has been improved. Digitized storage
will hopefully lead to more accurate and traceable information,
so in the future more clarity about the differentiation of adoles-
cent residential inpatients in life-course-persistent and adoles-
cence-limited groups can be reached and the treatment pro-
grams for these groups can be further specialized.
This study has several limitations. First, although the results
of the inpatient group compared to the control group are con-
vincing, the number of inpatient files that could be included in
the study is rather small. The second limitation of this study is
that, although we know from a large minority of inpatients that
they showed signs of disruptive behavior at a young age, no
information is available of the development of these children at
a later primary school age or during early adolescence.
The authors wish to thank Danielle Beekenkamp, Judith
Meerman and Danicia Tjwa, students at the “The Hague Uni-
versity”, who collected part of the inpatient data and all of the
control group data from the Youth Health Care files for their
bachelor thesis. The authors also acknowledge the inpatients
and adolescents who consented to participate, Zita Haijer, who
as manager at De Fjord enabled the study, and Jos Leenes and
Amos Daal for providing the essential literature.
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