Background: Externalizing symptoms in children (aggression, oppositionality, property and status violations), and the Attention Deficit Hyperactivity Disorder (ADHD) triad of problems (inattention, hyperactivity, impulsivity) display a substantial co-morbidity. The “short temper” problem is common to these syndromes, which are predictive of a range of negative life outcomes including substance abuse and criminality in adulthood. There is a gender gap for the syndromes (boys are more affected), for criminality (men are more criminal) and knowledge (we know less about girls’ criminal careers). Aims: The main aim was to compare crime rates and crime profiles among former Child and Adolescent Psychiatric (CAP) patients with corresponding data for matched controls, focusing externalizing and internalizing psychiatric symptoms, sex and adverse social factors. Method: Data for 6055 former CAP-Stockholm outpatients were extracted from available treatment registers. For each CAP patient, two matched controls from the general population were randomly selected from the same area of residence, of the same sex and with the same year of birth (N approx. 12,000). Data on criminality for these individuals were obtained from a Swedish police register which also includes crimes committed prior to age 15. Results: Overall, twice as many former CAP patients were registered for crimes at a mean age of 21.4 compared to the controls. The over-representation was larger for crimes of violence. Females were registered for a much lower number of crimes, particularly crimes of violence (gender gap). The gender gap among the CAP patients was smaller than among controls. Compared with controls, CAP patients characterized by externalizing problems at referral had an odds ratio (OR) for crimes of 5 for males and 10 for females. Neglect was the only adverse social factor which was associated with a higher crime rate and affected boys more than girls. Compared to previous Swedish CAP cohorts, the criminality of the current cohort was much higher. Conclusion: In-depth studies of female crime careers characterized by externalising problems are needed. Child psychiatric services must find new and more effective ways of identifying and treating children with such problems, regardless of sex. The findings can guide the choice of strategies which will reduce crime rate.
It appears to be possible to classify the onset of criminality and its subsequent development over the life-course into a small set of typical patterns. Moffitt’s [
With respect to psychiatric disorders in adulthood, some are associated with a moderate increase in criminality, such as psychotic illnesses, others with a substantial increase, particularly personality disorders with externalizing symptoms and comorbid substance abuse. Many of these disorders have precursors in childhood and adolescence [
Still worse outcomes were obtained in a cohort of 80 delinquent boys, admitted at an average age of 14 and treated between 1975 and 1980 at Lövsta, the Swedish “borstal school” specializing in psychiatric services for boys with an early onset of criminality. All were diagnosed with CD (DSMIII) and 70% with ADHD. Prepsychotic features (such as “cognitive slippage”) were common. At follow-up (age 30), 13% were dead, all by non-natural causes, and 9% had been diagnosed with schizophrenia. They had also been convicted of 12,000 offences including 700 crimes of violence. Only 8% (six boys) had attained a reasonable level of social adjustment [
The issue whether childhood diagnoses/syndromes or specific symptoms/problems are the best predictors of future criminality is studied among former Norwegian CAP in-patients [
In a population-based study of Kindergarten children followed over more than 20 years [
Boys/men commit crimes much more often than girls/women (the gender gap)― consequently studies of crime tend to focus boys/men. We know less about girls/ women’s criminality and their pathways into crime [
Summing up, the literature is not fully consistent, particularly with respect to recent vs older studies. There are period as well as geographical effects reflecting differences in how the problem of youth criminality is viewed and handled. The sampling problem (how much of the ice-berg is included) must play a role: the 80 most problematic boys of Sweden [
The present study analyses a set of broad issues relating to criminality and psychiatric problems. The Stockholm County Council’s Clinical Department for Child and Adolescent Psychiatry has collected relevant data in a structured manner over a period of more than 20 years and for more than 100,000 patients. By sampling from among these patients, it is possible to compile large data sets for the study of specific research issues.
The study has three specific aims: Firstly, to compare crime rates and crime profiles among former CAP patients with corresponding data for matched controls. Secondly, to link the crime data relating to former CAP patients to the types of problems that motivated their contacts with child psychiatric services, to sex and to adverse social background factors. Thirdly, by comparing the current CAP data with previous Swedish data we wanted to study two types of period effects?whether CAP patients of today are registered for crime more often than previously, and whether the “gender gap” has changed over time.
The Stockholm County Council’s Clinical Department for Child and Adolescent Psychiatry offers in- and outpatient services to children and adolescents up to age 18 within a catchment area of 1.5 million inhabitants. A computerised system is used for patient statistics (PASTILL) based on information collected for each child who visits any of the clinics. The clinician (child psychiatrist, psychologist or social worker) fills out a form with information on variables such as cause of referral and referral source, symptoms, diagnoses (according to DSM-IV), psychosocial stressors, length and type of treatment, residential neighborhood, and social background [
For this article, CAP patients were sampled from the complete PASTILL database according to the following inclusion criteria: born 1989 or earlier, having finished their contacts with the clinic in 2003-2005, having had outpatient contacts, and being younger than age 26 at inclusion in the database. With these constraints, this database consists of 3734 female and 2321 male former outpatients. The database includes information on, e.g., social background, residential data, family context, psychosocial stressors, symptoms, diagnoses, GAF ratings and treatment. In this study, a subset of variables was analyzed based on constraints that missing values should be rare and the information judged to be sufficiently robust.
For each included CAP patient, two same-sex controls were randomly selected from the population register from among children living in the same local neighborhood and who were born in the same year: 7468 females and 4642 males. In this way we aimed to control for effects of local contextual factors associated with different areas of residence. For a few CAP patients, only one control could be found within the residential area. As a result of the matching procedure, the controls do not represent a truly random sample of all individuals born in the years specified above and living in Stockholm. In the analyses the two control groups were combined (there were no significant differences between the two groups for any comparison).
During more than one hundred years a majority of the childhood psychiatric symptoms have been conceptualized as belonging to two higher-order factors: internalizing and externalizing ones (autoplastic and alloplastic in older terminology). This conceptualization has been repeatedly verified, also recently as part of the DSM-5 project [
Individual crime data were collected from the National Crime Register (NCR) administered by the National Council for Crime Prevention. The register contains annual information on offences reported to the police from age 15 (the age of criminal responsibility in Sweden). However, under-age persons may also be recorded by the police if suspected of crime. Thus, subjects who committed offences very early can be identified (actually from age 8, and with reliable data from age 13). The NCR register also contains information on whether the person was prosecuted for an offence and convicted, if older than 15.
The NCR register lists offences according to the Swedish Penal Code. The number of different offences listed was overwhelmingly large and a courser categorization of the offences, and their seriousness, was required. The offences were classified into eight main categories (based on Chapters of the Swedish Penal Code): Serious violence, Violence, Property crime, Fraud, Drug crime, Traffic violations, Drink driving and other offences. Criminality was registered separately for consecutive years making it possible to determine the age at onset of criminality, cumulative offending and criminal versatility during the teenage years. For each entry, the number of offences per age interval was coded as 0, 1, 2 - 4 and >4 crimes.
The CAP material represents a population rather than a sample. Hence, tests of statistical significance are meaningless with respect to many differences within the group, e.g., the fact that there are more females than males in the total material and relatively more males than females who display externalizing problems. Statistical significance constitutes a means of specifying the risk that a certain finding has been produced by chance, and this risk is negatively related to the sample size. In contrast, clinical significance relates to effect size as defined by Cohen, the d statistic [
The study was approved by the Regional Ethics Committee in Stockholm. The PSC records were linked to the CAP patient records via a single key, after which the complete database was anonymized in line with the recommendations of the ethics committee.
For most of the patients (around 90%), at least one classifiable reason for their contacts with CAP clinics was available, as well as information on the referring agent (family, school, social services officers, police [
As can be seen in
There was a significant difference with respect to sex―an over-representation of males in Groups 0 (neither internalizing nor externalizing problems) and 2 (externalizing problems), and an over-representation of females among those with internalizing problems (χ2 (3) = 226, p < 0.001). In
Reason for the CAP contact | # of patients | |
---|---|---|
Girls (n = 3734) | Boys (n = 2321) | |
No contact reason | 474 (13%) | 272 (12%) |
Internalizing problems | 3230 (87%) | 1460 (63%) |
Externalizing problems | 972 (26%) | 850 (37%) |
Parental problems | 1307 (35%) | 883 (38%) |
Relation problems within the family | 1024 (27%) | 455 (20%) |
Problems at school/leisure time | 600 (16%) | 619 (27%) |
Exposure to neglect/stressors | 595 (16%) | 275 (12%) |
Neuropsychiatric developmental problems | 215 (5.8%) | 437 (19%) |
Other problems | 400 (11%) | 257 (11%) |
Intern./Extern. | Girls | Boys | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
None | Int | Ext | Both | χ2 | None | Int | Ext | Both | χ2 | |
Parental problems | 17 | 22 | 53 | 55 | 448*** | 21 | 25 | 50 | 51 | 191*** |
Relational problems within the family | 18 | 19 | 28 | 34 | 80*** | 12 | 14 | 21 | 30 | 70* |
Problems at school/leisure time | 8 | 10 | 22 | 28 | 188*** | 16 | 18 | 33 | 36 | 103*** |
Exposure to neglect/stressors | 16 | 10 | 10 | 17 | 43NS | 10 | 10 | 7 | 13 | 9NS |
Neuropsychiatric developmental problems | 4 | 3 | 10 | 9 | 75*** | 17 | 10 | 20 | 25 | 58*** |
neglect, were much more common in Groups 2 and 3 (externalizing problems), with this pattern being similar for both sexes.
Age at the time of the subjects’ first entry in the crime register was similar for former CAP patients and controls; 14.9 vs. 15.3 for males (SD approx. 2.05) and 15.1 vs. 15.3 for females (SD approx. 1.98). The difference is less than 0.2 SD for both sexes?and even if statistically significant (very large N), it is clinically trivial. Thus, onset of criminality was similar for boys and girls regardless of whether they were former CAP patients or controls.
Overall, former CAP patients were registered for at least twice as many offences as the controls. For females, the CAP over-representation was non-significant for two offence categories: Traffic offences and Drink driving. CAP males were more criminal than control males for all offences.
In the following, we based the crime analyses on eight offence categories rather than on specific offences of which some were unusual and difficult to classify. Among the former CAP males, 38% had at least one entry in the crime register vs. 22% for control males. The corresponding percentages for females were 24% and 13%. The criminality of the patients and the controls for the various offence categories and for the two sexes is presented in
The results confirm previous research on female crime patterns. Their criminality is less frequent and less violent, particularly in relation to serious violence, by comparison with males. The focus of female crime is directed at property offences and fraud. The crime rates are, in general, higher among CAP-females (and males) by comparison with controls, particularly for violence and serious violence.
In the next step we analyzed the criminality (number of offences) of CAP patients for a subset of specific and common offences (rather than the eight crime categories) in order to attain as much specificity/homogeneity as possible. Subjects were subdivided by sex and the groups based on the externalizing vs. internalizing causes of referral (Groups 0, 1, 2 and 3). The results are presented in
Crime category | Girls | Boys | ||||
---|---|---|---|---|---|---|
CAP | Controls | CAP | Controls | |||
Serious violence | ||||||
1 | 17.0 | 4.8 | 68.6 | 24.2 | ||
2 | 4.5 | 0.8 | 36.5 | 12.9 | ||
3 | 0.8 | 0.0 | 9.2 | 4.1 | ||
χ2 | 82.3*** | 131*** | ||||
Violence | ||||||
1 | 34.9 | 14.4 | 103.8 | 51.7 | ||
2 | 25.9 | 6.8 | 92.6 | 28.9 | ||
3 | 5.1 | 1.9 | 47.0 | 21.0 | ||
χ2 | 151*** | 192*** | ||||
Property crimes | ||||||
1 | 136.1 | 79.1 | 119.7 | 75.3 | ||
2 | 44.2 | 17.1 | 77.9 | 21.6 | ||
3 | 4.7 | 3.3 | 25.5 | 12.8 | ||
χ2 | 156*** | 155*** | ||||
Fraud/Economic | ||||||
1 | 19.1 | 10.0 | 46.9 | 21.7 | ||
2 | 2.8 | 1.3 | 16.9 | 7.6 | ||
3 | 0.2 | 0.4 | 3.5 | 0.9 | ||
χ2 | 31.5*** | 56.1*** | ||||
Traffic crimes | ||||||
1 | 4.4 | 2.1 | 35.7 | 25.7 | ||
2 | 0.6 | 0.4 | 16.0 | 7.3 | ||
3 | 0.0 | 0.0 | 4.9 | 3.5 | ||
χ2 | 2.6 NS | 19.9** | ||||
Drunk driving | ||||||
1 | 1.9 | 1.5 | 14.3 | 6.7 | ||
2 | 0.0 | 0.1 | 1.5 | 1.6 | ||
χ2 | 2.6 NS | 12.3* | ||||
Drug crimes | ||||||
1 | 18.8 | 6.0 | 40.6 | 24.6 | ||
2 | 10.5 | 3.2 | 35.9 | 10.9 | ||
3 | 1.1 | 0.7 | 19.7 | 8.3 | ||
χ2 | 79.1*** | 85.1*** | ||||
Other | ||||||
1 | 50.8 | 25.0 | 119.7 | 65.4 | ||
2 | 14.4 | 5.0 | 95.5 | 28.6 | ||
3 | 0.9 | 0.6 | 30.9 | 11.3 | ||
χ2 | 92.8*** | 196*** | ||||
Internalizing/ Externalizing | None | Internalizing | Externalizing | Both | Group | Sex | Interact | ||||
---|---|---|---|---|---|---|---|---|---|---|---|
Boys | Girls | Boys | Girls | Boys | Girls | Boys | Girls | ||||
Serious assault | |||||||||||
Freq. | 0.05 | 0.00 | 0.01 | 0.00 | 0.06 | 0.01 | 0.05 | 0.01 | |||
OR | 3.1 | 0.1 | 0.5 | 1.2 | 4.2 | 15.7 | 3.4 | 10.9 | 13.9*** | 61.6*** | 8.7*** |
Assault | |||||||||||
Freq. | 0.25 | 0.07 | 0.11 | 0.04 | 0.56 | 0.26 | 0.52 | 0.16 | |||
OR | 2.1 | 2.8 | 0.9 | 1.4 | 4.6 | 10.4 | 4.3 | 6.5 | 87.4*** | 165.7*** | 15.6*** |
Robbery | |||||||||||
Freq. | 0.08 | 0.00 | 0.03 | 0.00 | 0.18 | 0.02 | 0.19 | 0.02 | |||
OR | 1.9 | 1.3 | 0.6 | 1.3 | 4.2 | 9.6 | 4.3 | 10.5 | 20.1*** | 96.9*** | 12.4*** |
Burglary | |||||||||||
Freq. | 0.27 | 0.20 | 0.11 | 0.16 | 0.59 | 0.47 | 0.47 | 0.33 | |||
OR | 2.1 | 1.7 | 0.9 | 1.4 | 4.5 | 4.0 | 3.6 | 2.8 | 69.1*** | 10.3*** | 5.6*** |
Car theft | |||||||||||
Freq. | 0.06 | 0.00 | 0.02 | 0.00 | 0.19 | 0.02 | 0.12 | 0.02 | |||
OR | 1.8 | 1.0 | 0.7 | 0.3 | 6.0 | 6.7 | 3.9 | 8.0 | 29.5*** | 112.5*** | 16.8*** |
Serious Vandalism | |||||||||||
Freq. | 0.14 | 0.01 | 0.07 | 0.01 | 0.33 | 0.07 | 0.40 | 0.05 | |||
OR | 2.9 | 2.4 | 1.5 | 1.2 | 6.9 | 11.0 | 8.3 | 7.6 | 32.3*** | 150.2*** | 17.4*** |
Violence against staff | |||||||||||
Freq. | 0.10 | 0.01 | 0.05 | 0.01 | 0.24 | 0.06 | 0.19 | 0.07 | |||
OR | 2.1 | 2.3 | 1.0 | 2.5 | 5.0 | 12.0 | 3.9 | 13.7 | 28.9*** | 88.8*** | 8.7*** |
Drug crimes | |||||||||||
Freq. | 0.26 | 0.05 | 0.12 | 0.02 | 0.45 | 0.10 | 0.40 | 0.10 | |||
OR | 2.7 | 3.0 | 1.2 | 1.3 | 4.6 | 5.4 | 4.0 | 5.7 | 24.3*** | 128.6*** | 8.9*** |
The contextual and relational problems listed in
A higher number of former CAP patients than controls had entries in the crime register, in line with our main hypothesis. This difference was more pronounced for females: they had a substantially higher number of offences than controls in almost all crime categories, with males displaying a similar but less pronounced pattern. Among the controls, males were registered for far more offences in all crime categories except property crime and to some extent fraud/economic offences, in line with the gender gap observation. It might be noted that the gender gap was less pronounced in the CAP vs the control subjects. Among former CAP patients, reasons for referral suggestive of externalizing problems were associated with a substantially higher level of criminality as estimated by the number of persons with entries in the crime register as well as the number of specific offences, and this effect was more pronounced among the females. The highest Odds Ratios (OR) relative to controls (>12) were obtained for females with externalizing problems and for violent offences, i.e. serious assault and violence against staff/public servants. The combination of externalizing and internalizing problems was common, but criminality appeared to be almost exclusively linked with the externalizing problems, with no difference between the sexes. Hence, we could not replicate the finding reported by Hodgins and co-workers [
Age at the first registered crime did not differ much between former CAP patients and matched controls. There was no contribution from the majority of the contextual or relational factors that could explain the differences in criminal propensity among the patients, with one exception. Exposure to neglect was strongly and systematically associated with increased criminality for a majority of the crimes, particularly among the males. Finally, developmental problems, which were much more common among males, were significantly associated with assault.
Our main findings replicate many of the findings reported by Lee N Robins in her ground-breaking book 50 years ago [
In our study, former CAP patients with internalizing but not externalizing problems did not differ from controls and displayed a trend towards an inverse sex difference, males being less criminal than females. In contrast, for former patients with externalizing problems, the increase in criminality was substantial (ORs for males were typically around 5; for females twice as large). It should be noted that this category of CAP patients also had a much higher load of other problems at referral: parental, relational, school/leisure time and neuro-developmental problems. However, these contextual factors did not explain much of the variation in the material as a whole, with one exception: neglect. It is not very likely that a specific contextual factor increases the risk of criminality in a linear way. Some of the inconsistencies found in the literature appear to reflect the criminality outcome being modulated via non-linear interaction effects involving many factors. This has been illustrated in a study of maltreatment in childhood and cumulative criminal convictions from age 12 to 24. Overall there were few significant associations, and those which were significant represented specific combinations of a number of factors [
In the Stockholm CAP-cohort of the 1950s, only 3% of the females were later registered for criminality [
Sweden has a long tradition of longitudinal CAP studies and high-quality national registers. The study is based on a comparatively large sample of former CAP outpatients, and matched controls, using data collection forms that are similar to those used in previous Swedish studies. The design, and particularly the matching procedure, may be assumed to minimize the effect on crime propensities of the social conditions in residential areas. This should not be construed as an assumption that social factors are not significant in relation to criminality in the form of main or interaction effects. It is a strength that detailed records of criminality were available in a national register, and included data relating to under-aged perpetrators, albeit not reliable for subjects younger than age 13.
The PASTILL database has evolved over a long period of time. The assessments appear to have become more stringent with time. However, most of the outpatients had not received a diagnosis, and in the early years of the database, the diagnoses of those who also had a history as inpatients did not meet DSM-IV criteria-based standards. This was the reason for restricting our analyses to outpatients. The use of the reasons for referral appeared to be the most robust way of creating a rough categorization of the patients, resulting in a 2 * 2 matrix based on the presence of internalizing and externalizing features. The weakness of this procedure and the resulting measurement noise is compensated for by the force of a large N.
Crime onset (register data) was similar for males/females and CAP patients/controls. Former CAP patients were registered for twice as many crimes as controls at a mean age of 21.4 years. Females, both CAP patients and controls, were much less often registered for crimes compared to males, particularly for crimes of violence. The large sex differences in criminality among the controls were less pronounced among the CAP patients (smaller gender gap). CAP females with externalizing problems were registered for ten times as many crimes as their controls, and this difference was also substantially larger for crimes of violence. CAP males with externalizing problems were registered for five times as many crimes as their controls, and this difference was also larger for crimes of violence. CAP females with isolated internalizing problems were registered for more crimes than their controls while the corresponding category of males was registered for fewer crimes. Neglect, in contrast to other adverse social factors, is an independent contributor to high crime rates, particularly for males. There appears to be a period effect, suggesting that CAP treatment of patients with externalizing problems was more successful in preventing criminality previously than it is today―we need to develop a better understanding of why and address how such patients should be identified, referred, assessed and treated by the CAP services. Identifying generative mechanisms leading to crime, and providing appropriate interventions at critical points in the causal chain should reduce crime in a life-course perspective. Our findings help us to narrow the search for generative mechanisms.
Ivert, A.-K., Zyto, M., Adler, H., Levander, M.T., Rydelius, P.A. and Levander, S. (2017) Criminality among Former Child and Adolescent Psychiatric Patients and Matched Controls. Open Journal of Medical Psychology, 6, 16-30. http://dx.doi.org/10.4236/ojmp.2017.61002