Psychological Medicine, 1992, 22, 971-986.

Copyright 1992 Cambridge University Press

Primed in Great Britain

The outcome of childhood conduct disorder:

implications for defining adult personality disorder
and conduct disorder
MARK ZOCCOLILLO,1 ANDREW PICKLES, DAVID QUINTON
AND MICHAEL RUTTER
From the MRC Child Psychiatry Unit, Institute of Psychiatry, London

SYNOPSIS The effect of conduct disorder on adult social functioning in the areas of work,
sexual/love relationships, social relationships and criminality was studied in a sample of young
adults who spent much of their childhoods in group-cottage children's homes and an inner-city
comparison group. Most subjects with conduct disorder had pervasive (but not necessarily severe)
social difficulties compared to peers without conduct disorder. Less than half of this group met
DSM-III adult criteria for antisocial personality disorder and just over half were given a diagnosis
of personality disorder on interviewer clinical ratings. A latent class model that used both the
retrospective and contemporaneous indicators of conduct disorder confirmed the very high
continuity with adult social difficulties. Current diagnoses did not adequately describe this group
and conduct disorder appeared to be an almost necessary condition for multiple social disability
in adults in these samples.

the continuities from conduct disorders to adult

INTRODUCTION
Robins (1978) has noted that almost all adults
with chronic antisocial behaviour had shown
conduct disorder as children, but that only
about one-third of children with a conduct
disorder develop antisocial personality disorder
as adults. Many have interpreted these findings
as indicating that a significant proportion of
children with conduct disorder have a relatively
good outcome. However, part of this apparent
discontinuity between behaviours in childhood
and adulthood may be an artefact of using only
antisocial personality disorder as the adult
measure. By definition, criminal and aggressive
acts are a central feature of that disorder
(American Psychiatric Association, 1980), but
such behaviours may not be the only outcome
from conduct problems: a consideration of a
wider range of social maladaptation may be
appropriate. Although pervasive social mal-
adaptation is a feature of all personality dis-
orders (Russell & Hersov, 1983), examination of
' Address for correspondence: Dr Mark Zoccolillo, UCHSC,
Suite 120, 1611 S. Federal Boulevard, Denver, CO 80219, USA.
971
social functioning should not confine itself to
personality disorders, as currently defined. This
is both because there are major deficiencies in
current classifications of personality disorder
(Rutter, 1987) and because continuities may
occur below the diagnostic threshold.
This view is supported by a careful reading of
Robins' classic study (Robins, 1966), in which
23 % of the children with conduct disorder were
malfunctioning in some way that did not meet
criteria for antisocial personality disorder or any
other standard diagnosis in adult life, and only
16% grew up to be completely well-functioning.
It is thus evident that only some of the
maladaptive behaviours in adult life following
conduct disorder in childhood are well captured
by current diagnostic criteria. However, it was
also clear from Robins' data that minor social
maladaptation in adulthood was common; only
52% of the control group were considered free
of any problems in social adaptation on the
criteria used. The implication is that conduct
disorder is probably not the usual antecedent of
such adult problems, considered singly. The
972 M. Zoccolillo and others
extent to which it is the antecedent of more
pervasive adult difficulties constitutes the main
focus of this paper.
The data are taken from a study comparing
the adult social functioning of children who
spent a substantial part of their childhoods in
large cottage-based children's homes, because of
a breakdown in parenting, with a general
population comparison group from inner city
areas socially comparable to the ones from
which the children ' in care' were taken (Quinton
et al. 1984; Quinton & Rutter, 1988; Rutter et
al. 1990). Children admitted 'into care' have
some advantages for the study of conduct
disorder and its adult outcome because they
show high rates of behavioural difficulties in
childhood (Rutter & Wolkind, 1973; Wolkind &
Renton, 1979).
The data were examined to answer five
questions.
1. If poor adult personality functioning is
defined as pervasive social maladaptation, what
percentage of adults with pervasive social mal-
adaptation have had conduct disorder in child-
hood?
2. What is the outcome in terms of social
maladaptation in adult life for children with
conduct disorder (as compared with their peers
without conduct disorder)?
3. What proportions of subjects with conduct
disorder who are not entirely well functioning as
adults have DSM-III (American Psychiatric
Association, 1980) antisocial personality dis-
order?
4. What is the minimal number of symptoms
of conduct disorder to give a high likelihood of
pervasive social maladaptation in adult life?
5. Is the extent of the continuity between
childhood conduct disorder and pervasive adult
maladaptation modified by experiences and life-
changes?
STUDY DESIGN
As part of a longitudinal study from childhood,
detailed information was obtained on young
adults who had spent much of their childhoods
in two group cottage children's homes and on a
quasi-random comparison sample from econ-
omically deprived inner city areas, who had
never been in care. The comparison sample
included all those from the control group for a
study of the children of parents with some form
of psychiatric disorder who were at that time
living in the more deprived areas of one Inner
London Borough (Rutter & Quinton, 1981,
1984). This control group was taken from the
same school class as the children whose parents
had psychiatric problems, and departed from a
true random sample only insofar as the children
of patients may have been placed in particular
school classes (although there was no evidence
that this had occurred) and through the exclusion
of the few children who had ever been admitted
'into care' (in order to avoid overlap between
the groups). This group was suitable for this
purpose because the subjects were of comparable
age and from a geographical area similar to
those from which the 'in care' sample were
taken into the children's homes. The mean age
of both samples at follow-up was 26 years.
Contemporaneous teacher questionnaires
(Rutter, 1967) and Juvenile Court records were
available for both groups; in addition, parent
questionnaires (Rutter et al. 1970) were com-
pleted on the 'in care' group. Subjects in both
samples were interviewed in their mid-twenties
using a standardized investigator-based inter-
view and information was obtained on life
experiences and histories; behaviour in child-
hood and adolescence; adult social functioning
in major role areas; and psychiatric symptoms.
Criminal activity was rated from official records.
The findings are based on 254 subjects: 171
who had been in care (90 men and 81 women)
and 83 in the comparison sample (42 men and 41
women). These represent 87% of the women
and 73 % of the men who had been in care and
72% of the men and 80% of women in the
comparison group. For some of the multivariate
longitudinal analyses, only those subjects with
complete data both in childhood and at follow-
up were included; the respective proportions for
these analyses were 83, 67, 71 and 80%.
MEASURES AND STATISTICAL
ANALYSES
Conduct disorder
The interview schedules were reviewed by M.Z.,
who had not been involved in the original
interviewing. The presence of probable conduct
disorder (2 symptoms) and definite conduct
disorder (3 or more symptoms) was recorded,
 Adult outcome of conduct disorder 973

retrospective conduct disorder. Two prospective

Table 1. Operational definition of defining
conduct disorder measures were also used:
criteria for conduct disorder in childhood
official delinquency before the age of 15, and a
Probable conduct disorder: any two of the following behaviours positive rating of conduct, or mixed conduct
occurring before the age of 15. and emotional disorder, on the teacher's ques-
Definite conduct disorder: three or more of the following
behaviours occurring before the age of 15.
tionnaire measure, completed at some point
1. Frequent truancy between the ages of 7-5 and 15 years.
2. Expulsion or suspension from school for misbehaviour It should be noted that the interviews did not
3. Delinquency (arrested or referred to juvenile court because
of misbehaviour) cover all the common conduct disorder (CD)
4. Running away from home overnight at least twice symptoms systematically. Therefore, a positive
5. Persistent lying rating on the retrospective measure should be
6. Repeated sexual intercourse in a casual relationship
7. Repeated drunkenness or substance abuse interpreted as meaning that the subject showed
8. Thefts at least 2 or at least 3 symptoms. Tt is, however,
9. Vandalism unusual for the behaviours on which there was
10. Chronic violations of rules at home or at school (other
than truancy) not systematic information (lying, promiscuity,
11. Initiation of fights initiation of fights, running away) to occur in the
absence of others.
N.B.These criteria deliberately omit that on 'school grades markedly
below expectations' as scholastic underachievement did not
seem part of the general concept of conduct disorder and Adult functioning
because it was not susceptible to operationalization using
interview data. Social functioning since the age of 18 was
rated by the interviewers in the areas of work,
sexual/love relationships, and social relation-
Table 2. Operational criteria for adult social ships. The items used are given in Table 2. With
dysfunction respect to the inclusion of unemployment as one
Work
of the 'work' criteria, it should be noted that the
(One or more of the following) follow-up was undertaken prior to the rapid rise
1. Six or more jobs in past 4 years in unemployment during the 1980s.
2. Unemployed for at least one month or more than twice
since age 18 In the analyses that follow, a positive rating
3. Ever fired since age 18 on any one item in each area was used to define
4. Walked out of three or more jobs since age 18 a subject as having some level of social mal-
5. Persistent friction with workmates
adaptation in that area. Criminality was scored
Social relationships (past three months)
(One or more of the following) positively if the subject had ever been on
1. No confiding relationships probation, in prison, or received a conviction for
2. No shared leisure activities
3. No visiting of or by friends
other than trivial offences, since the age of 18.
4. Persistent friction with friends or neighbours Thus, 4 binary outcome variables: social relation-
Sex/love relationships since age 18 ships, work history, sexual/love relationships,
(One or more of the following) and official criminality were used to model
1. Two or more terminated cohabitations
2. Persistent discord or two or more discordant or
continuities between childhood conduct disorder
disrupted cohabitations and social maladaptation in early adulthood.
3. Violence in two or more relationships In addition, ratings were made of antisocial
4. Two or more deviant (alcohol, criminal, drugs) partners
5. Persistent problems in making or sustaining love personality disorder using DSM-III criteria, but
relationships excluding the requirement that conduct disorder
should be present. These, together with the
interviewers' rating of personality disorder, were
using criterion B for the DSM-III diagnosis of used to compare continuities to social mal-
antisocial personality disorder (American Psy- adaptation using clinical measures of personality
chiatric Association, 1980). These criteria are functioning with continuities that appear when
given in Table 1 and were chosen because they less severe measures, covering a wider range of
were based on the original work by Robins functioning, are used. The interviewers' per-
(1966), have good predictive power, and could sonality disorder ratings were based on assess-
be used to compare her findings with those from ments of pervasively poor functioning from
this study. This measure is referred to as early adolescence onwards, and grouped into
974 M. Zoccolillo and others
the two broad DSM-III clusters: 'dramatic'
disorders (antisocial, borderline, histrionic and
narcissistic disorders) and 'other' disorders (in
practice these mainly involved elements of the
avoidant and dependent types). The interviewer
ratings, however, were not based on DSM-III
operationalized criteria.
Analytic strategy
The analysis is presented in four stages: first, a
descriptive account of the relationship between
conduct disorder and clinically defined per-
sonality disorder; second, analyses of the re-
lationship between conduct disorder and the
broader measures of social functioning using
cross-tabulations and linear logistic modelling
(Dunn, 1981;Everitt & Dunn, 1983; McCullagh
& Nelder, 1983); third, the relationship of
personality disorder to social maladaptation;
and fourth, the fitting of latent class models in
order better to deal with problems arising from
classification error.
In fitting the linear logistic models, the
significance of an effect was assessed by a
comparison of the goodness-of-fit, as measured
by the Scaled Deviance, of pairs of models that
included or did not include the variable. This
difference in Scaled Deviance is a likelihood
ratio test statistic that is asymptotically x2
distributed. Significance levels quoted for such
%2s are for two-tailed tests throughout.
Since the main focus of the analyses was upon
the continuity of conduct disorder into adult
life, the central analytical problem concerned
the transition rates from conduct disorder and
non-conduct disorder into adaptive or mal-
adaptive states in adulthood. The usual simple
methods of calculating transition rates assume
that classification of individuals as to disorder
occurs without error at each occasion. Such
classification errors usually substantially atten-
uate, but can sometimes increase, simple
estimates of continuity.
With interval based measures of outcome a
common solution to this problem has been to
base the model on, and to estimate the relation-
ships between, structural or latent variables that
are not themselves directly observable, but for
which multiple indicator measures are available.
A similar treatment of measurement error is
possible with measures being used to define
latent categories, classes or states of disorder.
Their use in the evaluation of psychiatric
diagnostic criteria has been discussed by Young
(1983), and in the analysis of child smoking
behaviour by Fergusson & Horwood (1989).
Latent class methods can also be used to examine
the switching between latent classes over time,
the latent classes being measured by a different
set of indicators on each occasion (Coleman,
1964a, b). We describe the model used in two
parts. The first is the measurement model that
describes how the observed and latent variables
are related. The second is the structural model
that describes the inter-relationships among
latent variables.
The data provided both contemporaneous
and retrospective indicators of childhood CD
and contemporaneous indicators of adult
functioning in several areas. For each of these
indicators a measurement equation was defined
that described how the indicator was related to
the latent disorder.
Consider for individual / a fallible binary
indicatory Y(i), with values 0 and 1, that
measured a latent state of disorder Z(i), also
with values 0 and 1. We can define a measure-
ment equation of the linear logistic form that
relates Y and Z e.g.
log[odds of disorder according
to measure Y] =
\og{Pr[Y(i) = \]/Pr[Y(0 = 0]} = a + bZ(i).
The parameter ' a ' determines the probability of
a positive indicator, given that the individual is,
in fact, not disordered. The parameter '/>'
determines how much more probable is a positive
indicator were the individual actually disordered.
Similar equations can be defined for other
indicators, but with different parameters ' a ' and
'b\ In this study the measurement equations
were in two sets, one for the latent variable of
conduct disorder in childhood and the second
for the latent variable of pervasive social
dysfunction in early adulthood.
The parameters of these equations describe
the performance of each indicator, the a
constants being related to the rate of false
positives, and (a + b) being related to the rate
of false negatives. Two further complications
were allowed for in the application reported
here. First, an indicator need not perform in
the same way for all groups of individuals, for
example as appears to be the case with adult
 Adult outcome of conduct disorder
crime. Crime is very much rarer for women than
men, suggesting it to be a rather exceptional
behaviour for women. Secondly, where the
observed variable was ordinal, a measurement
equation of the proportional odds form
(McCullagh & Nelder, 1983) was used in which
the single ' a ' parameter was replaced by a set of
parameters or thresholds.
It is useful to contrast the construction of a
latent measurement with more familiar methods
of combining information from several observed
variables. The standard 'rule-based' methods
for the construction of a combined measure of
disorder or systematic diagnosis typically assign
prior weights to the contributing measures (often
all equal) and then specify some threshold for
the weighted sum of measures above which
disorder is indicated, for example two positive
measurements out of three. The diagnostic status
of a sampled subject is then determined by this
standardized rule without consideration of data
from other members of the sample. Contextual
considerations are thus limited to those that are
implicit within the original measures.
Within a latent class model the measures can
be considered as being used as screening
instruments, and the assignment of disordered
status to subjects differs in two ways from the
standard method. First, a screening instrument
is understood only to be assigning a probability
of disorder. Secondly, the performance of a
screening instrument, in terms of the relative
frequency of false positive and negative cases
and also the probability of disorder that is
assigned to any sampled subject with a given set
of observed measures, depends upon the preval-
ence of disorder. Applied to a group where the
disorder is rare, the occasional positive measures
are most likely to be false positives. For groups
within which the disorder is common rather
more of the positive measures will be true
positives. In the latent class model the prob-
ability of disorder assigned to a subject therefore
depends not only on that individual's measure-
ments, but also upon the estimated prevalence
of disorder provided by the context of measures
from the other 'similar' subjects.
An equation for estimating this prevalence or
prior probability of disorder within the sample
groups of similar subjects constitutes the first of
two components that form the structural model.
In the case of the data of this study, the equation
975
Factors Factors
influencing influencing
prevalence continuity
Sex of Care Deviance
child status of spouse
X i
Child
J Adult
disorder P 1-p disorder
Child non- 1-q Adult non-
disorder
q disorder
Childhood indicators Transition Adult indicators
matrix
FIG. I. Schematic representation of the latent Markov model of
continuity/discontinuity in childhood conduct disorder.
was again of the logistic form with the prevalence
of conduct disorder allowed to vary between
boys and girls, and between those 'in-care' and
those not.
The second part of the structural equation
model consisted of the simple Markov transition
matrix with transition probabilities p(i) and q(i),
the transitions being from the latent states of
non-disorder in childhood to disorder in adult-
hood and disorder in childhood to non-
disorder in adulthood. Fig. 1 gives an illustration
of the overall model.
Putting the structural and measurement
equations together allows us to write an ex-
pression for the probability of any observed set
of indicator values. This can be thought of as the
sum of two long expressions, each concerned
respectively with the probability of the indicators
were the child disordered or non-disordered.
Thus, the first expression is the prior probability
of being disordered, times the probability of the
observed values of the child indicators given
that the child is disordered, times the sum of two
further terms. Of these, the first term represents
the probability of continuing into the disordered
adult state times the probabilities of the observed
values of the adult indicators given adult
disorder. The second term represents the prob-
ability of switching into non-disorder in adult-
hood times the probabilities of the observed
indicators given no adult disorder. The second
long expression is entirely analogous to the first
but consists of the prior probability of not being
disordered in childhood, times the probability of
the childhood observations given no disorder,
976 M. Zoccolillo and others
times the probability of the adult observations
for the two paths one involving continuity of no-
disorder and the other switching into disorder.
Expression of this form for the probability of
the observed set of indicator values from each
individual in the sample, when multiplied
together give what is called the sample likelihood
function. The set of parameter values that
maximize this likelihood function are the maxi-
mum likelihood estimates. The significance of
effects examined was determined using the same
general procedure as for the linear logistic
models (likelihood ratio tests) to give
asymptotically x* distributed test statistics.
It was possible to obtain a simple picture of
the process as 'viewed' by the latent Markov
model by making use of' posterior probabilities'.
The latent variable approach, although pre-
cluding exact assignment of individuals to states
of disorder, can provide probabilities of disorder
or probabilities of alternative histories of dis-
order in childhood and adulthood. Summing
these posterior probabilities over sub-groups of
individuals in the sample allows 'expected
frequencies' using the latent classification of the
model to be directly compared with classi-
fications based on the observed measures of
disorder.
In considering the adult indicators, there arose
the possibility that an element of the continuity
observed might have been indirect, occurring
through the assortative mating of those with
conduct disorder followed by the independent
effect of a deviant spouse on measured adult
disorder in the subject. For this reason the
sex/love adult indicator, most sensitive to
deviation in the spouse, was not included in this
model.
The linear logistic analyses were performed
using GLIM (Baker & Nelder, 1978) and
EGRET (1990). The latent Markov analysis
was performed by maximum likelihood using
a purpose written FORTRAN program and
library optimization sub-routines (Numerical
Algorithms Group, 1989).
RESULTS
Conduct disorder and personality disorder
Traditionally, antisocial personality disorder has
been seen as the expected adult outcome for
definite childhood conduct disorder (3 or more
DSM-III symptoms) when there is any mal-
function in adult life. The extent to which this
was so in these samples was examined using the
DSM-III adult criteria for antisocial personality
(ASP). These analyses were confined to those
cases for whom there were sufficient data to
make this rating and for whom all the ratings of
social functioning were available.
Of the 35 males with conduct disorder in
childhood, 14 (40 %) were rated as showing ASP
in adult life compared with only 4 % (4/92) of
those without conduct disorder. All these men
met criterion D for DSM-III ASP, that is they
showed persistent antisocial behaviour after the
age of eighteen. All of the men showing ASP
were also diagnosed by the interviewers as
showing some form of 'dramatic' personality
disorder, but in addition to these that 'matched'
with the ASP ratings, a further 7 were rated by
the interviewers as showing personality disorder
(5 with a definite or probable 'dramatic' type
and two with some other variety - both the
latter diagnoses being complicated by low IQ).
Thus, 60 % of males with conduct disorder were
rated as showing personality disorder on one or
both schemes.
Of the 26 females with childhood conduct
disorder, nine (35%) showed ASP compared
with none of those without conduct disorder,
and a further four met the behavioural criteria
for ASP after the age of 18 but without the
persistence of the problems required to fulfil all
the DSM-III adult criteria. Of the 9 with ASP, 6
were rated by the interviewers as showing definite
personality disorder (all of a 'dramatic' type).
Five women with definite conduct disorder but
without ASP had an interview diagnosis of
probable or definite 'dramatic' personality dis-
order. Thus, 54% of women were rated as
showing personality disorder on one or both
schemes.
The discrepancy between operationally
defined ASP and the interviewer judgements for
women, but not for men, was examined by a
more detailed scrutiny of the case histories. For
the 3 cases with an ASP diagnosis without a
personality disorder rating at interview, the
interviewer ratings took into account improved
social functioning in recent years, including the
cessation of criminal activities for the 2 women
with a criminal record. The discrepant cases
were still rated as functioning relatively poorly
 Adult outcome of conduct disorder 977

but were no longer showing aggressive or

Table 3. Conduct disorder and adult social
disruptive behaviour. This pattern also applied
dysfunction
to 4 women not rated by the interviewer as
showing personality disorder but nevertheless Number of areas of adult
showing ASP behaviours after the age of 18 but dysfunction ('%)
Tol'U
without the additional criterion of persistence. 4 >3 ! S* 1 0 N
These apparent changes for the better in early
adult life (it remains to be seen whether or not (a) Prospectively measured conduct disorder
No CD 3 12 27 49 51 178
they will persist) emphasize the difficulty of CD 8 33 62 73 27 63
diagnosing personality disorder in early adult- (b) Retrospectively measured conduct disorder
hood (Hill et al. 1989). Number of symptoms
These initial analyses suggest that for both 0-1 1 6 17 40 60 159
2 5 34 48 77 23 21
males and females ASP, as measured by the > 2 13 43 81 88 12 61
DSM-III adult criteria, is nearly always preceded
by conduct disorder in childhood. When con-
tinuity was measured on these criteria it applied Table 4. Linear logistic model of adult
to one-third to two-fifths of those with conduct dysfunction (N = 241)
disorder (40% males; 3 5 % females). However,
it was apparent from the interviewer ratings that Parameter Standard
ASP was not the only type of personality Main effects model estimate error

disorder that occurred and that there were Constant -1-946

continuities to poor social functioning that did Sex (female) -1-121 (0-363)
Care status 1-289 (0-411)
not meet criteria for personality disorder. Probable CD 1112 (0-517)
Because of this, the analyses that follow Definite CD 2-844 (0-402)
consider the continuities between conduct dis- Scaled deviance 214-85
order and adult social malfunction, regardless of Tests based on alterations on this model
whether malfunction is associated with a clinical LR
df X P
rating of personality disorder or not.
Removing main effects
Linear logistic analyses Sex 1 1006 0002
Care 1 10-81 0001
Table 3a shows the power in this sample of the CD 2 62-90 < 0001
prospective conduct measure, being positive on Adding interactions
either the teacher rating or official delinquency, Sex.CD 2 119 0-6
Care.CD 2 017 0-9
for predicting adult social functioning. The odds Sex .Care 1 1-63 0-2
ratio for one or more areas of dysfunction was Sex.CD + Care.CD +
2-8 (95% interval 1-5 5-4) and that for two or Sex.Care + Sex.Care.CD 7 4-19 0-8
more areas of dysfunction was 4-4 (2-4-8-4). Pooling of CD categories 1 8-96 < 0001
Logistic regression models were estimated with
adult social functioning as the outcome and the
conduct measure, sex and 'care' status as CD (more than 2 symptoms) were 7-6 (3-317-4)
independent variables. Accounting for the effects for 1 area of dysfunction and 17-2 (7-7-38-4) for
of these other variables reduced the estimated 2 areas, even after accounting for the effects of
odds ratios to 1-9 (1-0-3-7) and 31 (1-6-6-0), for sex and care status within a logistic regression.
1 or more and 2 or more areas of dysfunction The corresponding odds ratios for probable CD
respectively. Although some continuity is clear, (2 symptoms) were 3-7 (1-2-11-5) and 30 (1-1-8-6)
discontinuity is not uncommon with, in par- respectively. The effects of probable and definite
ticular, 38 % of those positive on this prospective CD were not significantly different when con-
measure of conduct disorder going on to have sidering 1 or more areas of adult dysfunction
problems in just one area or none at all. but were significantly different for the more
This element of discontinuity is less evident in severe outcome of 2 or more areas.
the data using the retrospective data shown in Table 4 shows the results of one of the linear
Table 3b. The estimated odds ratios for definite logistic analyses, the model identified being the
978 M. Zoccolillo and others

nothing about possible sex differences) and the

Table 5. Distribution of areas of adult
absence of interaction effects involving conduct
dysfunction by sex, care status and childhood
disorder and group or sex designation were
retrospective conduct disorder symptoms
largely due to the low statistical power of the
Number of areas of adult dysfunction tests.
The greater continuity indicated from retro-
0 1 2 3 4 Total spectively rather than prospectively measured
Control boys CD, may have arisen for one or both of two
CD symptoms reasons. The retrospective measure might have
a-i 21 3 4 0 0 28
2 1 2 1 1 0 5 been a better indicator of actual CD than the
S3 2 0 3 2 1 8 contemporaneous teacher questionnaire score
Total 24 5 8 3 1 41 and delinquency, either because it was a better
Care boys measure or because the teacher questionnaire
CD symptoms
a-i 17 11 8 6 1 43 score missed subjects who developed CD after
2 3 3 2 3 1 12 the administration of the scale (between the ages
S3 1 2 10 9 5 27
of 7-5 and 15). Alternatively, the retrospective
Total 21 16 20 18 7 82
Control girls measure may have been contaminated by
CD symptoms elements of current adult functioning such that,
a-i 28 10 1 0 0 39 ceterisparibus, those with a worse adult outcome
2 1 0 0 0 0 1
S3 | 0 0 0 0 1 recalled more childhood symptomatology than
Total 30 10 1 0 0 41 those with a good outcome. Some evidence
Care girls against the recall bias explanation was obtained
CD symptoms from an additional contemporaneous measure,
a-i 29 13 5 2 0 49
2 0 1 0 2 0 3 the Rutter parental scale, available on the 'in
S3 4 2 10 7 2 25 care' sample only. Twenty-seven per cent of the
Total 33 16 15 11 2 77 'in care' sample were positive on this measure.
But among those positive on the retrospective
measure, but negative on both the prospective
same whether forwards addition or backwards teacher scale and delinquency, 40% were posi-
elimination of higher order terms was used (see, tive on the parent scale.
for example, Aitkin et al. 1989). Whether using Visual inspection of Table 3 suggested that
either conduct measure or either outcome CD might be particularly associated with per-
measure, the effect of conduct disorder on the vasive adult dysfunction, the contrast with the
outcome was consistently identified as occurring no-CD distribution being generally greater
solely through a simple main effect and was not where multiple areas of dysfunction were con-
involved in any interaction effects with sex and cerned. Table 6 examines this question further.
care status. This result tempts the conclusion It shows that single isolated areas of dysfunction
that the effect of conduct disorder was common were almost always more common among those
to boys and girls from both care and general without CD than those with CD, the expected
population groups. However, as Table 5 makes higher rates of disorder for those with CD being
clear, there were only 2 girls with conduct seen only where two or more areas were
disorder in the general population sample concerned. The great majority (80%) of those
(control group) and, as it happened, neither with 3 or more areas of dysfunction had shown
showed any social dysfunction in adult life. CD on the retrospective measure, but 9 of them
Although greater in number, there were still only had not. Four of these 9 showed adult onset
13 with conduct disorder among the general psychiatric disorders (one alcohol abuse and
population boys, and 5 of these showed one or crime, one atypical psychotic disorder, and two
fewer areas of adult dysfunction, Thus, the recurrent or chronic depression). Of the re-
pattern of results stem largely from the maining 5, four had been identified as conduct
institution reared sample. Nothing can be said disordered on the prospective measures. The
about the adult outcome of conduct disorder in remaining one appeared to have started de-
girls from the general population (and hence linquent behaviour at about age 15, having been
 Adult outcome of conduct disorder 979

The prevalence rates of the four indicators

Table 6. Distributions of areas of adult
among the general population men and women
dysfunction by sex and childhood retrospective
varied substantially, being 15 and 0% for crime,
conduct disorder
12 and 2 % for sex/love relationships, 20 and
Men Women 15% for social and 32 and 12% for work. This
reinforced the view that these indicators could
Adult dysfunclion No CD % CD % No CD % CD % not be assumed equivalent - with, for example,
None 54 13 65 20 severity or degree of pervasiveness of dysfunc-
One tion being accurately represented by the simple
Crime 7 2 2 0 count of areas affected. In addition, conflict
Marriage 1 2 3 3
Social 3 2 11 0
among the childhood conduct disorder measures
Work g g 9 7 had already been noted. The presence of these
Two measurement problems might have resulted in
CxM 1 2 0 3 the true pattern of continuity being obscured.
CxS 1 4 0 3
CxW 6 17 1 0 We attempted to recover that true pattern
MxS 1 4 6 3 through the use of the latent class model.
MxW 1 2 0 13
SxW 6 2 0 10
The latent class model fitted used the 2-
Three level categorical (binary) prospective conduct
CxM xS 3 2 0 0 measures of the teacher rating, official delin-
CxM xW 1 12 0 10 quency and house-parent rating (in care sample
CxSxW 1 g 0 7
MxSxW 3 g 2 13
only) and the 3-level ordinal retrospective
Four interview measure. These four observed
CxM xSxW 1 13 0 7 variables were each related to a latent binary
Sample si/e (N) 71 52 g8 30 variable of conduct disorder by means of logistic
measurement equations of the form of equation
1 (see Appendix). The three observed binary
a persistent truant before that. In adult life he adult measures of adult crime and dysfunction
had a severe recidivist crime record with multiple in social and work areas were similarly related to
social problems. a latent binary variable of pervasive adult
dysfunction. The sex/love indicator was dropped
Personality disorder and social maladaptation at this stage because of a concern to focus as
It is clear that the measures of social mal- much as possible on direct continuity. The
adaptation show more continuity between con- process of assortative mating to a deviant
duct disorder and adult dysfunction than per- partner, followed by that chosen partner's own
sonality disorder diagnoses. Eight-six per cent of contribution to dysfunction in this area, con-
the 35 men with three or more symptoms of CD stitute a possible indirect route for continuity to
showed social maladaptation in two or more occur, one that we wished to exclude for this
areas, whereas only 40% were given a DSM-III analysis.
diagnosis of antisocial personality disorder and The specification of these measurement equa-
a further 20% an interviewer diagnosis of tions required decisions on what were to be free
personality disorder of some other type. The parameters. This required detailed consideration
comparable figures for the 26 women with a of the prevalences of each of the indicators and
similar level of conduct disorder were 73 % with their sensitivity and specificity to the underlying
pervasive social maladaptation, 35 % with DSM- latent condition. As part of this process multi-
III antisocial personality disorder and 19% with variate logistic regressions were undertaken
another type of personality disorder. using the random effects logistic regression
program of EGRET (1990). As a result of these
Latent class analysis analyses common parameters were assumed for
Table 6 raised the question as to whether each of several of the indicators, allowing some im-
the adult indicators was equally associated with provement in statistical efficiency. In addition,
this pervasive dysfunction that appeared to the performance of the crime indicator was
constitute the adult outcome for childhood CD. identified as being different for men and women.
980 M. Zoccolillo and others

Table 7. Measurement characteristics, prevalence Table 8. Shifts in probability of conduct

estimates and transition rates from the latent disorder with information on indicators
class model
Probability of CD (%)
Childhood disorder No information
Prior probability 10
False positive False negative or prevalence
Prospective indicators
Delinquency + 58
Teacher or house-parent Delinquency 8
questionnaire score 4 53
(CD or mixed) B score (or A score) + 56
Delinquency by age 15 2
B score (or A score) 6
75
Retrospective interview Both B-score and delinquency + 97
2 or more symptoms 10 29 Both B-score and delinquency 4
3 or more symptoms 5 45 Retrospective indicator
Definite + 55
Poor adult social functioning Probable + 44
Definite - 3
False positive False negative

Adult crime many positives owing to high rates of false

Boys 10 negatives (probability of a child with CD being
33
Girls 3 66
Social 16
negative on an indicator measure). The retro-
56
Work 13 spective measure using 2 or more symptoms as
25
the cut-off identified many more of the positives
at the expense of a higher rate of false positives.
Prevalence levels of Tightening the cut-off to 3 or more symptoms
childhood CD
Care boys 64
had the expected result of identifying fewer of
Control boys 23 the conduct disordered children but reducing
Care girls 41 the number falsely identified as conduct dis-
Control girls 3
Transition probabilities ordered. Among the adult measures, that for
From childhood crime possessed a low rate of false positives but
CD to good adult a high rate for false negatives. This is consistent
social functioning
From childhood non-CD to poor adult with our expectation, especially for women, that
social functioning crime identified a more unusual, possibly more
extreme, group. The estimated prevalence rate
of the latent or underlying CD showed greater
The final specification of the seven measurement range across the 4 sex and care status categories
equations (see Appendix) involved 11 free than any of the 4 observed indicators, consistent
parameters. with the attenuation effects of misclassifications.
As explained, the structural model consisted Table 8 shows an alternative way in which the
of specifying free parameters for the subgroups measurement error results can be presented, that
of children that differed with respect to the is in terms of the impact on the estimated
prevalence of underlying or latent conduct probability of conduct disorder of knowledge of
disorder and similarly specifying free parameters the values of the indicators. Thus, official
for the transition rates between latent conduct delinquency alone shifts the (arbitrarily chosen)
disorder and latent adult dysfunction. The prior probability from 10 to 58% but with a
results shown in Table 7 are for a structural positive teacher scale score as well the assignment
model that allows 4 prevalence levels, 1 for each probability leaps up to 97%, emphasizing the
sex and group designation, and 2 simple tran- value of multiple indicators.
sition r a t e s - 6 free parameters in all. Returning to Table 7, the fitted model
The contemporaneous measures of CD are estimated the transition rate from no-disorder in
seen to have had very low false positive rates childhood to the disordered state in adulthood
(probability of a child without CD being positive as being very low. It should be emphasized here
on the indicator measure) but to have missed that adult disorder here refers to one that at an
 Adult outcome of conduct disorder 981

Table 9. The effect of spouse: assortative mating, indirect through reduction of disorder or direct
upon adult indicators
Model allowing for

Indirect Direct
effect effect
Assortative through on Scaled LR
mating disorder indicators deviance (X2) df P

A No No No 1638-36
B Yes No No 1622-53 (A B) 15-83 2 00004
C Yes Yes No 1616-42 (B-C) 611 2 005
D Yes Yes Yes 1607-75 (C D) 8-67 2 001
E No Yes Yes 1621-34 (E-D) 13-59 2 0001
F Yes No Yes 1608-76 (F-D) 101 2 0-6

Table 10. Patterns of continuity of disorder as the gaining of a non-deviant partner (Quinton &
shown by frequencies on observed and latent Rutter, 1988). This was examined by allowing
measures (N = 227) various aspects of the model to depend upon the
presence of a non-deviant partner. Allowing the
Adult Social Adaptation prevalence of childhood CD to vary with partner
Boys
characteristics took account of assortative
Girls
mating (Table 9). Allowing the transition
Childhood CD Good Poor Good Poor probabilities to vary accounted for any role in
Using combination of observed measures of child
actual switching between states of latent dis-
and adult disorders* order. Separate parameters for each of these
No 59 15 83 5 effects were estimated for men and women.
Yes 10 30 12 13
Comparisons of model A with model B
Using retrospective measure alone
No 51 15 81 3 indicated that the assortative mating effect was
Probable 11 5 2 2 significant, and model B with model C indicated
Definite 7 25 12 13
a significant effect for a non-deviant spouse on
ig
Estimated using latent or underlying
child and adult disorders
discontinuity between childhood disorder and
No 49 5 80 0 adult functioning. Further investigation showed
Yes 8 52 3 30 substantial sex-differences in these effects, with
* Conduct disordered if definite on retrospective or two out of
assortative mating appearing only to occur for
three childhood indicators positive. Poor adult social adaptation if 2 conduct disordered girls, who were rarely ending
or more out of 3 indicators positive. up with non-deviant men, while there was little
difference between conduct disordered and non-
disordered boys. As a result, even though the
underlying level is pervasive (though not necess- estimated transition rate out of conduct disorder
arily severe). Particular circumstances may still was raised to 4 8 % for women with a non-
generate poor (or good) functioning in a single deviant partner, as compared to less than 4 %
social domain independently of any pervasive for those without, the rarity of such women gave
dysfunction. Greater evidence was found of this little statistical significance. The effect for
discontinuity out of childhood CD though this men was somewhat less substantial, 26 versus
rate was estimated with considerable impre- 0%, but more men found non-deviant partners.
cision. As a result, the rate of 8% estimated Allowing for a third possible route for the
possessed a wide confidence interval, being not effect of a non-deviant partner, such that the
significantly different from zero (likelihood ratio adult functioning of all individuals was im-
f 201, P = 0-2) and having an upper 9 5 % proved, whether conduct disordered or not,
likelihood interval estimate of 19%. confused the picture. A comparison of model D
Previous research had suggested that for the with C suggested this effect to be significant and,
'in care' girls such transitions out of childhood in its presence, assortative mating (E-D) but not
disorder had been particularly associated with the switching effect (F-D) remained significant.
982 M. Zoccolillo and others
Table 10 provides a simple comparison of the
extent of childhood to adulthood continuity as
shown by classifications based directly upon the
observed data and by that using the expected
frequencies or posterior probabilities from the
latent class model allowing for non-deviant
partner effects. The latter model suggests that
the pervasive adult dysfunction is not only very
sensitive to prior childhood CD, but also a
highly specific sequela.
DISCUSSION
Even after the effects in being in-care, and of sex,
were controlled, conduct disorder in the popu-
lation studied had a powerful effect on later
social functioning. Looking forward from child-
hood to adulthood, about two-fifths of children
with CD (40 % of males and 35 % of females)
went on to show a DSM-III antisocial per-
sonality disorder in early adult life. Many of the
remainder had persistent social difficulties that
were pervasive across several domains of their
life. The precise proportion, of course, depends
on the criteria used. However, just over two-
thirds (86 % of males and 73 % of female) in our
samples showed dysfunction in at least two social
domains (see Table 5). The latent class analysis
(see Table 10) gave a broadly similar picture in
that it estimated pervasive social dysfunction in
88% of adults with CD. We may conclude,
therefore, that probably about three-quarters of
children with a clinically significant conduct
disorder will go on to exhibit pervasive and
persistent social malfunction (although often
well below the threshold for diagnoses of
personality disorder). Our sample of control
girls with CD was much too small for any
conclusions, however, and further research is
needed to determine whether these conclusions
apply to girls in the general population.
Six features of these findings require particular
emphasis. First, as already noted, antisocial
personality disorder accounted for only about
half the cases of pervasive persistent social
dysfunction in early adult life. This was evident
in Robins' (1966) classical follow-up of a child
guidance clinic sample and it was also apparent
in her more recent analysis of the Epi-
demiological Catchment Area data (Robins,
1986). Secondly, pervasive, persistent, adult
social dysfunction only rarely occurred in the
absence of childhood conduct disturbance except
when it was secondary to some form of adult-
onset psychiatric disorder such as alcoholism,
psychosis or affective disorder. This was ap-
parent from both the linear logistic and latent
class analyses. The finding confirms the tradi-
tional psychiatric assumption that personality
disorder almost always has its onset in childhood
or adolescence (although it may not be recog-
nized as such until adulthood).
Thirdly, conduct disorder was not a good
predictor of isolated areas of social dysfunction;
indeed, most individuals with just one domain of
social dysfunction were in the general population
comparison group. Fourthly, although it was
decidedly uncommon for there to be a transition
from normal conduct in childhood to personality
disorder in adult life even when social cir-
cumstances were poor, the reverse did not apply.
A minority of individuals with conduct disorder
in childhood went on to show satisfactory social
functioning in adult life: 13% of males and 9%
of females on the latent class analysis which
infers pervasive (but not necessarily severe)
social malfunction after correcting for measure-
ment error, and 23 and 48 % respectively using
the combination of observed childhood
measures and the direct measure of adult social
dysfunction. This transition was strongly
associated with the presence of a supportive
non-deviant spouse.
Fifthly, even holding conduct disorder in
childhood constant, the fact of being reared in
an institution (a variable that indexed a range of
adversities) increased the risk of pervasive social
dysfunction in adult life. Although conduct
disorder as such is the major risk factor, rearing
circumstances (and all that they reflect) added to
the risk. Sixthly, only a few symptoms of conduct
disorder (not necessarily including violent or
extreme behaviour) were needed for there to be
pervasive social malfunction in adult life. This
suggests that the threshold to identify persistent
clinically significant conduct disorder set in
DSM-III-R may be too high. Nevertheless, a
poor outcome in adult life was significantly
more frequent for young people with definite
CD than with probable CD; also it was more
likely when CD was evident on several in-
dependent measures. Clearly, further research is
required to determine the most appropriate
 Adult outcome of conduct disorder
threshold for diagnosis; as well as to delineate
the particular pattern of CD most strongly
associated with personality disorder in adult
life. Other research suggests that it may
involve associated hyperactivity/inattention
(Farrington et al. 1990).
These findings derive from a study of a
particular sample and it is necessary to consider
four key respects in which sample characteristics
may impose constraints on generalizations from
our findings. First, we have defined conduct
disorder in terms of the mostly quite severe
behaviours specified in DSM-III. That definition
would not include many cases of conduct
disorder as specified in ICD-9 (World Health
Organization, 1978), the definition of which
extends into what would now be considered
oppositional-defiant disorder. While it is clear
that some instances of the latter in early
childhood go on to become DSM-III style
conduct disorders in later childhood or ado-
lescence (Loeber, 1992), systematic data on adult
outcome are lacking.
Secondly, the main sample was comprised of
children from high-risk (presumably genetic and
environmental) backgrounds reared in institu-
tions. There was some suggestion that the
outcome may have been somewhat better
(although still poor) in the comparison group; a
larger sample is needed to test this possibility. It
is also relevant that the comparison group was
itself socially disadvantaged and it is necessary
to query whether the results would be similar in
young people from a middle-class background.
Robins (1966) found a non-significantly slightly
lower risk of sociopathy in middle class youths;
her analysis of retrospective data from a general
population sample (Robins, 1986) showed
findings broadly similar to those reported here;
and Zoccolillo & Rogers' (1991) short-term
follow-up of girls admitted to a psychiatric
hospital with conduct disorder also showed a
poor outcome. Further research, studying chil-
dren from varying backgrounds, is necessary to
identify the features that carry a particularly
high risk of a poor adult outcome. However, the
degree of congruence of findings across studies
suggests that there is likely to be substantial
generalizability of the broad pattern of our
findings, even though the precise level of risk for
poor adult functioning may vary with as-yet-to-
be-identified risk factors.
983
Thirdly, very few of our sample experienced
major therapeutic interventions or environ-
mental manipulations. Accordingly, we cannot
know the extent to which the adult outcome is
modifiable. The better outcome associated with
harmonious marriage to a non-deviant spouse
(in the small minority where this occurred)
suggests the potential for change. The challenge
to develop effective modes of treatment is there,
but it has to be admitted that the successes
recorded to date are distinctly modest (Rutter &
Giller, 1983; Robins, 1991).
Fourthly, our follow-up was undertaken when
the subjects were still in their mid-20s and we do
not know whether or not improvements in
functioning will take place later (we are currently
undertaking a further follow-up to examine this
possibility). It should be noted that Robins'
(1966) follow-up took place when the subjects
were a decade or so older than ours.
With these features (and caveats) in mind we
need to consider the implications for concepts of
childhood conduct disorder and for adult per-
sonality disorder. The traditional emphasis on
the continuity between conduct disorder and
antisocial personality disorder, although truly
reflecting one crucial aspect of the empirical
findings, has had several unfortunate conse-
quences. To begin with, it has led to under-
estimates of the relatively poor social outcome
in early adult life for children with clinically
significant conduct disturbance. Our findings
suggest that some three quarters showed per-
sistent social dysfunction that extended over
several domains of their life (including love
relationships, work, and friendships) as well as
often, but by no means always, including
criminality. The diagnosis of antisocial per-
sonality disorder does not provide an adequate
coverage of the range of disabilities in adult life
that are the sequelae of conduct disorder in
childhood. As already noted, this was also
apparent in Robins' (1966, 1986) studies. In
addition, it was evident in Zeitlin's (1986) follow-
up of child psychiatric patients who received
psychiatric treatment in adult life and in Quinton
et a/.'s (1990) follow-up of children reared by
mentally ill parents. The data are rather sparse
so far and it would be premature to draw
conclusions on the range of patterns of adult
dysfunction following conduct disorder in child-
hood.
984 M. Zoccolillo and others
Nevertheless, it does seem that, at least in
adult life and especially in women, antisocial
behaviour may not constitute the key denning
characteristic of the personality disorder that
shows continuity with conduct disturbance. Our
data raise the possibility that it is pervasive and
persistent social dysfunction that provides the
coherence, and not criminal activities. Such
dysfunction in males usually includes crimin-
ality, but in women that is much less often the
case. Of course, the DSM-III criteria emphasize
that the concept includes inconsistency in work,
impaired parenting, a lack of stable love/sex
relationships, failure to honour financial
obligations, impulsivity and recklessness - as
well as lying, unlawful activities and aggress-
iveness. Clearly, there is a need for diagnostic
assessments to provide systematic coverage of a
person's functioning in a range of social domains
(Hill et al. 1989). The breadth of social mal-
function inevitably raises queries on whether
the DSM-III subcategorizations of different
varieties of personality disorder have validity.
Certainly, other research has shown the high
frequency with which there is overlap between
supposedly different varieties of personality
disorder (see e.g. Pope et al. 1983) and between
personality disorder, affective disturbance, sub-
stance abuse, somatization disorder, and suicidal
attempts (Robins, 1966; Bohman et al. 1984;
Goodwin & Guze, 1984; Zoccolillo & Cloninger,
1986). Moreover, conduct symptoms have been
reported as antecedents of borderline personality
disorder as well as antisocial personality disorder
(Soloff & Millward, 1983; Andrulonis & Vogel,
1984). We conclude that there is a great need
for research examining communalities and
differences between supposedly different per-
sonality disorders. Research is also needed to
determine whether the childhood antecedents of
other varieties of personality disorder (such as
'avoidant') are similar to or different from those
found for ASP and other 'dramatic' personality
disorders. The subdivisions of personality dis-
order in DSM-III-R, problematical as they are,
do reflect interesting differences in qualities and
style of social functioning. The question to be
tackled now is whether these differences in
pattern have different antecedents or conse-
quences.
A further issue concerns the homogeneity or
otherwise of conduct disturbance in childhood.
Adult outcome might constitute a useful
differentiating feature. Our measures of the
pattern of behaviour in childhood were not
sufficiently discriminating for any useful sub-
division of conduct disorders. Other research
has suggested that early onset, the presence of
hyperactivity/inattention, and poor peer
relations constitute important predictors of a
poor adult outcome (Henn et al. 1980; Parker &
Asher, 1987; Magnusson, 1988; Loeber, 1988,
1990; Farrington et al. 1990). However, it
remains quite uncertain whether these define
different varieties of conduct disorder or rather
whether they constitute measures of severity. It
may also be queried whether conduct disorder
should be regarded as a diagnostic category or a
behavioural dimension. Robins & McEvoy
(1990) found that it functioned as a dimension in
its associations with substance abuse. However,
they relied on retrospective data and the possi-
bility of bias in recall must be considered.
Prospective data are required to answer the
question.
Obviously, not every child who commits a
delinquent act or who truants or who initiates
fights can be considered at a serious risk for
adult personality disorder. That is because the
prevalence of these behaviours in childhood is
much too high (Rutter & Giller, 1983) for that
to be the case. Many essentially normal children
engage in occasional disruptive or defiant or
illegal behaviours at some time. Nevertheless,
our findings indicate that the prognosis for
clinically significant conduct disturbance is more
serious than often appreciated. The key question
is at what level or persistence or pervasiveness of
conduct disorder is there an appreciable risk of
adult social dysfunction? Is the risk the same
regardless of the age of the child at which the
conduct disorder occurs? Further research is
required to answer these questions.
A further question concerns the reasons for
the continuity between conduct disorder in
childhood and personality disorder in adult life
and the modifiability, or otherwise, of the
process. Our findings show that substantial
change is possible even in adult life, given
particularly good social circumstances. Of
course, such change occurs in only a minority of
individuals. However, it is necessary to ask
whether that is because conduct disordered
individuals act in ways that make it unlikely that
they will experience favourable social conditions
or because patterns of behaviour in such
 Adult outcome of conduct disorder 985

individuals are intrinsically resistant to change? Table Al. Measurement equation: free
Also, we have to enquire whether the continuities parameters
derive from persistently adverse environmental
Males Females
circumstances or from intrinsic qualities in the
conduct/social disorder as such? Would a lasting a b a b
remission of conduct disorder be more common Childhood measures
if more children experienced markedly improved Houseparent B-score al bl al bl
family circumstances? Alternatively, do the Teacher B-score al bl al bl
Delinquency a2 bl a2 bl
persistent conduct disorders differ funda- Retrospective CD
mentally from the transient ones in having a Probable a3 bl a3 bl
greater genetic component? It is striking that the Definite a4 bl a4 bl
few available data suggest that the heritability of Adult measures
Adult crime a5 b2 a6 b2
juvenile delinquency is very low whereas that of Adult work a7 b2 a7 b2
adult crime is much greater (Rutter et al. 1990). Adult social a8 b3 a8 b3
Our data are not of a kind that can provide
answers to these questions. However, what they
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