The association between ADHD and antisocial personality disorder (ASPD): A review

Abstract

Objective:
Children with ADHD have an increased risk of later developing personality disorders and criminal behavior. The object of the present review is to analyze the associations between ADHD and antisocial personality disorder (ASPD).

Method:
A review of literature was done using EMBASE, PsycINFO, and Medline databases.

Results:
Eighteen prospective studies (n = 5,501) showed that ADHD with and without comorbid conduct disorder (CD) is a strong predictor for the risk of later development of antisocial personality disorder (ASPD). Some of the 13 cross-sectional/retrospective studies (n = 2,451) suggested that ADHD and CD might be a separate subtype of ADHD, that especially impulsivity in ADHD is a predictor for later development of ASPD, or that callous-unemotional traits in the ADHD children are called for a risk factor for later ASPD.

Conclusion:
There is an increased risk for children with ADHD with or without comorbid CD to develop later onset of antisocial personality disorder.

Full text

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Journal of Attention Disorders
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DOI: 10.1177/1087054713512150
published online 27 November 2013Journal of Attention Disorders
Ole Jakob Storebø and Erik Simonsen
The Association Between ADHD and Antisocial Personality Disorder (ASPD): A Review
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Article
Background
ADHD is one of the most common child psychiatric disor-
ders with a prevalence of 3% to 5% (Scahill & Schwab-
Stone, 2000). The disorder is characterized by impulsiveness,
attention deficits, hyperactivity, and difficulties in social
interaction with parents, other children, and teachers. A
growing number of adults are diagnosed with ADHD,
which has an estimated prevalence of 1% to 2% (Polanczyk
& Rohde, 2007). In both the Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-V; American
Psychiatric Association [APA], 2013) and the World Health
Organisation’s (WHO) International Classification of
Diseases–Tenth Revision (ICD-10), there are subgroups
that are characterized as mainly inattentive, or mainly
hyperactive-impulsive and as a combination of the two.
More than 50% of children with ADHD have other psychi-
atric disorders, primarily behavioral problems, learning dif-
ficulties, anxiety, and depression (Dalsgaard, Nielsen, &
Simonsen, 2013). Recent research has shown that children
with ADHD also have an increased risk of later developing
personality disorders, bipolar psychoses, substance abuse
and criminal behavior (Dalsgaard, Mortensen, Frydenberg,
& Thomsen, 2002; Miller, Nigg, & Faraone, 2007; Schmidt
& Petermann, 2009; Storebø and Simonsen, 2013). It is
well known that conduct disorder, and criminal and antiso-
cial behavior are prevalent in children with ADHD
(Dalsgaard et al., 2002). Studies of prison populations also
show a great preponderance of diagnosis of adult ADHD
(Curran & Fitzgerald, 1999). Children with both ADHD
and antisocial behavior have worse prognosis compared
with children with one of the problems alone (Moffitt,
1990). Some studies have suggested that the association
between ADHD and antisocial behavior is mediated by con-
duct disorder (CD; Farrington, Loeber, & Van Kammen,
1990). In our searches, we found several reviews investigat-
ing the association between ADHD and antisocial personal-
ity disorder (ASPD)/antisocial behavior/CD (Foley, Carlton,
& Howell, 1996; Rösler & Retz, 2008; Sobanski & Alm,
2010; Thapar, van den Bree, Fowler, Langley, & Whittinger,
2006). Rösler and Retz (2008) underlined that children with
ADHD and CD are at risk of developing later ASPD, but
children with ADHD solely are not. Thapar et al. (2006) in
their review of the association between ADHD and antiso-
cial behavior underlined that there are few longitudinal
studies and a great need for that kind of studies.
The ASPD (in ICD-10: dissocial personality disorder) is
a common psychiatric disorder with a prevalence of around
512150JADXXX10.1177/1087054713512150Storebø and RoskildeStorebø and Roskilde
research-article2013
1Psychiatric Research Unit, Region Zealand, Holbæk, Denmark
2Child and Adolescent Psychiatric Department, Region Zealand, Holbæk,
Denmark
Corresponding Author:
Ole Jakob Storebø, Child Psychiatric Clinical, Birkevænget 3, 4300
Holbæk, Denmark.
Email: ojst@regionsjaelland.dk
The Association Between ADHD and
Antisocial Personality Disorder (ASPD):
A Review
Ole Jakob Storebø1,2 and Erik Simonsen2
Abstract
Objective: Children with ADHD have an increased risk of later developing personality disorders and criminal behavior.
The object of the present review is to analyze the associations between ADHD and antisocial personality disorder (ASPD).
Method: A review of literature was done using EMBASE, PsycINFO, and Medline databases. Results: Eighteen prospective
studies (n = 5,501) showed that ADHD with and without comorbid conduct disorder (CD) is a strong predictor for the
risk of later development of antisocial personality disorder (ASPD). Some of the 13 cross-sectional/retrospective studies
(n = 2,451) suggested that ADHD and CD might be a separate subtype of ADHD, that especially impulsivity in ADHD is
a predictor for later development of ASPD, or that callous-unemotional traits in the ADHD children are called for a risk
factor for later ASPD. Conclusion: There is an increased risk for children with ADHD with or without comorbid CD to
develop later onset of antisocial personality disorder. (J. of Att. Dis. 2013; XX(X) 1-XX)
Keywords
ADHD, risk factor, impulsivity, conduct disorder, antisocial personality disorder
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2 Journal of Attention Disorders XX(X)
1% (CI [0.6%, 4.1%]) in nonclinical population/community
studies (Lenzenweger, 2008). It gives rise to a substantial
expenditure of public resources and considerable treatment
challenges in psychiatric institutions, general practices, and
social institutions. These patients often have other concur-
rent or lifelong diagnoses such as depression, eating disor-
ders, substance abuse, anxiety, and/or self-harm behavior as
well as other personality disorders.
Aim
The object of the present review is to analyze the statisti-
cally significant associations between ADHD and ASPD.
Method
A comprehensive search of EMBASE, PsycINFO, Medline,
and hand-searching yielded 546 “hits,” and on basis, these
80 articles were selected for a more detailed reading of the
full texts. We did not include “psychopathy,” a more severe
form of antisocial disorder in the search strategy, but it
came up as an additional keyword in many articles (see
search strategy in Appendix 1). This reading finally pro-
duced 35 relevant articles for inclusion. Most of the articles
were excluded due to the lack of the diagnosis of ADHD
and/or ASPD/criminality/psychopathy. Our search strategy
revealed some articles on ADHD and criminality/psychopa-
thy and they were included. One article was found by hand-
searching. Eighteen were prospective studies, 13 were
cross-sectional/retrospective studies, and 4 were review
articles (Table 1). The 4 reviews are included in the back-
ground section of this review (Figure 1).
Results
The 18 prospective studies (n = 5,501) investigated differ-
ent types of association between ADHD and antisocial per-
sonality disorder, CD, and criminality (Biederman et al.,
2006; Biederman et al., 2008; Biederman et al., 2010;
Faraone, Biederman, Jetton, & Tsuang, 1997; Faraone,
Biederman, Mennin, Russell, & Tsuang, 1998; Lahey,
Loeber, Burke, & Applegate, 2005; Lee & Hinshaw, 2004;
Loeber, Burke, & Lahey, 2002; Mannuzza, Klein, Bessler,
& Malloy, 1993; Mannuzza, Klein, Bessler, Malloy, &
LaPadula, 1998; Mannuzza, Klein, & Moulton, 2008;
Monuteaux, Faraone, Gross, & Biederman, 2007; Mordre,
Groholt, Kjelsberg, Sandstad, & Myhre, 2011; Pardini &
Fite, 2010; Patterson, DeGarmo, & Knutson, 2000;
Satterfield et al., 2007; Satterfield & Schell, 1997; Van Lier,
Wanner, & Vitro, 2007). Several studies showed that in chil-
dren with ADHD, CD is a strong predictor for the risk of
later ASPD (Lahey et al., 2005; Loeber et al., 2002;
Mannuzza et al., 1993). In a study by Pardini and Fite
(2010), ADHD symptoms predicted increases in opposi-
tional defiant disorder (ODD) and CD symptoms, and the
authors pointed at the possible developmental path from
childhood ADHD to CD. This was especially the case for
the combined subtypes of ADHD, whereas the inattentive
subtype was more prognostic of future academic difficulties
(Pardini & Fite, 2010). Some other studies also found that
ADHD could lead to the development of CD (Biederman
et al., 2008; Monuteaux et al., 2007). Monuteaux et al.
(2007) showed that childhood ADHD was a significant risk
factor for CD in girls, with a hazard ratio of 5.8, 95% CI
[2.9, 11.5]. Loeber et al. showed that ADHD is a higher risk
factor for the development of ASPD than ODD (Loeber
et al., 2002). Mannuzza et al. (1998) found a prevalence on
ASPD of 12% in the ADHD group compared with a preva-
lence of 2% in the control group, and this gives an adjusted
odds ratio on 4 (90% CI [1.01, 15.65]) for the development
of later ASPD among the children with ADHD. Mannuzza
et al. (2008) presented results describing a developmental
pattern from childhood ADHD to adolescent antisocial per-
sonality disorder, to substance abuse, ending up with crimi-
nality. The authors underlined the importance of breaking
this chain of events by preventing the development of
ASPD (Mannuzza et al., 2008). Patterson et al. (2000)
pointed at a possible path from ADHD to ASPD, mediated
by disrupted parental discipline practice. Biederman et al.
(2010) investigated the risk for the development of ASPD in
girls with ADHD and found a hazard ratio for ASPD of 6.8
(95% CI [3.7, 12.6]).
Other studies found that children with ADHD without
CD also were at high risk of later onset of ASPD (Biederman
et al., 2006; Biederman et al., 2010; Mannuzza et al., 1998;
Mannuzza et al., 2008).
Although the word criminality was not included in our
search strategy, we were able to investigate the relationship
between ADHD and the later onset of criminality. Children
with both ADHD and CD were in increased risk of adult
criminality, whereas children with ADHD only did not have
this risk (Mordre et al., 2011; Satterfield et al., 2007;
Satterfield & Schell, 1997). In a long-term prospective
study by Satterfield et al. (2007), 44% of the ADHD boys
with comorbid CD were arrested as adults. Mordre et al.
(2011) support this as they state that there is no direct asso-
ciation between ADHD and criminality. CD alone or in
combination with hyperactivity in childhood was highly
related to later delinquency (Mordre et al., 2011).
Faraone et al. found evidence for supporting the hypoth-
esis that ADHD with comorbid CD is a distinct subtype of
ADHD and also for supporting the ICD-10 decision for
retaining hyperkinetic CD as a separate diagnostic category.
This also means that the future work with the revisions of
DSM-V should consider including this comorbid condition
as a separate category. The authors underline that the
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Storebø and Roskilde 3
Table 1. The Association Between ADHD and Antisocial Personality Disorder.
First author Article title Year Location n
Design and sample
source Methods and measures
Biederman Young adult outcome of ADHD:
A controlled 10-year follow-up
study
2006 USA 260 Prospective  K-SADS
 Structured clinical interview for
DSM-IV (SCID)
Biederman The long-term longitudinal
course of oppositional
defiant disorder and CD in
ADHD boys: Findings from a
controlled 10-year prospective
longitudinal
2008 USA 260 Prospective  K-SADS-E
 Structured clinical interview for
DSM-IV (SCID)
 Child Behavior Checklist (CBCL)
 Socioeconomic status (SES)
Biederman Adult psychiatric outcomes of
girls with ADHD: 11-year
follow-up in a longitudinal case-
control study
2010 USA 260 Prospective  K-SADS-E
 Structured clinical interview for
DSM-IV (SCID)
Faraone Familial subtypes of ADHD:
A 4-year follow-up study of
children from antisocial-ADHD
families
1998 USA 260 Prospective  Global assessment of functioning
scale (GAF)
 Social adjustment inventory for
children and adolescents (SAICA)
 Child Behavior Checklist (CBCL)
 Socioeconomic status (SES)
Faraone Attention deficit disorder and
conduct disorder: Longitudinal
evidence for a familial subtype
1997 USA 218 Prospective  Kiddie SADS-E
 Structured clinical interview for
DSM-III-R (SCID)
Lahey Predicting future antisocial
personality disorder in males
from a clinical assessment in
childhood
2005 USA 163 Prospective  Schedule for affective disorders
and schizophrenia (SADS)
 Structured clinical interview
(SCID)
Lee Severity of adolescent
delinquency among boys
with and without ADHD:
Predictions from early
antisocial behavior and peer
status
2004 USA 175 Prospective  Child Behavior Checklist (CBCL)
 Laboratory measure of covert
antisocial behavior (ASB)
 Youth self-report
 Self-reported delinquency
Loeber What are adolescents’
antecedents to antisocial
personality disorder?
2002 USA 177 Prospective  Diagnostic interview (DISC-C and
DISC-P)
 Computerized diagnostic interview
schedule (revised)
 Self-report on substance abuse
 Child Behavior Checklist (CBCL)
 Adult criminality (criminal records)
Monuteaux Predictors, clinical characteristics
and outcome of CD in girls
with ADHD: A longitudinal
study
2007 United
Kingdom
262 Prospective  K-SADS-E
 Structural clinical interview for
DSM-IV (SCID)
 Socioeconomic status (SES)
 Global assessment of functioning
(GAF)
 Moos family environment scale (FES)
Mannuzza Lifetime criminality among boys
with ADHD
2008 USA 207 Prospective  Official arrest records
Mannuzza Adult outcome of hyperactive
boys. Educational achievement,
occupational rank and
psychiatric status
1993 91 Prospective  Educational achievement
 Occupational status
 ADHD symptoms
Mannuzza Adult psychiatric status of
hyperactive boys grown up
1998 USA 158 Prospective  Semi-structured DSM-III-R
interview
(continued)
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4 Journal of Attention Disorders XX(X)
First author Article title Year Location n
Design and sample
source Methods and measures
Mordre The impact of ADHD and CD in
childhood on adult delinquency:
A 30-year follow-up study using
official crime records
2011 Norway 541 Prospective  Children’s global assessment scale
(CGAS)
 Crime rates
Pardini Symptoms of conduct
disorder, oppositional defiant
disorder, ADHD and callous-
unemotional traits as unique
predictors of psychosocial
maladjustment in boys:
Advancing an evidence base for
DSM-IV
2010 USA 1,517 Prospective  Diagnostic interview schedule for
children, parent version (DISC-P)
 Child Behavior Checklist (CBCL)
 Official criminal records
 Self-report of delinquency (SRD)
 Teacher report form (TRF)
Patterson Hyperactive and antisocial
behaviors: Comorbid or two
points in the same process?
2000 USA 206 Prospective  Child Behavior Checklist (CBCL)
 Child delinquency
 Parent discipline
 Parent antisocial behavior
Satterfield A prospective study of
hyperactive boys with
conduct problems and normal
boys: Adolescent and adult
criminality
1997 USA 176 Prospective  Arrest rates
Satterfield A 30-year prospective follow-
up study of hyperactive boys
with conduct problems: Adult
criminality
2007 USA 254 Prospective  Official arrest records
Van Lier Onset of antisocial behavior,
affiliation with deviant friends
and childhood maladjustment
2007 Canada 316 Prospective  Self-reported-delinquency-
questionnaire (SRDQ)
 Reciprocal friends antisocial
behavior
 Social behavior questionnaire
(SBQ)
Cross-sectional studies
Barry The importance of callous-
unemotional traits for
extending the concept of
psychopathy to children
2000 USA 154 Cross-sectional  Diagnostic interview schedule for
children (DISC)
 Psychopathy Checklist Revised
(PCL:R)
 Sensation seeking scale for children
(SSS-C)
 Reward-dominance computer task
Bennett Reactive versus proactive
antisocial behavior: Differential
correlates of child ADHD
symptoms?
2004 USA 84 Cross-sectional  Antisocial behavior subtyping
scale
 Eyberg child behavior inventory
(ECBI)
Carlotta The role of impulsivity, sensation
seeking and aggression in the
relationship between childhood
ADHD symptom and antisocial
behavior in adolescence
2011 Italy 729 Cross-sectional  Wender Utah rating scale (WURS)
 Self-reported delinquency scale
(SRDS)
 Barratt-impulsivity scale-11-
adolescence
 Zuckermann-Kuhlmann sensation
seeking scale (SSS)
 Reactive-proactive aggression
questionnaire (RPQ)
 Stop signal task
Table 1. (continued)
(continued)
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Storebø and Roskilde 5
First author Article title Year Location n
Design and sample
source Methods and measures
Caspi A replicated molecular genetic
basis for subtyping antisocial
behavior in children with
ADHD
2008 England 2,232
and
1,037
Cohort and cross-
sectional
 Child and adolescent psychiatric
assessment
Eisenbarth Psychopathic traits in adult
ADHD patients
2008 Germany 71 Cross-sectional  Structural clinical interview of
DSM-IV (SCID-I and SCID-II)
 Psychopathic personality inventory
revised (PPI-R)
Faraone Attention-deficit disorder and
conduct disorder in girls:
Evidence for a familial subtype
1999 USA 262 Cross-sectional  Structural clinical interview of
DSM-IV (SCID-I and SCID-II)
 Kiddie schedule for affective
disorders and schizophrenia-
epidemiological version
(K-SADS-E)
Johansson Linking adult psychopathy with
childhood hyperactivity-
impulsivity-attention problems
and conduct problems through
retrospective self-reports
2005 Sweden 186 Cross-sectional  Psychopathy Checklist Revised
(PCL:R)
 Diagnostic interview of
personality-questionnaire (DIP-Q)
 Wender Utah rating scale (WURS)
Lindberg ADHD and sleep in homicidal
men with antisocial personality
disorder
2004 Finland 24 Cross-sectional  Sleep examination (PSG)
 Wender Utah rating scale for
ADHD (WURS)
Monuteaux Genetic risk for conduct
disorder symptom subtypes in
an ADHD sample: Specificity to
aggressive symptoms
2009 USA 444 Cross-sectional  Schedule for affective disorders
and schizophrenia for school-age
children-epidemiologic version
Sevecke The relationship between
attention deficit hyperactivity
disorder, conduct disorder and
psychopathy in adolescent male
and female detainees
2009 Germany 213 Cross-sectional  Psychopathy Checklist (PCL:YV)
 Diagnostic system for mental
disorders in childhood and
adolescence (DISYPS-KJ)
Semiz Effects of diagnostic comorbidity
and dimensional symptoms of
ADHD in men with antisocial
personality disorder
2008 Turkey 105 Cross-sectional  Wender Utah rating scale (WURS)
 Psychopathy Checklist Revised
(PCL:R)
 Conners adult rating scale
(CAARS)
 Structural clinical interview of
DSM-IV (SCID-I)
Soderstrøm Adult psychopathic personality
with childhood-onset
hyperactivity and conduct
disorder: A central problem
constellation in forensic
psychiatry
2003 Sweden 100 Cross-sectional  Structural clinical interview of
DSM-IV (SCID-I)
 Yale-Brown obsessive-compulsive
scale (Y-BOCS)
 Structural clinical interview of
DSM-IV (SCID-II)
 Psychopathy Checklist Revised
(PCL:R)
Vitacco Predictors of adolescent
psychopathy: The role of
impulsivity, hyperactivity and
sensation seeking
2001 USA 79 Cross-sectional  Psychopathy Checklist (PCL:SV
[screening version])
 BASC-self-report of personality
(BASC-SRP)
 Barratt-impulsiveness scale (BIS)
 Adolescent Symptom Inventory-
Youth Self-Report–Fourth edition
(ASI-4)
Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994); DSM-III-R = Diagnostic and Statisti-
cal Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987).
Table 1. (continued)
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6 Journal of Attention Disorders XX(X)
research does not determine whether the familial etiology
of ADHD + CD is genetic or environmental (Faraone et al.,
1997; Faraone et al., 1998).
The weaker evidence in the 13 crossover studies (n =
2,451) investigated different associations between ADHD and
ASPD (Barry et al., 2000; Bennett, Pitale, Vora, & Rheingold,
2004; Carlotta, Borroni, Maffei, & Fossati, 2011; Caspi et al.,
2008; Eisenbarth et al., 2008; Faraone, Biederman, &
Monuteaux, 2000; Johansson, Kerr, & Andershed, 2005;
Lindberg et al., 2004; Monuteaux, Biederman, Doyle, Mick,
& Faraone, 2009; Semiz et al., 2008; Sevecke, Kosson, &
Krischer, 2009; Soderstrom, Sjodin, Carlstedt, & Forsman,
2004; Vitacco & Rogers, 2001). Some of the studies focused
on the diagnosis and subtypes as they pointed out that the fre-
quent comorbidity between ADHD and CD raises the possi-
bility that ADHD + CD could be a separate condition as it is
the hyperkinetic subtype in ICD-10 but not in DSM-IV (4th
ed.; APA, 1994; Caspi et al., 2008; Faraone et al., 2000;
Monuteaux et al., 2009). In the study by Caspi et al., the
authors confirmed the presence of genetic heterogeneity in
ADHD, suggesting the evidence for clinically and biologi-
cally subtypes in ADHD; one of these are at high risk of
developing ASPD (Caspi et al., 2008). Faraone et al. (2000)
also underline the hypothesis that the ADHD syndrome com-
bined with CD in girls might be familiarly distinct from
ADHD only. In the study by Semiz et al. (2008), it was shown
that 65% of the ASPD adults measured by DSM-IV also met
the DSM-IV criteria for ADHD. A history of childhood
neglect, parental divorce, early maternal separation, and sui-
cide attempts were more common in ASPD participants with
comorbid ADHD (Semiz et al., 2008).
Carlotta et al. (2011) found that proactive aggression
mediated the relationship between a history of childhood
ADHD symptoms and antisocial behavior in the adolescence.
One study points out that ADHD and ASPD might share the
same nervous system deficit (Lindberg et al., 2004).
We also found studies investigating the relationship
between ADHD and psychopathy: Investigating impulsivity
Records idenfied through database
searching
(n = 746)
ScreeningIncluded Eligibility Idenficaon
Addional records idenfied through
other sources
(n = 2)
Records aer duplicates removed
(n = 591)
Records screened
(n = 591)
Records excluded
(n = 511)
Full-text arcles assessed for
eligibility
(n = 80)
Full-text arcles excluded,
with reasons
(n = 45)
Studies included in
qualitave synthesis
(n = 35)
18 Prospecve studies
13 Retrospecve studies
4 Reviews
Figure 1. PRISMA 2009 flow diagram.
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Storebø and Roskilde 7
as a predictor for ASPD, Vitacco and Rogers (2001) showed
that impulsivity was associated both with conduct problems
and with psychopathy. Sevecke et al. (2009) found sex dif-
ferences, where in males ADHD did not contribute to psy-
chopathy total scores. However, among females, ADHD
contributed independently to psychopathy total scores on the
Psychopathy Checklist, Youth Version (PCL:YV). These
results suggest a unique relationship between ADHD, where
callous-emotional traits and an impulsive irresponsive life is
mediating factors, and overall psychopathy in females.
Furthermore, this association was stronger in girls with few
CD symptoms (Sevecke et al., 2009). Eisenbarth et al.
(2008) investigated psychopathic traits in adults with ADHD
and found that these adults had psychopathic traits related to
CD and that the traits were related mostly to behavioral
aspects and not to the emotional aspects of psychopathy.
They also found sex differences in their data as the associa-
tion was not significant in females with ADHD (Eisenbarth
et al., 2008). One study showed that adult criminals diag-
nosed with ASPD were highly likely to have a history of
both ADHD and conduct problems but not either one alone
(Johansson et al., 2005).
Discussion
In our review, we included 18 prospective studies looking at
the association between ADHD and ASPD. This is in con-
trast to the review by Thapar et al. that included only few
prospective studies in their review. Most of the literature
underlined that CD together with ADHD also is a perquisite
for the development of ASPD. The two reviews by Rösler
and Retz (2008) stated that children with both ADHD and
comorbid CD are at risk of developing later ASPD, but chil-
dren with ADHD solely are not. In contrast to this, we found
studies describing that children with ADHD only also were
at high risk of later onset of ASPD. Some studies found that
ADHD when connected to ODD could lead to the develop-
ment of CD and that ADHD could be a risk factor for the
development of CD. CD is a strong predictor for ASPD.
Several studies presented results that pointed at a possible
developmental path from ADHD to ASPD. One study
underlined that this could be due to disrupted parental prac-
tice. There seems to be a more complicated disorder when
there is conduct problems together with the ADHD core
symptoms. In ICD-10, there is a subtype including conduct
disturbance called the “hyperkinetic disorder,” whereas in
DSM-V, there is no such subtype. This is possibly a weak-
ness in the new DSM-V, and there seems to be a need for a
more specific and detailed assessment of children’s con-
ducts difficulties. ADHD is partly a genetically derived
neuropsychiatric disorder (Lionel et al., 2011), and one can
speculate why some children with ADHD also develop con-
duct problems. The conduct problems might be due to envi-
ronmental factors as disrupting parental practice, but in
research, it is not determined whether the etiological factors
of ADHD and CD are based mostly on genetic or environ-
mental factors. A history of childhood neglect, parental
divorce, early maternal separation, and suicide attempts
seem to be more common in ASPD participants with comor-
bid ADHD, also without CD, but there seems to be a path-
way, as some children with ADHD also develop CD. Much
of the evidence in this review shows that the comorbidity
between ADHD and CD gives a much more complicated
disorder that often leads to the development of ASPD and/
or delinquency. It is important to investigate which factors
lead to the development of comorbid CD in children with
ADHD. Aggression, callous-emotional, and the degree of
impulsivity seem to be some important factors, and there is
a great need for further research in the genetic and environ-
mental factors. Most of the 18 prospective studies showed
that children with ADHD and comorbid CD were at
increased risk of adult criminality, whereas children with
solely ADHD are not. There seems to be no direct link
between ADHD and the later onset of criminality. ADHD
both together with CD and alone are a risk factor for the
development of ASPD. We have not found research investi-
gating the role of intervention, and the possibility that early
intervention could hinder the development of ASPD or CD.
Conclusion
There is an increased risk for children with ADHD with or
without comorbid CD to develop later onset of antisocial
personality disorder. Many earlier reviews have stated that
CD is a perquisite for later onset of ASPD in children with
ADHD, but we found studies with data showing that also
children with ADHD solely are at the risk of development of
the later onset of ASPD. Children with ADHD and comorbid
CD have increased risk of adult criminality, whereas chil-
dren with solely ADHD are not. No studies have looked at
the treatment of ADHD as a mediator of the risk for ASPD.
Appendix
PsycINFO
Database: PsycINFO <2002 to March Week 3 2012>
Search Strategy:
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1 adhd.ab. or adhd.si. or adhd.ti. (10028)
2 attention deficit disorder/ or exp attention deficit dis-
order with hyperactivity/ (9866)
3 exp Antisocial Personality Disorder/ (1547)
4 1 or 2 (11386)
5 3 and 4 (50)
***************************
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8 Journal of Attention Disorders XX(X)
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Ole Jakob Storebø, PhD, is a clinical psychologist and senior
researcher at Child and Adolescent Psychiatric Department and
Psychiatric Research Unit, Region Zealand.
Erik Simonsen, MD, PhD, Dr.h.c., is a professor at Roskilde
University and Head of Psychiatric Research Unit, Region Zealand.
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