Youth Violence and Juvenile Justice: Psychopathy and ADHD in Adolescent Male Offenders

Youth Violence and Juvenile Justice
http://yvj.sagepub.com Psychopathy and ADHD in Adolescent Male Offenders

Sebastian G. Kaplan and Dewey G. Cornell Youth Violence and Juvenile Justice 2004; 2; 148 DOI: 10.1177/1541204003262225 The online version of this article can be found at: http://yvj.sagepub.com/cgi/content/abstract/2/2/148
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Kaplan, Cornell / PSYCHOPATHY Youth Violence and Juvenile ARTICLE 10.1177/1541204003262225 Justice AND ADHD IN MALE OFFENDERS
PSYCHOPATHY AND ADHD IN ADOLESCENT MALE OFFENDERS

Sebastian G. Kaplan Dewey G. Cornell
University of Virginia
What is the relationship between psychopathy traits and attention deficit/hyperactivity disorder (ADHD) in juvenile offenders? The authors examined psychopathy scores, as measured by the Psychopathy Checklist: Youth Version and three indices of ADHD in 122 incarcerated male juvenile offenders. In addition, we investigated whether psychopathy and ADHD predicted violent behavior. Psychopathy Checklist: Youth Version Total and Factor 1 scores did not correlate with measures of ADHD, although Factor 2 scores were weakly associated with two of three ADHD indices. Psychopathy Checklist: Youth Version scores, but not ADHD indicators, were correlated with violent behavior. Keywords: psychopathy; attention deficit/hyperactivity disorder; juvenile offenders; violence
What is the relationship between psychopathy and attention deficit/hyperactivity disorder (ADHD)? The construct of psychopathy has received increased attention in recent years (Hare, 1998; Seagrave & Grisso, 2002). Research with the Psychopathy ChecklistRevised (PCL-R) (Hare, 1991) typically identifies two classes of personality characteristics as core components of psychopathy; traits such as callousness and superficial charm distinguish an interpersonal style associated with Factor 1 of the Psychopathy Checklist, and poor anger control and impulsivity reflect an antisocial pattern of behavior associated with Factor 2 (Hare, 1999). Research has attempted to apply the construct of psychopathy to children and adolescents (Frick, Bodin, & Barry, 2000; Lynam, 1997). Lynam (1996) proposed that children exhibiting a combination of hyperactivity, impulsivity, and attention deficits (HIA), as well as conduct problems (CP) are afflicted with a virulent strain of conduct disorder best described as fledgling psychopathy(p. 209). These children show many of the attributes found in adult psychopaths, such as earlier onset of behavior problems, and a more severe and diverse repertoire of antisocial behaviors (Lynam, 1996), as well as higher rates
Authors Note: We thank Dr. Dennis Waite, Dr. Livia Jansen, and the staff and youths at the Reception and Diagnostic Center in Richmond, Virginia, for their participation in this study. We also thank Dr. Daniel Murrie, David McConville, and Andrea Levy-Elkon for their assistance throughout this project. Correspondence concerning this article should be directed to Sebastian G. Kaplan, Programs in Clinical and School Psychology, Curry School of Education, University of Virginia, 405 Emmet Street, Charlottesville, VA 22903-2495; e-mail: sgk4j@ virginia.edu.
Youth Violence and Juvenile Justice, Vol. 2 No. 2, April 2004 148-160 DOI: 10.1177/1541204003262225 2004 Sage Publications
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Kaplan, Cornell / PSYCHOPATHY AND ADHD IN MALE OFFENDERS
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of self-reported delinquency (Lynam, 1998). However, Lynam used a community sample of preadolescents and did not use any form of the Psychopathy Checklist to measure psychopathy. Barkley (1998) described ADHD children and adults as experiencing persistent problems with inattention and/or impulsivity-hyperactivity. Symptoms often found in individuals with ADHD include being easily distracted, acting as if driven by a motor, and often interrupting or intruding on others (American Psychiatric Association, 2000). Burns (2000) raised the argument that measures of psychopathy and ADHD might be correlated because they have overlapping items. Certainly items such as need for stimulation and impulsivity on Factor 2 of the Psychopathy Checklist correspond with symptoms of ADHD. Therefore, it is important to examine to what extent persons with high psychopathy scores also meet diagnostic criteria for ADHD and whether the construct of psychopathy has predictive validity beyond what can be attributed to ADHD symptomatology. Study of the relationship between psychopathy and ADHD is important to understanding developmental processes involved in psychopathy and might be useful in identifying early forms of intervention for juveniles exhibiting psychopathy-like characteristics. Seagrave and Grisso (2002) noted the lack of adequate knowledge about the construct of juvenile psychopathy and raised cautions about the clinical use of a concept that has not yet been adequately studied. Characteristics such as impulsivity and inattention are particularly problematic because it can be difficult to distinguish clinically significant impulsivity and inattention from similar behaviors that are within normal limits. Nevertheless, previous research provides evidence that comorbid conditions of ADHD and conduct disorder may lead to earlier onset of conduct disorder symptoms (Thompson, Riggs, Mikulich, & Crowley, 1996), higher number of arrests (Forehand, Wierson, Frame, Kempton, & Armistead, 1991), more physical fighting (Walker, Lahey, Hynd, & Frame, 1987), a diverse pattern of antisocial behavioral (Walker et al., 1987), and an increased risk of developing antisocial personality disorder and psychopathy in adulthood (Vitelli, 1998). Christian, Frick, Hill, Tyler, and Frazer (1997) identified a group of children they believed had psychopathic characteristics. They assessed impulsive-CP and callousunemotional traits, as well as conduct disorder/oppositional defiant disorder symptoms in a group of 120 clinic-referred children. Children with elevations on all three areas constituted the psychopathic conduct cluster (n = 11) and showed significantly higher numbers of oppositional, aggressive, and covert property-destructive symptoms than the children with elevations on impulsive-conduct problem traits alone. In addition, 100% of the children in the psychopathic conduct cluster had diagnoses of ADHD. McBride (1998) assessed the relationship between ADHD (or in some older cases, attention deficit disorder, ADD) and psychopathy using a sample of 233 adolescent offenders mandated to a sex offender treatment program. ADHD/ADD diagnoses were based on routine assessments conducted by staff clinicians. Psychopathy, as measured by a file review using the Psychopathy Checklist: Youth Version (PCL-YV) (Forth, Kosson, & Hare, in press), was correlated with the presence or absence of ADHD or ADD (r = .40). In addition, psychopathic offenders were 3 times more likely to receive a diagnosis of ADHD or ADD (57%) when compared to a nonpsychopathic group (18%). Although the current study suggests a relationship between juvenile psychopathy and ADHD in sex offenders, more research is needed to investigate this relationship in a broader juvenile offender population.
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Instrumental Versus Reactive Violence The relationship between psychopathy and violent behavior is well documented (Hare, 1996, 1998). Moreover, psychopathy is most strongly associated with instrumental or goal-directed forms of violent crime as opposed to more reactive or hostile forms of violence (Cornell et al., 1996; Williamson, Hare, & Wong, 1987). Instrumental violent crime refers to criminal behavior such as a robbery in which violence serves as a means of obtaining an external goal, such as money or valuables. In contrast, a reactive violent crime is motivated by anger, revenge, or frustration in which the violent act is intended primarily to harm the victim. Few studies have examined instrumental versus reactive violence in relation to juvenile psychopathy. Stafford and Cornell (2003) found that adolescent inpatients with elevated psychopathy scores displayed higher rates of overall aggression, and instrumental and reactive violence, than other adolescent inpatients. Murrie (2002) found statistically significant relationships between psychopathy scores, as measured by the PCL:YV, violent offenses, as well as instrumental violence in incarcerated juvenile offenders. Do differences in instrumental and reactive violence exist between youth with ADHD and youth without ADHD? Atkins and Stoff (1993) assessed instrumental and hostile acts of aggression in children with conduct disorders (ages 8 to 12 years) who were identified as positive or negative for ADHD. Children with ADHD and those without ADHD had significantly higher instrumental acts of aggression than normal controls. Only the ADHD group had significantly higher hostile acts than the control group. It would be useful to know whether ADHD is associated with higher rates of reactive aggression among juvenile offenders and whether ADHD contributes to an increased level of aggression among juvenile offenders who score high on psychopathy. The current study addressed two primary research questions in a juvenile offender population: (a) What is the relation between ADHD and ratings of youth psychopathy? and (b) How does the presence of ADHD influence the relationship between psychopathy and violent behavior? Method Participants The participants in the current study were 122 male adolescents, ages 13 to 18 years, with an average age of 16.0 years (SD = 1.13), incarcerated in the Reception and Diagnostic Center of the Virginia Department of Juvenile Justice. Of the participants, 48 were White, 65 were African American, 6 were Hispanic, and 3 were of other ethnic backgrounds. Of these participants, 64% had a violent offense on record, and 15% had a history of sex offending. Twenty-five percent of participants had a recorded clinical diagnosis of ADHD, 32% had oppositional defiant disorder, 61% had conduct disorders, and 33% had a mood disorder. Of participants, 24% had a dual diagnosis of ADHD and conduct disorder, and another 6% had a dual diagnosis of ADHD and oppositional defiant disorder. We selected participants randomly from consecutive weekly intake rosters, provided they met the following criteria: (a) not presently psychotic, (b) full scale IQ score above 70, (c) consent from parent or guardian, and (d) consent from adolescent. We did not exclude any participants because of psychosis; however, we did exclude 16 youths because clinical records indicated cognitive functioning in the mentally retarded range; 20 because a parent
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or guardian denied permission for the study; and 17 because the adolescent declined to participate. In addition, six participants who were interviewed using the PCL:YV could not be included in our data analyses because of missing diagnostic information in their clinical record. Measures PCL:YV. The PCL:YV evolved from attempts to adapt the PCL-R for use with child and adolescent populations (Chandler & Moran, 1990; Forth, Hart, & Hare, 1990; Trevothan & Walker, 1989). Forth and Mailloux (2000) summarized findings from research using the PCL:YV that found that psychopathy total scores in incarcerated samples were substantially higher than scores from community samples and that young offender and community adolescent psychopathy total scores were significantly correlated with number of conduct disorder symptoms (r = .52 and .75, respectively), and number of aggressive conduct disorder symptoms (r = .47 and .38, respectively). Forth and Mailloux (2000) obtained a two-factor structure of the PCL:YV consistent with previous findings using the adult scale. Factor 1 can be considered an interpersonal/ affective dimension and includes items such as glibness/superficial charm, grandiosity, manipulativeness, dishonesty, and callousness. Factor 2 reflects behavioral or lifestyle features, such as impulsivity, irresponsibility, early behavioral problems, a lack of goals, and a history of juvenile delinquency (Forth et al., in press). We followed the standard administration and scoring procedures for the PCL:YV (Forth et al., in press). Following a semistructured clinical interview and review of correctional files, we scored each item 0, 1, or 2 depending on how strongly the item applied to the individual and then summed the item scores to arrive at a total score. Forth and Burke (1998) provided a summary of reliability information from various studies with the PCL:YV showing the measure has satisfactory internal consistency ( = .75 to .90), interitem reliability (r = .13 to .33), and interrater reliability (r = .90 to .98). Following the review of five videotaped cases for training purposes, four raters (clinical psychology doctoral students) independently scored 10 cases to determine interrater reliability of their PCL:YV Total scores. Three pairs of interviewers obtained intraclass correlations of .98, .96, and .98 for 10 cases. To address possible coder drift, each pair of researchers conducted another reliability study near the end of data collection and obtained intraclass correlations of .98, .99, and .95 for another six cases. Table 1 shows descriptive statistics for study measures. Measures of ADHD. We used three variables that measured characteristics of ADHD within our sample: (a) diagnosis of ADHD, (b) history of psychostimulant medication, and (c) the ADH scale of the Personality Inventory for Youth (PIY) (Lachar & Gruber, 1995). All incarcerated youth underwent a routine, extensive evaluation over a 30- to 45-day period at the state correctional facility. The evaluations provided diagnoses of ADHD, if applicable, based on diagnostic interviews by clinical staff members, behavioral observations by direct care staff members, and review of clinical, legal, and educational records. In addition, institutional records contained medication history for each juvenile, including use of psychostimulants used in the treatment of ADHD. All youth completed the PIY as part of their intake evaluation. The PIY is a multidimensional self-report used to evaluate children and adolescents from 9 to 18 years of age.
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Youth Violence and Juvenile Justice TABLE 1 Descriptive Statistics (n = 122)
Variable PCL:YV PCL:YV Total score PCL:YV Factor 1 score PCL:YV Factor 2 score PIY ADH scale Diagnosis of ADHD? No Yes Psychostimulant medication? No Yes
M 21.79 7.85 7.42 50.74
SD 6.99 3.72 2.72 10.98
Min 8 1 2 33
Max 37 16 13 82
Frequency
92 30 70 52
75.4 24.6 57.4 42.6
NOTES: ADHD = attention defict/hyperactivity disorder; PCL:YV = Psychopathy Checklist: Youth Version; PIY = Personality Inventory for Youth.
The PIY consists of 270 true-false items written at a third-grade reading level, which takes roughly 45 min to complete. The PIY contains the ADH scale, also called the Impulsivity/ Distractibility scale, to measure inattention, impatience, impulsivity, and bravado (Lachar & Kline, 1994). The ADH scale is a self-report version of the Hyperactivity scale on the Personality Inventory for Children (PIC) (Lachar, 1982), which Breen and Barkley (1984) found to be a valid measure of hyperactive behavior in children. Lachar and Gruber (1993) found a statistically significant correlation of .34 between the ADH scale of the PIY and the Hyperactivity scale of the PIC, whereas Lachar and Kline (1994) found statistically significant correlations between the ADH scale and the Disinhibition subscale of the Sensation Seeking Scale V (SSS) (Zuckerman, 1979) and the Uncontrolled subscale of the Personal Experience Inventory (PEI) (Winters & Henley, 1989) (r = .51 and .56, respectively). Assessment of Violent Behavior Institutional aggression. We collected staff ratings of institutional aggression using an adapted version of the Overt Aggression Scale (OAS) (Yudofsky, Silver, Jackson, Endicott, & Williams, 1986; as modified by Stafford & Cornell, 2003), which provides a total aggression score as well as scores for six categories: verbal aggression, physical aggression against objects, physical aggression against self, physical aggression against peers, physical aggression against staff members, and other aggression. Institution staff members (direct care workers and mental health clinicians) recorded the frequency and severity of aggressive behavior on a 4-point scale during their regular, weekly evaluation team meetings. The OAS ratings were included as part of the forms and records completed on each youth in the course of their evaluation at the facility. The ratings were determined by consensus of the staff in attendance at the team meetings. We evaluated the interrater reliability of the OAS by having two correctional facility staff members independently complete the OAS for 20 participants. Intraclass correlations for the OAS Total and subscale scores were as follows: Total Score = .88, Verbal Aggression = .80, Aggression
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Against Objects = .53, Aggression Against Self = 1.0, Aggression Against Staff = .89, Aggression Against Peers = .73, and Other Aggression = .77. In addition to the OAS, we reviewed the institutional discipline record from each participants file for the presence of violent infractions while incarcerated, defined as any altercation involving a threat of violence or actual contact with another peer or staff member. Violent infractions took place either during the 4- to 6-week evaluation at the Reception and Diagnostic Center or during previous periods of incarceration. From file reviews, we categorized 51 youths as violent while incarcerated, defined as committing at least one violent act during their stay at the correctional facility, and 65 youths as not violent while incarcerated. We excluded 6 of the 122 participants from this analysis because of insufficient information. Violence history. Based on file review, we coded participants criminal charges as violent (n = 78) or nonviolent (n = 39). Examples of violent crimes were robbery, assault, sex offenses, and malicious wounding. Examples of nonviolent crimes were statutory offenses, such as driving without a license, truancy, alcohol- and cigarette-related offenses, disorderly conduct, nonviolent probation violations, and crimes involving the use and distribution of controlled substances. We excluded 5 of 122 cases for this analysis because of insufficient information in the records. Based on the review of other institutional records (including school reports, court evaluations, and medical and mental health evaluations) researchers also rated whether participants violence history was reactive (n = 50) or instrumental (n = 39). Ratings of violence history included criminal behavior for which the adolescent was charged, as well as incidents of unadjudicated violent behavior, such as fights in school or in the correctional facility. We placed participants in the reactive violence category when a youths file only mentioned violent incidents that were committed in the context of an interpersonal disagreement. For youths coded as having committed instrumental violence, we found at least one incident where violence was used as a means to an end, as in the case of robbery or sexual assault (Cornell et al., 1996). Interrater reliability for 16 cases was 100% in distinguishing between reactive or instrumental violence. We were unable to classify 33 of 122 cases because the files lacked sufficient information to distinguish reactive from instrumental violence. Procedure Prior to conducting the PCL:YV interviews, we reviewed each participants file to gather information, such as offense history, family background, school history, and previous evaluations. At the start of each interview, we explained that we were conducting a study about adolescents in correctional institutions, and each participant signed an assent form. Participants were ensured that the researchers had no affiliation with the Department of Juvenile Justice, their answers would remain confidential, and their names would not appear on any reports. When the interviews were completed, we conducted a second round of file reviews to categorize participants based on instrumental, reactive, or nonviolent behavior. In the second round of file reviews, researchers were blind to the PCL:YV scores of the participants whose files they reviewed; that is, a researcher who conducted a PCL:YV interview for a particular participant did not review that individuals file during the second round of file reviews.
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Results PCL:YV and ADHD We conducted three sets of analyses to investigate the relationship between psychopathy and three separate measures of ADHD. The first analysis involved comparisons of psychopathy scores (PCL:YV Total, Factor 1, and Factor 2 scores) for youths with and without a diagnosis of ADHD. The second analysis compared psychopathy scores of participants with and without a history of psychostimulant medication. The third analysis correlated psychopathy scores with the ADH scale of the PIY. We recognized that ADHD is a controversial and challenging diagnosis and that different observers and different diagnostic approaches often do not agree on the presence of ADHD symptoms (Barkley, 1998; Gomez, Burns, Walsh, & Alves de Moura, 2003). No single approach to diagnosis appears to be superior to all others. Therefore, we elected to use three separate, although not independent, indices of ADHD, so that the limitations of any one index would not prevent us from identifying a relationship between ADHD and psychopathy. These three indices identified somewhat different groups of youths. For example, 52 of 122 juveniles had a history of taking psychostimulant medication, however only 30 of 122 juveniles were diagnosed with ADHD by the clinical staff of the correctional institution, and only 24 juveniles had a history of taking psychostimulant medication and receiving a staff diagnosis of ADHD. The point-biserial correlation between a clinical diagnosis of ADHD and the PIYs ADH scale was .30. The correlation between previous psychostimulant medication and the ADH scale was .22. The relatively weak associations among the ADHD indicators is not surprising given recent research concerning the small levels of trait variance compared to source variance in ADHD symptoms using different sources of diagnostic information (Gomez et al., 2003). We also considered the possibility of combining the ADHD indicators into a more comprehensive measure. We conducted analyses distinguishing youths who met at least two of the ADHD criteria, and then we did additional analyses using youths who met all three of the ADHD criteria, however, none of these analyses produced substantially different results than the findings presented here. One-tailed t tests revealed that mean PCL:YV Total and Factor 1 scores did not differ significantly for participants who did or did not meet criteria for ADHD; however, differences between mean Factor 2 scores were statistically significant, t(120) = 2.46, p < .05, and accounted for 7% of the variance. Mean PCL:YV Total, t(120) = 1.80, p < .05; Factor 1, t(120) = 2.34, p < .05; and Factor 2, t(120) = 2.10, p < .05, scores were significantly higher for participants with a history of psychostimulant medication use and each accounted for 2%, 4%, and 3% of the variance, respectively (see Table 2). The PCL:YV Total and factor scores did not correlate significantly with the PIYs ADH scale; for Total scores, the correlation coefficient was .08, for Factor 1 it was .02, and for Factor 2 it was .15. Institutional Aggression To predict staff ratings of violence using the OAS Total and subscale scores, we used the following variables: PCL:YV Total scores, diagnosis of ADHD, history of psychostimulant medication, and ADH Total scores. The regression equation used to predict OAS Total scores was not statistically significant, F(4, 112) = 1.15, p > .33, nor were any of the regression equations for the OAS subscale scores.
Kaplan, Cornell / PSYCHOPATHY AND ADHD IN MALE OFFENDERS TABLE 2 Psychopathy Scores of ADHD and non-ADHD Juvenile Offenders
PCL:YV Total Score M (SD) ADHD Diagnosis Yes (n = 30) No (n = 92) History of Medication Yes (n = 52) No (n = 70) 23.6 (6.45) 21.2 (7.10) 23.1 (7.55) 20.8 (6.43) t Value 1.62 1.80* R
2
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Factor 1 M (SD) 8.57 (3.50) 7.62 (3.78) 8.75 (3.88) 7.19 (3.47) t Value 1.21 2.34* R
2
Factor 2 M (SD) 8.48 (2.59) 7.09 (2.68) 8.02 (2.84) 6.99 (2.56) t Value R
2
.03 .02
.02 .04
2.46* .07 2.10* .03
NOTES: ADHD = attention deficit/hyperactivity disorder; PCL:YV = Psychopathy Checklist: Youth Version; PIY = Personality Inventory for Youth. Correlations between the PIY ADH scale and PCL:YV Total (r = .08), Factor 1 (.02), and Factor 2 (.15) scores were not significant. *p < .05.
We conducted a three-step logistic regression analysis to examine whether PCL:YV scores improved the prediction of institutional assault beyond indicators of ADHD, with results shown in Table 3. After entering age in Step 1, we entered diagnosis of ADHD, history of psychostimulant medication, and ADH scale elevations at Step 2, none of which were statistically significant predictors of institutional assault. However, PCL:YV Total scores were predictive of assault when entered at Step 3, with the full model accounting for 20% of the variance. The ability of the PCL:YV to predict institutional aggression was analyzed in more detail by Murrie (2002); the current study is concerned only with the effect of including ADHD indicators in the prediction model. Violent Criminal Behavior We also used logistic regression analyses to predict history of violent crime and instrumental versus reactive violence (see Table 3). For history of violent offenses, neither age nor the three ADHD variables were predictive of group membership, however, PCL:YV Total scores did significantly predict a violent offense history when included at Step 3, with the full model accounting for 10% of the variance. In terms of instrumental versus reactive violence, neither age at Step 1 nor the three ADHD indicators at Step 2 were predictive of group membership. However, when PCL:YV Total scores were added to the logistic regression equation at Step 3, psychopathy scores and history of psychostimulant medication significantly improved the prediction accuracy for group membership. Juveniles with a medication history were more likely to have committed reactive offenses. The full model at Step 2 accounted for 17% of the variance in predicting instrumental versus reactive violent behavior. Discussion The current study found evidence of a weak relationship between psychopathy and ADHD. We found that our indices of ADHD were associated with Factor 2 scores, but not total scores or Factor 1 scores, on the PCL:YV. Factor 2 scores of the PCL:YV were signifi-
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Youth Violence and Juvenile Justice TABLE 3 Prediction of Institutional and Offense Violence With Psychopathy and ADHD
Wald Statistic SE R
2
Hosmer-Lemeshow .97 2.74
Institutional assault Step 1 Age Step 2 Age ADHD diagnosis Psychostimulant medication ADH scale Step 3 Age ADHD diagnosis Psychostimulant medication ADH scale PCL:YV Violent offense Step 1 Age Step 2 Age ADHD diagnosis Psychostimulant medication ADH scale Step 3 Age ADHD diagnosis Psychostimulant medication ADH scale PCL:YV Instrumental or reactive Step 1 Age Step 2 Age ADHD diagnosis Psychostimulant medication ADH scale Step 3 Age ADHD diagnosis Psychostimulant medication ADH scale PCL:YV
1.74 .60 .51 1.04 .88 .82 .21 .41 .90 10.86***
.22 .14 .36 .44 .02 .17 .24 .30 .02 .11
.17 .18 .51 .43 .02 .18 .54 .46 .02 .03
.02 .07
.20**
15.42
.01 .04 2.42 .00 1.96 .02 2.01 .04 2.25 4.14*
.02 .04 .90 .01 .03 .02 .85 .10 .03 .06
.17 .18 .58 .46 .02 .19 .60 .47 .02 .03
.00 .05
.67 14.25
.10
6.90
.27 .03 .49 2.37 1.34 .00 .40 4.20* 2.23 7.00**
.10 .03 .42 .79 .03 .01 .40 1.17 .04 .10
.19 .20 .59 .51 .02 .21 .64 .57 .02 .04
.00 .07
.08 7.12
.17*
12.17
NOTES: ADHD = attention deficit/hyperactivity disorder; PCL:YV = Psychopathy Checklist: Youth Version. Follow-up analyses indicated that there were no statistically significant interactions between psychopathy scores and any of the three ADHD indicators. *p < .05. **p < .01. ***p < .001.
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cantly higher for participants with an ADHD diagnosis and history of psychostimulant medication. Factor 2 measures behavioral elements of psychopathy, such as impulsivity and need for stimulation, which are common characteristics of individuals with ADHD, so some degree of correspondence would seem inevitable. This relationship was not very powerful, because juvenile offenders with a diagnosis of ADHD did not obtain significantly higher total psychopathy scores, and there was no relationship between ADHD and other characteristics of psychopathy. Indicators of ADHD had a negligible effect on the prediction of violent behavior in comparison to ratings of juvenile psychopathy. For example, indicators of ADHD were not predictive of violent institutional behavior; however, the addition of psychopathy scores did improve the prediction of violence while incarcerated. Only one regression analysis generated support for the value of the ADHD indicators. PCL:YV Total scores and psychostimulant medication made statistically significant contributions to the distinction between instrumental and reactive violence. Psychopathy scores were associated with instrumental violence whereas psychostimulant medication history was associated with reactive violence. This finding suggests a potential disassociation between psychopathy and ADHD because they are associated with different forms of aggressive behavior. Why do juvenile offenders with a history of psychostimulant medication score higher on Factor 2 of the PCL:YV? This association may be an artifact of the overlap in symptoms of impulsivity and poor self-control used to diagnose both conditions. Impulsivity is not specific to ADHD; the DSM-IV criteria for ADHD recognize that symptoms of ADHD can be due to a variety of other disorders (American Psychiatric Association, 2000). Moreover, it is also possible that youths with psychopathy engage in so much impulsive, disruptive behavior that authorities are led to believe that the youths have ADHD and attempt to treat their behavior problems with medication. We observed that the mental health staff at the correctional institution did not diagnose ADHD in 28 of the 52 juveniles who had a history of being treated with psychostimulant medication. We also considered whether the ADHD indicators would have predicted aggression if entered before psychopathy. Therefore, we reversed the order of entry for all three logistic regression analyses (institutional assault, violent offenses, and instrumental vs. reactive violence) and entered PCL:YV scores at Step 3 and ADHD indicators at Step 3, after controlling for age at Step 1. In these analyses, the addition of ADHD indicators at Step 3 was not statistically significant, although PCL:YV scores were statistically significant predictors at Step 2. There are several limitations to the current study. We relied on diagnoses of ADHD assigned by the clinical staff; and although they conducted careful evaluations and had the benefit of several weeks of observation, we were not able to conduct a reliability study or use standardized clinical interviews. Future studies might use a more standardized diagnostic process as well as consider the influence of other mental disorders. Another study limitation was our reliance on archival data for several of our measures of violent behavior; records sometimes had missing information, and of course it is likely that some violent incidents were not observed or not recorded. All these limitations would tend to lessen the strength of relationships examined in the current study. Another important limitation is the file review conducted in association with the psychopathy interview. Because part of the standard procedure in administering the PCL:YV is the review of a juveniles file, the interviewers knowledge of the juveniles violence history could influence ratings of psychopathy. This is a common limitation in studies of psy-
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chopathy and violence history; however, there is evidence that the relationship between prior violence and psychopathy is not an artifact of knowing the subjects history of violence. Cornell et al. (1996) demonstrated a relationship between psychopathy and instrumental violence even when psychopathy raters were blind to the offenders offense history. Despite great interest in the relationship between ADHD and psychopathy, we know of no published study of ADHD, or youth with ADHD-like symptoms, that used one of the Hare psychopathy checklists to measure psychopathy. This is a serious gap in the effort to link ADHD symptoms to psychopathy. The lack of a strong link between PCL:YV scores and ADHD indicators in the current study tends to contradict the theory that there is an intrinsic relationship or developmental pathway that leads from inattention and impulsivity to psychopathy. In conclusion, we believe that clinicians involved with the juvenile justice system should be cautious about claiming a causal link between psychopathy and ADHD; we found a modest overlap in symptoms, but nothing similar to the strong relationship one would expect if psychopathy were a developmental consequence of hyperactivity and impulsivity. The weak association between ADHD and psychopathy that we found indirectly supports the discriminant validity of the PCL:YV. Despite the overlap in symptomatology between psychopathy and ADHD, the inclusion of PCL:YV scores greatly improved the identification of violent behavior in male juvenile offenders over and above the prediction made by ADHD indicators, which had no statistically significant predictive ability by themselves. Our results suggest that the construct of juvenile psychopathy as assessed by the PCL:YV contains important information that is not found in measures of ADHD symptoms. We recommend that future studies of the relationship between juvenile psychopathy and ADHD symptoms use the PCL:YV to tap this information.
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