association of testosterone and dihydrotestosterone with externalizing behavior in adolescent boys...

Psychoneuroendocrinology 28 (2003) 932–940www.elsevier.com/locate/psyneuen

Association of testosterone anddihydrotestosterone with externalizing behavior

in adolescent boys and girls

Athanasios Marasa,∗, Manfred Lauchta, Dirk Gerdesa,Cindy Wilhelma, Sabina Lewickab, Doris Haackb,

Lucie Malisovab, Martin H. Schmidta

a Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of MentalHealth, P.O. Box 122120, 68072 Mannheim, Germany

b Institute of Pharmacology, University of Heidelberg, INF 366, 69120 Heidelberg, Germany

Received 10 July 2002; accepted 22 September 2002

Abstract

Background: While an association between androgens and different types of aggression hasbeen well documented in male offenders, the influence of androgens on externalizing behaviorin adolescents at risk for antisocial behavior has not been investigated so far.

Methods: Plasma levels of the main androgen metabolites testosterone (T) and 5α-dihydrote-stosterone (DHT) were measured inN = 87 fourteen-year-old (36 boys, 51 girls) from a pro-spective longitudinal study of children at risk. Externalizing behavior at age 8, 11 and 14was assessed using the Achenbach Child Behavior Checklist (CBCL) and Teacher ReportForm (TRF).

Results: Significant higher androgen levels (T, DHT) were found in male, but not in femaleadolescents with elevated scores of externalizing behavior. Moreover, boys with persistentexternalizing behavior exhibited the highest levels of plasma androgens.

Conclusions: There is a link between T, DHT and externalizing behavior in male adolescentsat risk for psychopathology. Due to the findings of highest androgen levels in boys with persist-ent externalizing behavior, a role of androgens in the development of disruptive or later anti-social disorders can be hypothesized. 2003 Elsevier Science Ltd. All rights reserved.

∗ Corresponding author. Tel.:+49-621-1703247, fax:+49-621-23429.E-mail address: [email protected] (A. Maras).

0306-4530/03/$ - see front matter 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S0306-4530(02)00119-1

933A. Maras et al. / Psychoneuroendocrinology 28 (2003) 932–940

Keywords: Aggression; Delinquency; Androgens; Child psychiatry; Adolescence

1. Introduction

Although there is clear evidence from animal studies that androgens provide bothorganizational and activational effects on aggressive behavior (Brain and Haug,1992), the available findings in humans are inconclusive (review by Archer, 1991;Rubinow and Schmidt, 1996). The human concept of ‘aggression’ or ‘aggressiveness’comprises different facets of a complex behavior pattern subsuming various formsof disturbed social interactions like proactive, reactive, instrumental, verbal, physical,overt and covert kinds of aggression. Moreover, in studies establishing a positivelink between androgens and aggression elements of violent, destructive, dominant,hostile, delinquent and antisocial behavior are involved as well (Mattson et al., 1980;Christiansen and Knussmann, 1987; Dabbs and Morris, 1990; Dabbs et al., 1991).In humans, far more than in animals, the manifestation of aggression is influencedby learning processes during socialization. Besides interindividual differences, typesof aggressive behavior can be combined at one time and are changing in their occur-rence over life span intraindividually. Especially in children and adolescents runningthrough stages of social and biological development within a short time, aggressivebehavior can vary considerably, although it has been shown that aggressiveness isone of the most stable personality traits during the course of life (Huesmann etal., 1984).

In child and adolescent psychiatry the term externalizing problems reflects one ofthe two main dimensions of psychopathology that have been detected in multivariateanalyses of behavior problems in children and adolescents subsuming both delinquentand aggressive behavior (Achenbach, 1991). Higher levels of externalizing behaviorin children and adolescents have been shown to predict violence and criminality inadulthood (Loeber and Hay, 1997).

Few studies provide evidence of androgen effects on child and adolescentbehavior. Published findings are mainly confined to children from clinical samplesand results are inconsistent (Susman et al., 1987; Olweus et al., 1988; Constantinoet al., 1993; van Goozen et al., 1998, 2000). So far, longitudinal studies investigatingthe link between androgens and behavior outcomes in non-clinical samples are miss-ing. Moreover, various androgen and epiandrosterone metabolites can display differ-ent and in part additive effects on brain organization and activation. Thus, it isreasonable to measure at least the concentration of testosterone (T) and 5alpha-dihyd-rotestosterone (DHT), both strongly effecting fetal and perinatal brain developmentand later brain function and plasticity ( Swerdloff et al., 1992; Rubinow and Schmidt,1996; Fitch and Denenberg, 1998).

The aim of the present study was to investigate the influence of androgens onexternalizing behavior in adolescents at risk for later antisocial development. Andro-gen levels, controlled for gender and Tanner status, were compared between groupsdefined by their intensity of aggressive and delinquent behavior as measured by

934 A. Maras et al. / Psychoneuroendocrinology 28 (2003) 932–940

parent and teacher ratings. Both, concurrent behavior as well as the persistence ofbehavior were considered.

2. Methods

2.1. Participants

Information regarding psychopathology and development has been taken from anongoing longitudinal study of children at risk for later psychopathology. A total of362 infants from the Rhine-Neckar region of Germany born between February 1st,1986, and February 28th, 1988, were recruited from two obstetric and six children’ shospitals providing medical care for about two million people. Infants were includedconsecutively into the study according to a two-factorial design intended to enrichand control the risk status of the sample. As a result, about two thirds of the studysample had experienced moderate to severe pre- and perinatal complications suchas preterm birth or neonatal asphyxia, while about two thirds of the families sufferedfrom psychosocial adversities such as marital discord or chronic difficulties. Infor-mation on the risk status was derived from maternal obstetrical and infant neonatalrecords as well as from standardized parent interviews. To control confoundingeffects of family environment and infant medical status only firstborn singletons ofGerman speaking parents with no severe physical handicaps, obvious genetic defectsor metabolic diseases were selected. Participation rate at the time of recruitmentwas 64.5% with a slightly lower rate in parents from psychosocially disadvantagedbackgrounds. All families were Caucasian and the majority were of low socio-econ-omic status. Additional details on this sample have been reported previously (Lauchtet al., 1997).

At the time of the current investigation, participants were 14 years old. Earlierassessments had been conducted at the ages of three months, two, four-and-a-half,eight, and eleven years. At age eleven a total of 343 children of the original samplewere followed up (i.e. retention rate = 94.8%). The subsample of adolescentsdescribed here (N = 87; 36 male, 51 female) represents the first hundred cases fromthe ongoing 14-year-assessment. The percentage of those who refused to give bloodwas 13%. Exclusion criteria were any neurological impairment and an IQ � 80. Thestudy was approved by the ethics committee of the University of Heidelberg. Parentsand participants gave written informed consent. For further description of the samplesee Table 1.

2.2. Assessment

The Child Behavior Checklist (CBCL) was completed by the children’s primarycaregiver and the Teacher Report Form (TRF) by the children’s teacher. AdditionalCBCL and TRF data was available from the 11- and 8-year-assessments. Scores ofthe externalizing problems scale as well as the aggressive and delinquent behaviorsubscales were used. Children were assigned to groups of high vs low externalizing


Table 1Sample description

Male (n=36) Female (n=51)

Age (years) 14.4±0.3 14.5±0.3

Tanner Stage (score 1–5) 3.6±0.5 (range: 2.5–5.0) 4.1±0.6 (range: 3.0–5.0)

CBCL (T-score)Externalizing 52.9±7.1 51.2±8.7Aggressive Behavior 54.8±5.5 54.1±5.8Delinquent Behavior 53.7±5.6 54.1±5.9

TRF (T-Score)Externalizing 54.1±9.2 53.6±9.3Aggressive Behavior 56.6±6.9 55.8±6.9Delinquent Behavior 55.1±5.2 55.7±7.2

behavior according to their scores on the CBCL and TRF. The high externalizinggroup was defined by T-scores�60 (i.e. borderline clinical range) on either instru-ment, the low externalizing group had T-scores � 60 on both instruments.

Stage of pubertal maturation was assessed by self-ratings of the adolescents usingstandardized figure drawings depicting Tanner’s sexual maturation scale (scorerange: 1–5). Earlier studies have approved a reasonable agreement between self-assessments and physicians’ ratings (Duke et al., 1980; Morris and Udry, 1980;Brooks-Gunn et al., 1987).

2.3. Procedure for plasma collection and analysis

Blood (35 ml) was taken between 5 and 6 p.m. The samples were collected inpolypropylene tubes containing citric acid and centrifuged at 1500 × g for 10 min.Plasma was stored at –80 °C until analysis. T and DHT were measured with in-house RIAs after extraction and chromatographic separation. Briefly, extracts of 500µl plasma were chromatographed on celite mini-columns (750 mg) with propyleneglycol as a stationary phase. The DHT-fraction was eluted with 8% ethyl acetate ini-octane, followed by testosterone (20% ethyl acetate in i-octane) and quantified withspecific RIAs. RIA results were corrected with individually (for each sample) determ-ined recovery (for DHT 60% and T 78%). The sensitivity, intraassay variation andinterassay variation were 1 pg, less than 7% and less than 18% for DHT, and 1 pg,less than 5% and less than 14% for T, respectively.

2.4. Statistical analysis

Statistical analysis of group differences was performed using one- and two-waymultivariate analyses of variance with group (and gender) as factors followed byunivariate analyses and single comparisons. Analyses of covariance were used to


control for differences in Tanner stage. To determine associations between androgenlevels and scores on CBCL/TRF syndrome scales, Spearman rank correlationswere computed.

3. Results

Mean plasma T and DHT levels in 14-year-old boys and girls from the high andlow externalizing groups are presented in Table 2. Both androgen metabolites weresignificantly higher in male adolescents with high externalizing behavior comparedto the low externalizing group. As expected, girls had significantly lower T and DHTlevels than boys (F(2, 82) = 62.30, p � 0.000). However, in females androgen levelsdid not differ according to externalizing behavior (significant group by gender inter-action: F(2, 82) = 7.14, p � 0.001). When controlling for Tanner stage, the groupeffect on DHT remained significant (F(1, 33) = 8.72, p � 0.006), while differencesin T levels were reduced to only marginal significance (F(1, 33) = 3.58, p =0.068).

To explore associations between androgens and subtypes of externalizing behavior,correlations between T/DHT levels and CBCL/TRF syndrome scales were consideredin males. Significant correlations were found between Delinquent Behavior and T(TRF: rho = 0.361, p � 0.05) and DHT (CBCL: rho = 0.353, p � 0.05; TRF: rho= 0.344, p � 0.06) in males. Correlations with Aggressive Behavior were generallylower and (with one exception) insignificant.

To further analyze the link between androgen levels and the course of externalizingbehavior, male adolescents were assigned to one of three groups according to persist-ence of their problem behavior: the persistent group had scores of at least borderlineclinical range (T � 60) at all assessments (8-, 11- and 14-year-assessment), scoresof the episodic group were in the borderline/clinical range at one or two assessments,and the never group had scores below borderline/clinical range at all assessments.Table 3 presents mean plasma T and DHT concentrations for each group. Resultsindicate a significant group effect with the highest androgen levels found in thegroup of male adolescents with persistent externalizing behavior. When adjustingfor Tanner stage, group differences remained significant.

Table 2Mean plasma T and DHT levels in groups of adolescents with high and low externalizing scores

Low Externalizing High Externalizing F(1, 34) p(m=19, f=31) (m=17, f=20) F(1, 49)

T (ng/dl) Male 171.4±126.2 259.4±118.5 4.62 0.039Female 36.4±17.2 36.0±18.1 0.07 0.935

DHT (ng/dl) Male 22.1±10.9 38.0±21.5 8.07 0.008Female 13.9±5.0 13.4±4.0 0.13 0.729


Table 3Mean plasma T and DHT levels in groups of male adolescents differing in persistence of externalizingbehaviora

Never Episodic Persistent F(2, 26) p Significant(n=9) (n=13) (n=7) contrasts

T (ng/dl) 115.2±70.6 236.4±138.9 270.3±141.6 3.82 0.035 1�2, 3

DHT (ng/dl) 19.1±10.1 28.8±16.8 45.4±25.3 4.44 0.022 1�3

a Note: post hoc single comparisons: never=1, episodic=2, persistent=3. Total N reduced, because com-plete CBCL and TRF data were not available at all assessments

4. Discussion

Our finding of elevated androgen levels in male adolescents with externalizingbehavior is in line with earlier studies investigating the link between androgens anddifferent types of aggression in adolescents (Mattson et al., 1980; Olweus et al.,1988; Dabbs et al., 1991). The closer association with DHT, which has a muchhigher affinity to the androgen receptor than T, may explain deviant results of otherswho were unable to demonstrate a significant correlation between T and aggressivebehavior (Constantino et al., 1993). Another reason for inconsistency might be thatthe construct of aggression is operationalized in different ways in the various studies.In our study, Achenbach’s concept of externalizing behavior was used which com-prises patterns of aggressive and delinquent behavior based on parent and teacherratings. It has to be considered, however, that Achenbach’s psychopathological con-cept and instruments are less clear-cut with respect to quantify or assess differenttypes of aggression. Even though the subscale Aggressive Behavior claims to meas-ure aggression, obviously the content of the specific items is highly varied. The sameapplies to the Delinquent Behavior subscale including a number of items whichappear to measure problem behavior related to aggression as well. This ambiguityis reflected by our finding of a closer relationship between androgens and the Delin-quent Behavior subscale in comparison to the Aggressive Behavior scale. In addition,our sample from a general population, though at risk for antisocial behavior, is notcharacterized by high grades of delinquency or violence as found in criminal popu-lations. Thus, our results indicate that the impact of androgens on adolescent behaviormay also be extended to milder forms of externalizing behavior problems which aretypical of a non-clinical ‘normal’ population.

From the developmental perspective the onset and persistence of aggressivebehavior is a central issue. Recent theories of developmental psychopathology sug-gest two major pathways to later aggressive and antisocial behavior, an early onset,life-course-persistent trajectory and a late-onset, adolescence-limited path (Moffitt,1993; Patterson et al., 1989). A key assumption of these theories is that each typeof antisocial development has its unique natural history and etiology. Our resultsindicating that childhood-onset persistent externalizing problems are associated with


higher levels of androgens may be interpreted as an evidence supporting this etiolog-ical distinction. Life-course persistent pathways occur ten times more frequently inmales than in females, a fact confirming the possible influence of androgens as well.

In contrast to previous studies (Dabbs and Hargrove, 1997), our study failed tosupport an association between androgens and externalizing behavior in females.However, these findings mainly pertain to criminal adults, while opposing results inchildren (Susman et al., 1987; Sanchez-Martin et al., 2000) suggest that the influenceof androgens on female aggression might depend more on severity of problembehavior and developmental status.

The development of aggression in childhood and adolescence is a multifactorialprocess. It is unlikely that androgens can account for every facet of aggressive orantisocial behavior. Thus, the early influence of androgens on brain developmentmay form a basic vulnerability of the individual to act or react in a more or lessaggressive or antisocial manner. Furthermore, emotional experiences during child-hood, socialization processes (like parenting, peer groups, academic performance,acquisition of social skills), personality traits (like intelligence or temperament) andother neurobiological systems (like the serotonergic network, Nelson and Chia-vegatto, 2001) are important factors in the etiology and manifestation of aggressivebehavior. Our finding that the link between androgens and behavior was specific tomales, and that adolescents with persistent externalizing behavior between 8 and 14years exhibited the highest androgen levels, supports the hypothesis of an androgeneffect in early brain development, which may contribute to the development of anti-social disorders.

The present investigation was cross-sectional with regard to the measurement ofandrogens which were assessed at the age of 14 years only. Thus, we report on anassociation between androgens and externalizing behavior, a possible bi-directionalrelationship between androgens and behavior, as described by other investigators(e.g. Mazur and Booth, 1998), could not be examined. Based on their studies ofwinners in human competition, the authors hypothesized that social dominance cancause an increase of testosterone levels (Booth et al., 1989). Their findings maysuggest that increased androgen levels can just as well be an effect of aggressivebehavior. Future assessments of the Mannheim Study of Risk Children in late ado-lescence will allow us to investigate whether androgen levels can predict lateraggressive behavior or vice versa and whether elevated androgen levels may beviewed as cause or consequence of aggressive behavior.

Acknowledgements

We thank all families who participated in the study; Sibylle Heinzel and ElisabethReichert for invaluable help with the execution; Barbara Leube and Betty Weyererfor critically reading the manuscript, and thoughtful suggestions.


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association of testosterone and dihydrotestosterone with externalizing behavior in adolescent boys...

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