gender and disorder specific criminal career profiles in former adolescent psychiatric in-patients

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Journal of Youth and Adolescence PP1180-joyo-485228 April 17, 2004 17:41 Style file version July 26, 1999

Journal of Youth and Adolescence, Vol. 33, No. 3, June 2004, pp. 261–269 (C© 2004)

Gender and Disorder Specific Criminal Career Profilesin Former Adolescent Psychiatric In-Patients

Ellen Kjelsberg1

Received October 24, 2002; revised June 30, 2003; accepted December 17, 2003

A Norwegian nation-wide sample of 1087 former adolescent psychiatric in-patients, 584 males and503 females, were followed up 15–33 years after first hospitalization. On the basis of detailed hospitalrecords from index hospitalization all were rediagnosed according to DSM-IV. The patient list waslinked to the national criminal register and the diagnostic groups were compared as to gender-specificfrequency of registered criminality. Next, the criminal career characteristics were compared in thosewith criminal records at follow-up, relative to mental disorder at index hospitalization. The prevalenceof registered criminality, both overall and for specific types of crimes, differed significantly betweendiagnostic groups and between genders. In both genders criminal convictions were most frequentin disruptive behavior disorders and personality disorders. Among males, the lowest violent crimerate was observed in those with psychotic disorders. Males had more severe criminal careers thanfemales, both quantitatively and qualitatively. The diagnoses and criminal profiles of the 10 mostactive criminals in the study sample were described closer, as were the 11 individuals found guilty ofhomicide.

KEY WORDS: adolescent psychiatry; delinquency; violent crime; gender differences.

INTRODUCTION

There is emerging consensus that an association ex-ists between criminal behavior, particularly violent of-fending, and mental disorders (Brennanet al., 2000;Marzuk, 1996; Steadmanet al., 1998; Swansonet al.,1990; Tiihonenet al., 1997). The results indicate that therate of criminal behavior differ across diagnostic cate-gories. Adolescence is by far the age associated with thehighest risk of criminal debut (Moffitt, 1993; Stattin andMagnusson, 1996). Former adolescent psychiatric patientsare at high risk of later criminal behavior (Kjelsberg andDahl, 1998; Loeber and Hay, 1997; Nicolet al., 2000;Rutteret al., 1998; Satterfield and Schell, 1997; Smith,

1Department of Psychiatry, University of Oslo, Norway. Medical doc-tor from the University of Oslo and a qualified psychiatrist. Currentlyfull time postdoctoral researcher with main interests in antisocial de-velopment and adolescent delinquent behavior. To whom correspon-dence should be addressed at Centre for Research and Education inForensic Psychiatry, Ulleval University Hospital, Gaustad BuildingNo. 7, N-0320 Oslo, Norway; e-mail: [email protected].

1995). The link between adolescent mental disorders andlater criminal behavior is important and is in need of fur-ther research. It is essential to investigate the various men-tal disorders separately. Males and females should also beinvestigated separately.

The usefulness of criminal career research has beeneloquently described by Blumsteinet al.(1988). An indi-vidual’s criminal career can be described according to avariety of factors, such as age at crime debut, crime fre-quency, crime severity, crime diversity or specialization,duration of the criminal career, and the age of desistancefrom further criminal activity.

The aim of the present study was to explore the linkbetween various mental disorders and registered crimealong these criminal career dimensions. Data from a long-term register follow-up study of former adolescent psychi-atric in-patients were used to explore these issues. It washypothesized that the prevalence of registered criminalityas well as the criminal careers would vary considerably,depending on the mental disorder at hospitalization in ado-lescence. Marked gender differences in criminal behaviorwere expected as well. It was hypothesized that the gender

261

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262 Kjelsberg

differences would be of a qualitative as well as a quanti-tative nature.

MATERIAL AND METHODS

The study population has been elsewhere describedin detail (Kjelsberg and Dahl, 1998). It consisted of allthe 1276 patients who were consecutively admitted tothe adolescent unit at the National Center for Child andAdolescent Psychiatry in Oslo, Norway, during the years1963–1981. The hospital was the only in-patient facilityfor adolescent psychiatric patients in the country at thetime. No regional admission rules were in force; thus thesample can be considered nation-wide.

Altogether 1095 patients, 85.8% of the original sam-ple, could be unequivocally identified by personal identifi-cation numbers needed for the subsequent record linkage.

Because the study wanted to investigate adolescentpsychiatric in-patients, 8 individuals with age above 19at the time of hospital admission were excluded. In theremaining 1087 mean age at admission was 15.0 years(SD= 1.5, range= 11–19). The follow-up was conductedin 1996, 15–33 (SD= 5.5, mean 24.5) years after firsthospitalization. A total of 145 patients had died. Meanobservation time from last hospitalization to the end of thefollow-up or death was 23.1 years (SD= 6.8, range= 1–33). The population was followed for a total of 25,132person years.

On the basis of hospital records, all patients wererediagnosed according to the diagnostic criteria in DSM-IV (American Psychiatric Association, 1994). The use ofpersonality disorder diagnoses in adolescence is contro-versial. In the present study a diagnosis of personalitydisorder was only given when the patient’s maladaptivepersonality traits appeared to be pervasive, not likely to belimited to the particular developmental stage, and presentfor at least 1 year. Seventy-eight (70%) of the 111 per-sonality disordered girls had borderline personality dis-order; in boys schizotypal personality disorder was mostfrequent, 23 out of 52 (44%). The diagnostic procedurewas conducted blind to outcome. An interrater reliabilitystudy was carried out, yielding a Kappa of 0.79.

On the basis of their DSM-IV diagnoses the studypopulation was divided into 8 diagnostic groups:

1. Disruptive Behavior Disorder (DBD) with Psy-choactive Substance Use Disorder (PSUD) co-morbidity (n = 235)

2. DBD without PSUD comorbidity (n = 312)3. Personality disorder (n = 163)4. Psychotic disorder (n = 98)5. Mood disorder (n = 76)

6. Anxiety disorder (n = 62)7. Organic disorder (n = 55)8. Other mental disorder (eating disorder, obsessive

compulsive disorder, Tourette’s disorder, etc.)(n = 86).

In the majority of the analyses, 5 of the above groups,namely groups 4 through 8, were collapsed into one resid-ual group, as they had similar crime rates and criminalcareer profiles. These groups were also too small for gen-der specific analyses to be performed in a meaningful way.Thus, in most of the analyses four diagnostic groups wereinvestigated:

I. DBD with PSUD (n = 235)II. DBD without PSUD (n = 312)

III. Personality disorder (n = 163)IV. Residual of mental disorders (n = 377).

The criminal activity of the study population was deter-mined by linkage of the patient list to the Norwegiancriminal registry. The register is based on personal iden-tification numbers and includes all persons who have re-ceived sentences for criminal offences and misdemeanors.In Norway, status offences are not covered by the criminalcode. Once registered, nobody is removed from the regis-ter. The register is of good quality and all patients, includ-ing those who were deceased, could be reliably checkedagainst it.

It was established that 564 (52%) of the 1087 probandshad criminal records at the follow-up. Forty individualswho had been found guilty of misdemeanors only, mostlyvarious traffic offences, were considered as noncriminals.This reduced the number of patients with criminal recordsto 524.

Among these 524, 158 (114 males and 44 females)had entered the criminal registry before hospitalization.After careful consideration it was decided to keep theseindividuals in the study, rather than excluding them fromfurther analyses. These individuals’ early criminal activi-ties might have been instrumental in landing them in hos-pital, thus leading to selection bias. However, they werehighly representative of the adolescent in-patient popula-tion one intended to study. Excluding them would haveresulted in an even more undesirable selection bias andmade the results less clinically meaningful. It was decidedto treat criminality before hospitalization as an indepen-dent variable, characteristic of the individual’s criminalcareer. Accordingly, in the subsequent survival analysesthe individual’s birth rather than first hospitalization wasused to calculate observation time to event or censoring.

Next, the 524 criminal records were assessed and sys-tematized. The records contained information about thedate and nature of each offence and the judge’s decision at

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Gender and Disorder Specific Criminal Career Profiles 263

each court appearance. In addition, all incarcerations wererecorded. A psychiatrist (the author) scored all criminalrecords, blind to diagnosis. The procedure was not relia-bility checked, as it consisted of mere systematization offactual data found in the criminal registry.

Statistical Analyses

Group differences were investigated using Chi-squaretest or Exact test on categorical variables andt test on con-tinuous variables. Continuous variables were further in-vestigated using one-way analysis of variance (ANOVA)and covariance (ANCOVA). Pairwise group differenceswere investigated, using Bonferroni adjustment for multi-ple comparisons.

The scores on some of the variables were positivelyskewed. As recommended by Tabachnick and Fidell(1996) these were log transformed before statistical anal-yses were carried out. This procedure improved the skew-ness to acceptable levels. In the tables means and SDs ofvariable values before log transformations are listed, whileF- and p-values pertain to log-transformed data.

The association between diagnosis at index hospital-ization and age at entry into the crime registry or censoringwas studied by the use of survival analysis, i.e. Kaplan–Meier plots and log-rank testing.

Table I. Gender Specific Crime Prevalence at Follow-Up for Different Mental Disorders in 584 Male and 503 Female Former Adolescent PsychiatricIn-Patients

Convicted of Convicted of Convicted of Convicted ofcommitting any crime violent crimes drug offences sex offences

DSM-IV disorder at Males Females Males Females Males Females Males Females Malesindex hospitalization N (%) N (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Disruptive behaviordisorderwithpsychoactive substanceuse disorder comorbidity

123 (21) 112 (22) 98 (80) 71 (63)∗ 75 (61) 17 (15)∗∗ 66 (54) 48 (43) 12 (9)

Disruptive behaviordisorderwithoutpsychoactive substanceuse disorder comorbidity

231 (40) 81 (16) 182 (79) 29 (36)∗∗ 99 (43) 1 (1)∗∗ 68 (29) 7 (9)∗∗ 16 (7)

Personality disorder 52 (9) 111 (22) 25 (48) 56 (51) 10 (19) 15 (14) 10 (19) 25 (23) 3 (6)Psychotic disorder 54 (9) 44 (9) 11 (20) 4 (9) 3 (6) 1 (2) 2 (4) 3 (7) 0 (0)Mood disorder 31 (5) 45 (9) 8 (26) 7 (16) 5 (16) 1 (2) 2 (7) 3 (7) 0 (0)Anxiety disorder 30 (5) 32 (6) 6 (20) 5 (16) 2 (7) 1 (3) 0 (0) 1 (3) 1 (3)Organic disorder 31 (5) 24 (5) 10 (32) 2 (8)∗ 6 (19) 0 (0) 2 (7) 0 (0) 0 (0)Other mental disorders 32 (6) 54 (11) 8 (25) 2 (4)∗ 3 (9) 0 (0) 1 (3) 0 (0) 0 (0)

Total 584 (100) 503 (100) 348 (60) 176 (35)∗∗ 203 (35) 36 (7)∗∗ 151 (26) 87 (17)∗∗ 32 (6)

Chi-square/Exact text 153.1 107.9 97.3 31.9 97.4 85.3 14.1

DF 7 7 7 7 7 7 7

p value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.05

Note.Significant gender differences (Chi-square, 1 DF):∗p ≤ 0.01; ∗∗p ≤ 0.001.

The statistical package SPSS (2001) was usedthroughout.

RESULTS

Registered Criminality in Different MentalDisorders (Table I and Figs. 1 and 2)

The gender-specific prevalence of registeredcriminality (over-all, violent, drug related, and sexual)differed markedly between the 8 diagnostic groupsinvestigated. Numerous gender differences were alsodemonstrated.

The highest over-all crime rates were found in DBDand personality disorders, varying between 48–80% inmales and 36–63% in females. In the rest of the mentaldisorders investigated crime rates varied between 20–32%in males and 4–16% in females.

Violent criminality was more frequent in males thanin females: 35% vs. 7%. Males with DBD and PSUD hadthe highest prevalence of violent crimes, 61%. The lowestviolent crime rate in males was found among those withpsychotic disorders: 6%. In females, probands with DBDand concurrent PSUD and personality disorders had vio-lent crime rates of about 15%; in the remaining diagnosticgroups violent crime was infrequent (0–3%).

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264 Kjelsberg

Fig. 1. Male criminality. Kaplan–Meier survival curves illustrating age at entry into crime registry (any crime, violent crime, and drug offen-ces) or censoring in 584 male psychiatric in-patients, relative to diagnosis at index hospitalization.

Among those with DBD and PSUD comorbidity,54% of males and 43% of females had committed drugoffences. In males and females with DBD without PSUDcomorbidity drug offences were less frequent: 29% and9%, respectively. Nineteen percent of males and 23% offemales with personality disorders had committed drug of-fences. In the remaining diagnostic groups drug offenceswere infrequent in both genders (0–7%).

In males, sex offences were committed by 10% ofthose with DBD and PSUD comorbidity, 7% of those withDBD without PSUD, and 6% of those with personalitydisorders. No females had committed sex offences.

Gender-specific survival curves for age at first entryinto the crime registry, age at first violent crime, and age atfirst drug offence on record are depicted in Figs. 1 and 2,for 4 diagnostic groups: DBD with PSUD, DBD withoutPSUD, personality disorder, and the residual of mentaldisorders.

Fig. 2. Female criminality. Kaplan–Meier survival curves illustration age at entry into crime registry (any crime, violent crime, and drug offen-ces) or censoring in 503 female psychiatric in-patients, relative to diagnosis at index hospitalization.

In males with DBD, concurrent PSUD did not make adifference relative to the over-all crime rate; it did howevermake a significant difference relative to violent crimes anddrug offences. Males with personality disorder were lesscriminally active than males with DBD, irrespective ofconcurrent PSUD or not, whereas females with personal-ity disorder were more criminally active than females withDBD without PSUD but less active than females with DBDand PSUD comorbidity. The residual group was least crim-inally active in both genders. Log rank tests were highlysignificant (p < 0.001).

Criminal Career Profiles (Tables II and III)

Table II lists gender-specific mean scores for thecriminally active individuals among the 4 diagnosticgroups investigated. In males, patients with DBD andPSUD comorbidity had the most serious crime profiles.

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265

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266 Kjelsberg

These individuals committed their first crime on record atan earlier age, the total number of crimes on record weresignificantly higher, and they showed a larger variety intypes of crimes committed, as demonstrated by the highernumber of different criminal codes broken. They spent alonger time incarcerated, and their criminal activity level,defined as the number of crimes on record per year duringtheir criminally active years (the time span between thefirst and the last crime conviction on record, corrected fortime spent in incarceration and thus with low possibilityof committing crimes), was higher.

Table III presents the results from the Chi-squarecalculations and demonstrates further differences in malecriminal careers for the four diagnostic groups investi-gated. More than 50% of all males with DBD and PSUDhad committed their first crime before first hospital ad-mission; the remaining groups less often. Defining a re-peat offender as a person who has received more than onecourt conviction, 98% of males with DBD and concurrentPSUD were repeat offenders. More than 90% of maleswith DBD with PSUD had received unconditional deten-tion sentences, and their criminal records showed a higherpropensity towards escalating severity, as judged by thetype of offences committed, than the remaining diagnos-tic groups.

In males DBD with PSUD had the most severe crim-inal profiles, followed by DBD without PSUD, personal-ity disorder, and the residual of mental disorders, in thatorder.

Table III. Criminal Career Profiles in 348 Males and 176 Female Former Adolescent In-Patients with Registered Criminality at Follow-Up, Relativeto Their DSM-IV Diagnosis at Index Hospitalization in Adolescence (Chi-Square and Exact Test Statistics)

Having a criminal Repeat offenders, Having received Escalating severityrecord before first i.e. more than one unconditional of offences

hospitalization court conviction detention sentence over time

DSM-IV disorder at Males Females Males Females Males Females Males Females Males Femalesindex hospitalization N (%) N (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Disruptive behavior disorderwith psychoactive substanceuse disorder comorbidity

98 (28) 71 (40) 51 (52) 16 (23)∗∗ 96 (98) 60 (85)∗∗ 89 (91) 36 (51)∗∗ 35 (36) 7 (10)∗∗

Disruptive behavior disorderwithoutpsychoactivesubstance use disordercomorbidity

182 (52) 29 (17) 48 (26) 10 (35) 161 (89) 21 (72) 138 (76) 11 (38)∗∗ 50 (28) 2 (7)

Personality disorder 25 (7) 56 (32) 4 (16) 15 (27) 22 (88) 42 (75) 17 (68) 26 (46) 6 (24) 1 (2)∗∗Residual of mental disorders 43 (13) 20 (11) 11 (26) 3 (15) 24 (56) 9 (45) 20 (47) 5 (25) 4 (9) 1 (5)

Total 348 (100) 176 (100) 114 (33) 44 (25) 303 (87) 132 (75)∗∗ 264 (76) 78 (44)∗∗ 95 (27) 11 (6)∗∗

Chi-square/Exact text 24.1 2.8 48.0 13.1 33.0 4.8 10.7 3.6

DF 3 3 3 3 3 3 3 3

p <0.001 0.43 <0.001 0.004 <0.001 0.19 0.01 0.31

Note.Significant gender differences (Chi-square, 1 DF):∗p ≤ 0.01; ∗∗p ≤ 0.001.

Although group differences were less marked in fe-males, a persistent pattern regarding the order of severitywas found. As in males, the most severe criminal careerswere found in those with DBD and PSUD, and the leastsevere in the group of residual disorders. But, contrary tomales, females with personality disorder had more severecriminal profiles than females with DBD without concur-rent PSUD.

The Most Serious Criminals and Crimes

The 10 criminals with the cumulatively longest un-conditional jail sentences (180 months or more) were in-vestigated closer. They were all males, and at index hospi-talization they had all been diagnosed with serious DBD.Five of them had concurrent PSUD. Eight of the 10 hadcommitted various serious violent crimes: 1 had commit-ted murder, 2 had committed rape, and 3 were convicted ofaggravated robbery. Altogether 6 of the 8 had been foundguilty of causing bodily harm. Among the 2 without vio-lent crime records, one had committed numerous seriousdrug offences, and another a variety of property offences,including theft, document forgery, and embezzlement. Asmany as 5 of the 10 had committed sex offences, rangingfrom sex with a minor to rape. All had committed simpleproperty crimes and vehicle theft. They were all typicalrepeat offenders, with a mean number of 102 criminalacts on record (SD= 42.2, range= 27–167). Their first

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criminal act was recorded at a mean age of 15.1 (SD= 1.0,range= 14–17). All except one had a property offence asthe first criminal act on record.

In the total sample 11 patients, 8 males and 3 females,were convicted of homicide. Among the 8 males, 2 hadDBD with PSUD, 4 had DBD without PSUD, 1 had a para-noid personality disorder, and 1 suffered from Tourette’sdisorder at index hospitalization in adolescence. Of the 3females, 2 had DBD with PSUD and 1 a borderline person-ality disorder. While only 2 of the 8 males had PSUD co-morbidity at index hospitalization, all the females did. Allbut the one male with Tourette’s disorder were adolescentonset repeat offenders. In the 10 repeat offenders, the ageat criminal debut was 15.3 years (SD= 0.9, range= 14–16), the mean number of criminal acts on record was 32(SD= 32, range= 2–111), and the length of the crimi-nal career was 17 years (SD= 5.1, range= 10–27). Sixof the 11 were sentenced to lengthy preventive detention,implying that the courts considered the risk of future se-rious violent offending not negligible.

DISCUSSION

Registered Criminality in Different Mental Disorders

As hypothesized, registered criminality in formeradolescent psychiatric in-patients differed markedly atfollow-up relative to diagnosis at index hospitalization.The highest crime rates were found in males with DBD,irrespective of concurrent PSUD or not. In females withDBD concurrent PSUD or not made a significant differ-ence. High crime rates in DBD have been found in nu-merous other studies (Myerset al., 1998; Satterfield andSchell, 1997; Smith, 1995). In both genders individualswith personality disorders had high crime rates, again aresult supported by others (Griloet al., 1996).

In the remaining diagnostic groups crime rates werecomparatively low. But even in the diagnostic groups withthe lowest prevalence rates, namely anxiety disorders andpsychotic disorders, the crime rates in males were high,about 20%. That is doubled, compared to 10–11% in acomparable Norwegian general male population (Falck,1992). The increased criminal activity in individuals withdisorders such as depression and anxiety, disorders notparticularly associated with criminal behavior, is a clini-cally important finding that warrants further research.

Of particular interest is the low violent crime rate(6%) found in psychotic males. It is the lowest male vio-lent crime rate among the diagnostic groups investigated.This supports Brennanet al.’s (2000) finding that personswith psychotic disorders are at lower risk for violent crim-inality than persons with antisocial personality disorders

and substance abuse. Taking into account the relative in-frequency of psychotic disorders, compared to DBD, inthe general population, DBD males pose a much largerthreat to society as to violent criminality than psychoticmales do (Wallaceet al., 1998).

Criminal Career Profiles

As hypothesized there were numerous quantitativeand qualitative differences between the criminal careersof individuals with different mental disorder at hospital-ization in adolescence.

The order of severity of the criminal career was con-sistently different in males and females along the dimen-sions investigated. Males with DBD with concurrentPSUD had the most serious criminal careers, followedby DBD without PSUD, personality disorders, and theresidual of mental disorders, in that order. Also femaleswith DBD with concurrent PSUD had the most seriouscriminal careers, but females with personality disordershad more serious criminal careers than females with DBDwithout PSUD. This gender difference might partly bedue to the variation in personality disorder in males andfemales in the sample: the majority of female personalitydisordered adolescents had borderline personality disor-der, while schizotypal personality disorder was the person-ality disorder most frequently found in males. Differentcriminal profiles would be expected in these personalitydisorders.

Age at first court conviction was usually during mid-dle to late teens, significantly earlier in males than females.Males with DBD with PSUD comorbidity had the earliestcriminal debut and also the most severe criminal profiles.This agrees with Moffitt’s (1993) concept of early on-set in the more serious, chronic cases. The relatively latecriminal debut in the residual disorders in both genders isnoteworthy.

In the general population the majority of offendersare registered for one offence only, making desistancefrom further criminality after a first court conviction morecommon than continuation (Kyvsgaard, 1998). This isstrikingly different from the study population where therates of reoffending was very high in both males and fe-males, ranging from 98–72% in DBD and personality dis-orders to 56–45% in the residual of mental disorders.

A comparatively small group of repeat offenders areresponsible for a disproportionately large part of all crimescommitted in society (Stattin and Magnusson, 1991). Themajority of the offenders in the study sample consisted ofsuch high-level offenders, as demonstrated by the meannumber of crimes these individuals were convicted of. Tobe able to deter some of these individuals from embarking

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upon or discontinuing their criminal career could accord-ingly have a not negligible effect on the total amount ofcrimes committed in the society.

Gender Differences

It is widely accepted that females are less antiso-cially active than males (Cook and Laub, 1998; Rutteret al., 1998). Also in this clinical sample females hadlower prevalence of criminal convictions than males, bothoverall and regarding violent crimes and drug and sexoffences. And once embarking upon a criminal career,the career seemed to develop in a less serious manner, asdemonstrated by a later debut, a lower number of crimi-nal acts on record, less diverse criminal behavior, and alower number of criminal acts convicted of per year asactive criminal. Females were less often repeat offendersand they did less often than males show a tendency to-ward escalating severity of offences over time. Thus, thestudy demonstrates both quantitative and qualitative gen-der differences in the criminal career of former adolescentpsychiatric in-patients.

In their comprehensive study of sex differences in an-tisocial behavior, Moffittet al. (2001) found that femaleswere less criminally active than their male counterparts.And those females who exhibited criminal behavior didso less frequently than males, their antisocial criminal ca-reers were less serious, and they did less often engage inserious violent behavior. Moffittet al.’s study was a com-munity study, but the trends were similar to those foundin the clinical probands of the present study.

The Most Serious Criminals and Crimes

The 10 criminals with the longest jail sentences wereall males. These 10 males were typical repeat offenderswith numerous and diverse crimes on record. Contrary towhat could be expected, 5 of the 10 had not committedany really serious crimes but rather extremely numerousminor crimes.

Among the 11 found guilty of homicide it is note-worthy that none had a psychotic disorder. Typically, themurderers were heavy repeat offenders with early criminaldebuts and long and active criminal careers.

Strengths and Weaknesses of the Study

The strengths and weaknesses of the study samplehave been discussed elsewhere (Kjelsberg and Dahl, 1998).Of strengths mentioned were the large proportion of pa-tients traced at the follow-up, the long follow-up period,

the nation-wide nature of the sample, and the outcomemeasure consisting of official register data of good qual-ity. All patients were reliably rediagnosed on the basis ofinformation recorded at the time of hospitalization in ado-lescence. This constitutes a safeguard against recollectionbias and gives the study a quasi-prospective design.

That the probands were followed up at a mean ageof close to 40, well beyond the period of highest risk forcriminal debut, strengthens the assumption that those whohad not been convicted at follow-up were indeed true non-criminals.

The study has obvious limitations. It was conductedon adolescent in-patients and is not necessarily represen-tative of adolescent psychiatric patients in general. Thestudy concerns only registered criminality and official reg-isters record only a fraction of all crimes committed. Self-reported crime rates tend to be higher, but when it comes toserious and chronic offenders, then self-reports and officialrecords tend to identify the same individuals (Farrington,1994; Huizinga and Elliott, 1986). A generalization of thefindings is of course limited to nations with similar crim-inal judicial systems.

ACKNOWLEDGMENTS

The Norwegian Research Council has financed thisresearch project. I am indebted to Professor Odd Aalenfor valuable comments and advice regarding the statisticalprocedures.

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