Many pediatricians are asked to evaluate badly behaving children, who may or may not be "wicked ." The term "wicked" may have a definition in philosophy, but it is poorly defined in medicine.1 Pediatricians who look to the International Classification of Disease (ICD-9-CM)2 or to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),3 will not find any mention of the term. However, both diagnostic systems do recognize terms such as conduct disorder, antisocial behavior, and antisocial personality disorder. Thus, the literature deals with bad behavior that has an antisocial quality but not necessarily all bad behaviors.4 Antisocial behavior, as opposed to other bad behaviors, requires that the behavior violate the rights of another human being. Although wickedness does not have a crisp definition, the term is used in this article because it evokes a certain type of misconduct and is creatively imaginative.
Pediatrie psychiatrists and behavioral pediatricians who evaluate wickedness ideally should use a methodology that is both reliable and valid. The authors have developed a semi-structured interview protocol, the Clinical Assessment of Wickedness (CLAW). As in any medical assessment, this requires a combination of taking careful history, examining mental state, and testing.
CLAW: THE HISTORY
The family history of badly behaving children should be explored in several areas. The pediatrician should note whether the child is being raised by biological parents or alternative parents, such as foster parents, stepparents, or adoptive parents. If the child is being raised by nonbiological parents, pediatricians may wonder the reasons for the child's placement. If the biological parents are in a hospital because of mental illness or in prison because of criminal behavior, such risk factors should be noted.
Five risk factors that may contribute to child misconduct involve atmosphere, bonding ability, criminality, discipline, and parental attention.5 The atmosphere in which the child is reared should be noted. If the child is raised in a home full of intrafamilial discord, frequent and prolonged quarrels between the parents, separations or divorces between the parents, and expressions of hostility, the child is at risk. Good mental health requires that the developing child have affectionate bonding with an adult caretaker. Pediatricians should assess the quality and quantity of bonding by asking about the relationship with parents or caretakers, the quality of joint family leisure activities, the depth of intimacy in the child's communications with parents, and the degree of affectional identification with the parents.
Criminality in the parents may be a risk factor for criminality in the child. There is strong evidence of some transmission of criminality. It is unclear, however, whether the transmission is biogenetic or sociocultural. Pediatricians should therefore exploit the quantity and quality of any parental criminality. Discipline can either increase or decrease the risk of misconduct in a child. Children who have too little discipline - poor supervision or unclear pamatal expectations - are at high risk for bad behavior. Strict discipline, however, does not necessarily translate into well-behaved children. Children who are overly or harshly disciplined may also learn to behave similarly harshly and aggressively.
Pediatricians also should note how much exclusive parental attention the child receives. This is a statistic derived from dividing the number of caretakers available to the child by the number of children in the family. If the number of caretakers is high (two loving parents, four doting grandparents, and many aunts and uncles, all of whom supervise the child) and the number of children is low, the child will probably receive a lot of exclusive parental attention, which is a protective risk factor, hi contrast, if the number of caretakers is low (a single mother) and the number of children is large (many children with minimal spacing between them), then the amount of exclusive parental attention is likely to be low, which is a negative risk factor.
The school is the environment where children first interact with one another, and where bad behaviors easily are noticed. Pediatricians should note how the child interacts with peers and teachers. Is the child popular or unpopular? The child's academic status should be evaluated. Academic failure is a risk factor for future delinquency, and, if present, should be evaluated for possible causes, including lack of intelligence, learning disorders, or laziness. Some learning disorders, such as reading disorders, are stronger risk factors for bad behavior than others, such as mathematics disorders. Pediatricians also should note any behavioral problems in the school, including truancy, suspensions, or expulsions.
Young children are unlikely to have work histories, but older adolescents may have worked at some point in their lives. In both cases, however, the actual or fantasized work can give us useful clues. A child whose ambition is to join the military has a different mental state from a child who wants to be a librarian; the former may be biologically underaroused, in contrast to the latter. Similarly, a child who wants to join the military has a different mental state from a child who wants to join a gang. Both may be similarly biologically underaroused, but the former suggests pro-social fantasies, while the latter's fantasies are likely more antisocial.
We live in an increasingly multicultural society. Therefore, pediatricians should note the cultural heritage of the child. If the child does not belong to the majority culture, it should be determined whether the child is nativeborn or foreign-born. If native-born, immigration status and timing of parents should be determined. Pediatricians also should explore cultural practices that may present as misconduct, hi some cultures, it is not only permissible but expected that parents spank a naughty child, hi others, such behavior would be viewed with horror. Children who are exposed to minor spanking or harsh physical abuse may develop different risk factors for childhood aggression. Spanking or abuse should further be analyzed to see whether it was done in a context that is culturally permissive, which makes it less damaging, or out of sadistic anger, which makes it more damaging.
The child's attitude toward police and authority figures may be culturally determined. In some cultures, the police are viewed as enemies, and there is little expectation that the child would collaborate with the police and tell the truth. In other cultures, the expectations may be different.
The child's cleverness should be analyzed on two levels. Some children are gifted intellectually, excel academically, and are part of the cognitive elite. Such children are lower risk for becoming juvenile delinquents. Other children may not be part of the cognitive elite but may be "street smart," meaning that they may engage in misconduct but may escape detection. The least fortunate group is those who are neither part of the cognitive elite nor street smart. These children are likely to both commit misconduct and get caught.
The child's first relationship is with the parents. Pediatrician should determine if the child was planned, wanted, accepted, breastfed, and valued and protected as an infant, all of which suggest a good outcome. Reasons for value also should be determined (eg, for the sake of the child's own worth versus a narcissistic need of the parents'). The role of the parent may be that of teacher, friend, caretaker, therapist, playmate, cook, nurse, confidant, or cop. However, if the parent is only one of these - cop for example - the child's development may not be optimal.
Parenting styles should be analyzed; the best parents have a style that is authoritative as opposed to authoritarian. Some parents, however, have a style that is overly indulgent or even neglectful. An easy way to remember the "good enough" parent is through the mnemonic AB + CD + E + FG, representing the parental characteristics of affectionate bonding + control and discipline + example setting + foster growth.
The social peer group of the child should be analyzed.6 Loner characteristics may be suggestive of Asperger syndrome or schizophrenia. Values of any group to which the child belongs should be assessed. A child who joins the Boy Scouts is likely to engage in less misconduct than a child who joins a criminal gang.
Romantic relationships of the child also may be explored, especially in cases of sexual misconduct. Children often confuse love and lust. Freud suggested mature love required a relationship that ias permanent, exclusive, and reciprocal,7 but children may not achieve this because of their youthfulness. However, even adolescents may participate in romantic relationships that are desirable. Relationships should cause a sense of satisfaction that is holistically based, as opposed to only genitally based - where there is love or passion for a real, not imagined, person, rather than desire for a part of the body. Intimacy should be psychological as well as physical and should be reciprocated, rather than expressed unilaterally. Commitment is important to a romantic relationship, including monogamy versus promiscuity and a long-term relationship versus a brief, one-night relationship. The relationship should contain affection, or need, but not based on any power differential, such as age or money.
While there is no medical condition that necessarily causes misconduct, the DSM-IV does recognize "personality change due to a general medical condition."2 This may be of the aggressive type, the labile type, or the disinhibited type, all of which could be consistent with misconduct. This diagnosis should be considered if the child's misconduct is of recent origin and causally related to some medical condition, such as a head injury, that pediatricians should identify.
There is a large differential diagnosis of bad behavior in children. Most pediatricians are familiar with conduct disorder, but a frequently missed differential diagnosis is that of child or adolescent antisocial behavior.2 This is not a mental disorder but is a mental condition.
Other relevant differentials include adjustment disorder with disturbance of conduct and intermittent explosive disorder. Some specific forms of misconduct, including fire setting and stealing, may or may not be accounted for by mental disorders such as pyromania and kleptomania.
History of Substance Abuse
There is a clear association between substance abuse and misconduct, but the nature of the relationship is unclear; it may be a near correlation or a causal relationship. The direct relationship may be mat children first use drugs, which cause subsequent misconduct, or it may be that children first join groups of badly behaving peers, which is a cause for drug abuse. While debate continues, pediatricians should note the presence or absence substance misuse.
DSM-IVp 2 recognizes 11 named drugs: three permissive drugs - caffeine, alcohol, and nicotine; four prescriptive drugs - cannabis, opioids, sedatives, and amphetamines; and four proscriptive drugs - cocaine, hallucinogens, inhalants, and PCP. There are, of course, many other drugs not named in DSM-IV that can impair judgment and contribute to misconduct; the four most common of these drugs for 2004 may be ketamine, rohypnol, ecstacy, and gamma hydroxybutyrate (GHB).8 Pediatricians should know how to weigh the relative risk of each drug; some drugs may be epidemiologically common but less dangerous, such as alcohol, while others may be epidemiologically uncommon but more dangerous, such as phencyclidine.
The relationship between misconduct and being a victim of physical, psychological, or sexual abuse is unclear. Certainly, juvenile delinquents frequently report histories of victimization, which may be true, false, or * exaggerated. Even when they are true, it is unclear whether the subsequent misconduct is related causally or coincidentally. However, because there is such an association, pediatricians should make decisions relating to abuse on an individual basis.
History of Misconduct
One of the best predictors of future misconduct is past misconduct. Pediatricians should note when the child first demonstrated bad behavior. If the child initially was well behaved but then regressed into bad behavior, pediatricians should look for some event that may be related to this regression. If the trauma of the event may be addressed, possibly through psychotherapy, the prognosis is good. If the child has behaved badly since a very early age, however, pediatricians should suspect biological factors (eg, fetal alcohol syndrome or other subtle brain damage) or psychological factors (eg, neglect) that may have damaged the child's brain or mind. These problems may be very difficult to address, resulting in a bad prognosis.
The nature of past misconduct should always be explored. Violence against other people should be viewed more seriously than violence against property. A child who engages in only one type of violence is less disturbed than a child who enjoys all types of violence. The timing of past violence also should be analyzed to determine if it represents some biological rhythm - a phase of the menstrual cycle or a particular climactic season - or some psychological anniversary, such as the anniversary of a parental death. If so, a treatable cause may have been discovered.
In addition, location of past misconduct may be significant A child who is aggressive in all locations is likely to have a bad prognosis. However, a child who is well behaved in most environments but badly behaved in only one may have a good prognosis if the problem with that particular placement can be addressed. Preferred methods of committing misconduct are important for pediatricians' knowledge.
One important advance in the analysis of aggression is the realization that there are actually two distinct subtypes of aggression, affective and predatory.9 Affective aggression usually occurs in response to external provocation, with the aim being to eliminate the provocation. It is not premeditated, and the aggressor's mental state is usually hot, passionate, and frenzied; there is an unfocused quality to affective aggression. Often, children demonstrating affective aggression experience guilt and express remorse after losing their tempers. Such aggression is often inefficient in that it achieves little reward.
In contrast, predatory aggression usually comes in response to some internal stimulus, such as appetite or anger. Its aim is not to eliminate provocation but rather to enjoy a sense of satiation. Predatory aggression requires premeditation, and the aggressor's thinking is cold and calculating, with a clear focus on the victim. Such predators often experience little guilt and express no remorse. This type of aggression is usually efficient.
The pediatrician should analyze carefully whether the child's aggression is affective or predatory. If affective, it may respond to medical interventions, such as beta-blockers for rage attacks, selective serotonin reuptake inhibitors for anger attacks, and lithium for impulsive aggression. If the aggression is predatory, however, there are few medical interventions, and the only remedy may be behavioral therapy.
CLAW: EXAMINATION OF THE CHILD'S PHYSICAL STATE
Historically, there were theories relating misconduct to body type - ectomorphic, mesomorphic, or endomorphic. Although these are mostly out of fashion, the pediatrician should note any extreme body type because a tough mesomorph is more likely to win physical fights. Such aggressive behavior may be reinforced by the reward of winning the fights. There is not much else in the physical exam that may be helpful to pediatricians. Some psychiatrists examine minor physical anomalies more carefully, possibly relating them to the risk of severe mental illness in general but not specifically to violent mental illness.10 However, the mental state of the child is clearly more relevant.
CLAW: EXAMINATION OF THE CHILD'S MENTAL STATE
When pediatricians first meet their patients, they should note the presence or absence of general indicators of potential aggressiveness. A child who exhibits a forward lean, shows a hostile shoulder orientation, makes glaring eye contact, has clenched fists, and comes physically too close to the examiner should be viewed with more caution than others. Children's moods should be assessed in general. Pediatrie psychiatrists, familiar with DSM-IV, are trained to focus on those mood states that have a corresponding DSM-IV diagnosis, including depressed mood suggestive of a mood disorder or anxious mood suggestive of an anxiety disorder. Pediatricians, however, should note those emotional states that have no direct equivalency in DSM-IV, such as irritable or jealous mood.2 Pediatricians should not take the child's description of mood at face value, but rather interpret it Child who say that they are "paranoid" are not necessarily suffering from a paranoid disorder but may be appropriately suspicious. Juvenile delinquents who report they are "depressed" may not be suffering from a depressive disorder that needs antidepressant medication but simply may be bored.
Pediatricians should note whether the child has a history of perceptual problems, such as hallucinations. Tactile hallucinations may suggest a history of drug problems even if denied by the child, while auditory hallucinations may be more suggestive of a disease such as schizophrenia. Auditory hallucinations should be assessed for command. Children who hear commands to set houses on fire should be treated with more caution than children who hear voices flattering them.
The child's intellectual status, including intelligence and cognitive functioning, should be assessed. Capacity to pay attention, and capacity to perform the executive functions of planning, organizing, sequencing, and abstracting should be examined. Sometimes children repeat misconduct because, although they understand one type of misconduct is not permitted, they lack the ability to generalize and may commit a similar offense. Children may know not to steal a car, for example, but they may steal a bicycle because they could not abstract and understand the meta-picture. Examination of the child's thinking requires an analysis of the content of thinking (eg, delusions) and the organization of thinking (eg, intact or loose thoughts). A logical or illogical process of thought should be determined, as well as the flavor of thinking (eg, appropriate, paranoid, granthose) and the speed of thinking.
The examination of a child's mental state may end with an overall analysis of how well the child communicates, not only with an examination of specific aspects of speech and language, but also an overall impression of the efficiency of the communication and connectedness.
CLAW: EXAMINATION OF THE CHILD'S JUDGMENT
It is well know that the judgment of children is less mature than that of adults; however, the old term "judgment" is now being replaced by the term "decision making." Psychiatrists often test cognitive judgment by asking questions such as "what would you do if you found a stamped addressed envelope?" Such questions do not give a rich picture of decision making. The authors propose that the child's decision-making skills be analyzed under five axes:
* Consequential Thinking - Can the child identify the consequences of particular behaviors?
* Relational Thinking - Can the child relate one event to another during time, and understand why one event led to particular actions by other people?
* Alternative Solutions Thinking - Can the child generate different solutions to any problem?
* Personal Sensitivity - Can the child perceive a problem when it exists and identify the interpersonal aspects of any problems that may emerge?
* Steps/Means Ended Thinking - Can the child generate the intermediate steps required to achieve a goal?
Social judgment follows a pathway similar to neurological pathways; the final social behavior is the culmination of social sensitivity, followed by social reasoning and a social response. A bad social response may be the result of deficits in social sensitivity. For example, children may have attentional deficits and not pay attention to social cues, or may pay attention but not be able to decode social signals. Children may have deficits in social reasoning, such as inability to effectively read another person. In addition, children may successfully read other people but fail to empathize or understand the meta-picture. As a result, the social response may be undesirable either in quantity (eg, weight of the message may be too heavy, may be delivered too forcefully) or in quality (eg, affect may be inappropriate, communication may be flawed).
Some misconduct may be related to deficits in moral judgment. As in the analysis of social judgment, the pediatrician should note whether the child is morally sensitive or morally bund and whether the child is capable of moral reflection and analysis. Even if children are morally sensitive and capable of moral analysis, they may lack moral character and knowingly give more weight to nonmoral values than to moral values. Some children may even have moral sensitivity, do a moral analysis, have a good moral character, and choose to behave morally, but may lack moral motivation and, therefore, succumb to temptation.
Biological markers for childhood criminality is an area of active research. No such biological marker has been discovered, however. There is research relating to biological underarousal (measured by heart rate and skin conductance studies),11 low platelet MAO,12 low CSF 5FflAA,13 and low serotonin levels related to impulsive and possibly bad behavior.14
In another article in this issue, some neuropsychological tests mat may be relevant in the evaluation of misconduct are reviewed. (See the article by Scarpa and Raine, page 296.) Although no one test is specific to misconduct, there are psychological tests to assess some of the risk factors for misconduct. Thus, pediatricians may wish to order psychological testing of intelligence (standard IQ tests), impulsivity, concreteness, and psychopathic features, all of which may contribute to misconduct either singly or in combination.
After interviewing children, pediatricians will get an indication of personality and whether misconduct is suggestive. There are many ways to analyze personality; DSM-IV has a typology of personality disorders, and there are many competing typologies. The authors found the typology of Cloninger15 to be most useful, especially for children at risk for misconduct. Cloninger separates the child's temperament from the child's character. Under the temperament dimension, pediatricians would note whether children are high or low for harm avoidance. If children are optimistic, daring, outgoing, and energetic, they will be deemed low on harm avoidance and at greater risk. Similarly, if children score high on exploratory behavior (eg, impulsive, extravagant, irritable), they will be deemed high on the novelty-seeking dimension and would similarly be at greater risk. Cloninger further proposes assessing children for being high or low on dimensions such as selfdirectiveness, degree of cooperation, and self-transcendent qualities.
One of the strongest characteristics of wickedness in children is the presence of psychopathic features. DSM-IV2 does not include a psychopathic personality disorder but does recognize an antisocial personality disorder. Unfortunately, the criteria for this disorder emphasizes bad behaviors, thus confusing the disorder with being a juvenile delinquent, rather than emphasizing the psychopathic deficits that may place a child at risk for antisocial behaviors. Skilled pediatricians will, therefore, evaluate not only children's good or bad behaviors but also any psychopathic features.
These include an assessment of:
* biological factors - underarousal in children, evidenced by thrill-seeking or impulsive behaviors suggesting a need for stimulation;
* psychological factors - grandiosity, lack of remorse or guilt, irresponsibility;
* social factors - callousness, evidenced by a lack of empathy others' pain; being socially manipulative; and having relationships based on power and exploitation, not affection;
* behavioral factors - poor behavioral controls, dangerous behaviors resulting from a deficit in the fear response, and plans to live a parasitic lifestyle.
EXAMINATION OF PLEASURESEEKING BEHAVIORS
Pleasures of Stimulation
All children enjoy stimulation, but they may arrange this pleasure in a variety of ways. Some children demonstrate autistic head banging; although this is stimulating, few would say that it is healthy. Some children may engage in rape; although this may be sexually stimulating, it is also antisocial and criminal. Some children abuse amphetamines; although this is stimulating, it is both unhealthy and criminal. A child with good mental health may seek the stimulation of spicy foods or membership in an organization such as the Boy Scouts.
From the time of birth, newborns enjoy the oral pleasure of suckling the breast. Children continue to enjoy oral pleasures, which may range from illegitimate oral pleasures (drinking alcohol) to legitimate but selfish oral pleasures (eating) to legitimate but unselfish pleasures (feeding others).
Humans are social animals, and we all seek social attachments. Children with good mental health have appropriate attachments in a variety of areas, including to social pets, friends, and institutions such as school or church. However, children with attachment disorders may be socially disconnected from appropriate objects (fellow humans) and have odd attachments (to nonsocial pets such as lizards, or to institutions rather than to humans).
Pleasures of Productivity and Creativity
Good mental health includes creativity and productivity. Healthy children enjoy creating art, music, or literature. When mature, they may enjoy marriage and building families. Children with bad mental health may enjoy destroying rather than creating, and may not support the families they build as adults.
Pleasures of Fantasy
Children with good mental health are in touch with reality but also enjoy a rich fantasy life. Unless psychotic, they should know the difference between the two arenas. They should have the capacity of quickly moving from reality into fantasy at appropriate times, such as when in play or watching movies. The regression into fantasy should be voluntarily planned and not the result of involuntary, drug-induced intoxication, such as a PCP psychosis.
Pleasures of Mastery
As children age, they enjoy a sense of mastery over increasingly difficult physical and mental tasks. Good mental health includes mastering required skills such as reading skills, recreational skills, and athletic skills, as well as mastery of the self. Children with bad mental health may not achieve any of these masteries but seek only mastery of other objects, such as acquiring more toys, or unhealthy mastery of others, including rape.
None of the above methods of pleasure seeking is inherently good or bad, but is a range of pleasure-seeking Pediatricians should anathese methodologies for degrees of or antisocial behavior.
EVALUATION OF SELF-CONTROL
Some children who behave badly have in self-control. Pediatricians should analyze the quantity and quality of control. The locus of control - internal or external to the child - should be determined and the pathway for the expression of loss of control followed. If children fail to control themselves and demonstrate wicked behaviors, pediatricians should know if the fantasy was experienced in the unconscious and if it could be aborted at that stage. If the fantasy did enter consciousness, pediatricians should investigate whether it was premeditated or expressed in behavior without any premeditation. The latter case would be consistent with ICD-9-CM1 disorders such as explosive personality disorder or frontal lobe syndrome, or DSM-IV2 disorders such as intermittent explosive disorder or personality change of the disinhibited, aggressive, or labile types.
EXPLANATIONS FOR WICKEDNESS
If previously well-behaved children begin behaving badly, parents yearn for some explanation, which pediatricians are expected to generate. If pediatricians examine children who have committed misconduct and if the only explanation is "the child suffers from conduct disorder," it is unlikely that the referral source will ^ be overly impressed.
Pediatricians who work with wicked children should familiarize themselves with three broad types of explanation in the philosophy of science,16 namely j explanations based on group profiles, teleological explanations, and causal explanations.
Explanations Based on Group Profiles
One way to give a satisfying explanation is for the pediatrician to note that the child has membership in a group that would be expected to engage in bad behavior. This explanation is especially satisfying if such membership is not known to the parents and is discovered by the pediatrician. For example, a rape is committed by a juvenile who is typically well behaved. If the pediatrician can establish that the juvenile was intoxicated, and that such misconduct is typical of persons who are intoxicated, the explanation is satisfying because it reconciles the conflict between two apparently opposing statements. That is, the juvenile would not normally commit rape, but intoxicated people do commit rape, and there is new information that the juvenile was intoxicated. The pediatrician has thus removed the apparent inconsistencies, and the explanation makes sense.
In these explanations, pediatricians discover the intended but previously unknown consequence of the misconduct. Imagine a usually well-behaved child has killed his teacher. Wellbehaved children do not normally kill their teachers, so this odd behavior requires an explanation. The pediatrician discovers the teacher caught the child cheating on a test and threatened to punish the child. The child, being immature, could think of no other alternative to eliminate this threat and, therefore, removed the threat by killing. Again, this explanation is satisfying because it provides new information.
If a pediatrician can establish a cause for some misconduct, and if the causal connection was previously unknown, such an explanation will be satisfying. Law and medicine have different conceptions of cause. In law, the test for causation is the "but for" test; if the offender would not have committed the offense but for the causal agent, then there is a causal explanation. For example, a teen who would not have had a car crash but for his drunken state. In medicine, we are moving away from considerations of cause and examining medical risk factors that may be necessary, sufficient, both, or neither.
COMMUNICATING THE RISKS FOR WICKEDNESS
After pediatricians have completed the analysis, they usually are asked to communicate findings to the interested parties, including parents, judges, or school officials. It is less helpful to merely communicate that the child is good or bad, if conduct disorder was diagnosed or not, or even if the child is wicked or not. A richer picture is conveyed by describing the wickedness along five axes: probability of harm, rate of harm, imminence of harm, magnitude of harm, and availability of methods for harm.
The probability of harm may be conveyed either in quantitative terms expressed as a percentage, or more usually in qualitative terms - high probability or low probability. The rate of harm is usually conveyed in terms such as "frequent" or "rare." The imminence of harm may be differentiates between imminent problems that will occur within minutes or hours and nonimminent problems, which will occur within months or years. The magnitude of harm is best conveyed through behavioral examples. Pediatricians should convey that there is risk of the child committing a murder, which has a high magnitude of harm, or participating in a scuffle, which would be low magnitude. Harm may be perceived differently by different people, such as with risk of indecent exposure. Availability refers to availability of methods; for example, a child may only be dangerous if he or she has an available weapon. In addition, the availability of victims is also implied; for example, child molesters may only be dangerous if they are in the vicinity of children.
This article has reviewed one model for evaluating badly behaving or wicked children. Bad behavior is the final common pathway of a variety of biological, psychological, social, and cultural factors, and a proper evaluation requires knowledge of factors and clinical judgment as to the weight given to each factor.
1. Haroun A. Psychiatric aspects of wickedness: introduction. Psychiatr Ann. 1997;27(9):615615.
2. ICD-9-CM: International Classification of Diseases, 9th Revision, Clinical Modification, Spiral edition. Washington, DC: American Medical Association; 1998.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.
4. Haroun A. Conduct disorder or disordered conduct? In: The California School of Professional Psychology Handbook of Juvenile Forensic Psychology. San Francisco, CA: Jossey-Bass; 2002.
5. Holmes SE, Slaughter JR, Kashani J. Risk factors JD childhood thai lead to the development of conduct disorder and antisocial personality disorder. Child Psychiatry Hum Dev.2001;31(3):183-I93.
6. Buysse WH. Behaviour problems and relationships with family and peers during adolescence. J Adolesc. 1997;20(6):645659.
7. Soble A. The Structure of Love. New Haven, CT: Yale University Press; 1990.
8. Smith KM, Larive LL, Romanelli F. Club drugs: meoiylenedioxymethampnetamine, flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate. Am J Health Syst Pharm. 2002;59(11):1067-1076.
9. Vinello B, Stoff DM. Subtypes of aggression and their relevance to child psychiatry. J Am Acad Child Adolesc Psychiatry. 1997;36(3):307-315.
10. Arseneault L, Tremblay RE, Boulerice B, Seguin JR, Saucier JF. Minor physical anomalies and family adversity as risk factors for violent delinquency in adolescence. Am J Psychiatry. 2000; 157(6):9 17-923.
11. Scarpa A, Raine A. Psychophysiology of anger and violent behavior. Psychiatr Clin North Am. 1997;20(2):375-394.
12. Longato-Stadler E, af Klinteberg B, Garpenstrand H, Oreland L, Hallman J. Personality traits and platelet monoamine oxidase activity in a Swedish male criminal population. Neumpsychobiotogy. 2002;46(4):202-208.
13. Higley JD, Mehlman PT, Poland RE, et al. CSF testosterone and 5-HIAA correlate with different types of aggressive behaviors. Biol Psychiatry. 1996;40(n):1067-1082.
14. Lesch KP, Merschdorf U. Impulsivity, aggression, and serotonin: a molecular psychobiological perspective. Behav Set Law. 2000;18(5):581-604.
15. Constantino JN, Cloninger CR, Clarke AR, Hasbemi B, Przybeck T. Application of the seven-factor model of personality to early childhood. Psychiatry Res. 2002;109(3):229-243.
16. Brendel DH. Reductionism, eclecticism, and pragmatism in psychiatry: the dialectic of clinical explanation. J Med Philos. 2003;28(56):563-580.