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Criminal Justice and

Behavior
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Adolescent Antisocial Behavior as Predictor of Adverse Outcomes to Age 50: A


Follow-Up Study of 1,947 Individuals
Yasmina Molero Samuelson, Sheilagh Hodgins, Agne Larsson, Peter Larm and Anders Tengstrm
Criminal Justice and Behavior 2010 37: 158 originally published online 26 October 2009
DOI: 10.1177/0093854809350902
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ADOLESCENT ANTISOCIAL BEHAVIOR


AS PREDICTOR OF ADVERSE OUTCOMES
TO AGE 50
A Follow-Up Study of 1,947 Individuals
YASMINA MOLERO SAMUELSON
Research Centre for Adolescent Psycho-Social Health, Karolinska Institute

SHEILAGH HODGINS
Research Centre for Adolescent Psycho-Social Health, Karolinska Institute
Institute of Psychiatry, Kings College London

AGNE LARSSON
PETER LARM
ANDERS TENGSTRM
Research Centre for Adolescent Psycho-Social Health, Karolinska Institute

The study examined associations between antisocial behavior (ASB) before age 15 and eight adverse outcomes from age 21
to 50 among 1,623 men and 324 women who as adolescents consulted a clinic for substance misuse problems. Outcomes
were documented using Swedish national registers and included death, hospitalization for physical illnesses related to substance misuse, mental illness, self-inflicted harm, substance misuse, convictions for violent and nonviolent crimes, and
poverty. ASB before age 15 was associated with increased odds of all outcomes in adulthood except hospitalization for mental illness after adjusting for low family socioeconomic status, sex, Sex ASB, and substance misuse in adulthood and with
an increased number of adverse outcomes up to age 50. No gender differences were detected.
Keywords: antisocial behavior; adolescence; at-risk populations; long-term outcomes; epidemiology; sex differences

any adolescents engage in antisocial behaviors (ASB; Bird et al., 2001), yet little is
known about the long-term outcomes of these behaviors. Most long-term studies
have examined homotypic continuity and consistently report a link between ASB and adult
criminal offending (Elander, Simonoff, Pickles, Holmshaw, & Rutter, 2000; Farrington
& Maughan, 1999; Moffitt & Caspi, 2001; Moffitt, Caspi, Harrington, & Milne, 2002;
Raskin-White, Bates, & Buyske, 2001; Sampson & Laub, 1993; Stouthamer-Loeber, Wei,
Loeber, & Masten, 2004). Fewer studies have examined heterotypic continuity, and those
that have report an association between ASB and an array of adverse outcomes, including
physical illness (Odgers et al., 2007), premature death (Laub & Vaillant, 2000; Pajer, 1998),

AUTHORS NOTE: Funding for this study was provided by the Stockholm County Council with added support from Maria Ungdom. We would like to thank Statistics Sweden and all of the agencies who contributed
data to the study for their collaboration. Ethical approval for the study was granted by the Ethics Committee
of Karolinska Institute, Sweden. Please address correspondence to Yasmina Molero Samuelson, Research
Centre for Adolescents Psycho-social Health, St. Grans Hospital, Box 500, 112 81 Stockholm, Sweden;
e-mail: yasmina.molero-samuelson@sll.se.
CRIMINAL
No.
2, X,
February
CRIMINAL JUSTICE
JUSTICE AND
AND BEHAVIOR,
BEHAVIOR, Vol.
Vol. 37
XX,
No.
Month 2010
2007 158-174
158-XXX
DOI:
DOI: 10.1177/0093854809350902

Association
Correctional
Forensic
Psychology
2010
2007 International
American Association
forfor
Correctional
andand
Forensic
Psychology

158
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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 159

mental health problems (Kim-Cohen et al., 2003; Simonoff et al., 2004), suicide (Corneau
& Lanctt, 2004; Fergusson & Woodward, 2000; Fombonne, Wostear, Cooper, Harrington,
& Rutter, 2001), substance misuse (Moffitt et al., 2002), financial problems (Moffitt et al.,
2002), and social deprivation (Caspi & Moffitt, 1995; Jaffee, Belsky, Harrington, Caspi, &
Moffitt, 2006). The knowledge base is, however, thinner than it first appears, as many of
these reports are based on the same cohort (e.g. Jaffee et al., 2006; Kim-Cohen et al., 2003;
Moffitt et al., 2002; Odgers et al., 2007), follow-up has not extended beyond age 30
(Corneau & Lanctt, 2004; Fergusson & Woodward, 2000), and the samples have included
none (Laub & Vaillant, 2000) or very few girls who exhibited ASB (Moffitt et al., 2002).
The few longitudinal studies that extend beyond age 30 report a persistent risk of crime
(Bushway, Thornberry, & Krohn, 2003; Farrington & Maughan, 1999; Sampson & Laub,
1993), physical and mental illness (Odgers et al., 2007; Shepherd, Farrington, & Potts, 2004;
Simonoff et al., 2004), and mortality (Laub & Vaillant, 2000; Repo-Tiihonen, Virkkunen, &
Tiihonen, 2001). These studies, however, examined samples composed almost exclusively
of men, and each focused on only one or two outcomes. Consequently, there is little knowledge of outcomes in multiple domains assessed simultaneously in the same individuals or
of the persistence of these outcomes through adult life. Some studies have reported a differential risk of adversity in adulthood, depending on the severity of ASB (Moffitt et al.,
2002; Robins & Price, 1991), but again, little is known about the association between
the severity of ASB and outcomes in a variety of domains and about persistence over time.
Longitudinal data from the Dunedin Multidisciplinary Health and Development Study
revealed that childhood-onset ASB is related to poorer adult outcomes than is adolescentonset ASB (Caspi & Moffitt, 1995; Moffitt, 1993; Odgers et al., 2007), including physical
and mental health problems. Adolescent-onset ASB was also associated with an elevated
risk for illness and psychosocial problems in adulthood, although to a lesser extent. A review
of longitudinal investigations of girls with conduct disorder revealed a broad range of negative outcomes, including higher death rates, psychiatric morbidity, and service utilization,
as compared to healthy women in adulthood (Pajer, 1998). Among girls, the mean age of
onset of conduct problems is later than among boys, and it has been suggested that this later
onset is associated with more favorable outcomes (Moffitt, 1993). By contrast, other studies have suggested that girls, despite a delayed age of onset, exhibit poor outcomes similar
to boys who began engaging in ASB at a younger age (Silverthorn & Frick, 1999). There
are few long-term studies that compare outcomes among males and females, and results
are conflicting; whereas some studies suggest that outcomes are sex differentiated
(Fombonne et al., 2001), others report no sex differences (Fergusson & Horwood, 2002;
Moffitt, Caspi, Rutter, & Silva, 2001; Piquero, Brame, & Moffitt, 2005; White & Piquero,
2004). Results may vary because of differences in samples, definitions of outcomes, sources
of information, and length of follow-up, but these divergent findings indicate a need for
more longitudinal studies comparing males and females.
To conclude, knowledge of the consequences of ASB is limited because few studies
have measured a broad array of outcomes in the same individuals, tracked changes in
outcomes through adult life, and examined large samples of females as well as males.
Adolescence is a period of changes and challenges, of experimentation and risk taking
(Patton & Viner, 2007). It is critical to collect information on problems that persist and
those that resolve as individuals transition to adulthood. Public funds are limited, and
decisions regarding investments in assessment, treatment, and prevention programs for
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160 Criminal Justice and Behavior

boys and girls displaying ASB need to be informed by evidence of long-term outcomes. It
has been shown, for example, that even by age 28, the public service costs for children with
conduct disorder were 10 times higher than for children without conduct problems (Scott,
Knapp, Henderson, & Maughan, 2001). Knowledge of the long-term outcomes of childhood ASB is equally important for guiding research on the etiological processes involved
in maintaining ASB over the life span.
The present study examined eight adverse outcomes experienced by a cohort of individuals who as adolescents from 1968 to 1971 consulted a clinic for substance misuse problems.
Information on death, hospitalization for physical illnesses related to substance misuse,
mental illness, self-inflicted harm, substance misuse, criminal convictions for violent and
nonviolent crimes, and poverty was collected from Swedish national registers from age 21
to 50. Whereas other studies and the Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM-IV) have used a younger age to identify early-onset conduct problems
(American Psychiatric Association, 1994; Moffitt et al., 2008; Moffitt & Caspi, 2001; Odgers
et al., 2007), the present study examined ASB that onsets prior to age 15. This may identify
both childhood and adolescent onset ASB. However, in Sweden in the late 1960s, 15 was a
meaningful cutoff. The age of criminal responsibility was 15 years, and the legal age of
adulthood was 21 years. Unlike children in many other countries, at this time the cohort
members in the current study entered school at age 7 and finished high school at age 19. A
major study of the stability of crime among a cohort of Swedish boys defined childhood
criminal behavior as offenses committed before age 15 (Stattin & Magnusson, 1991). In the
clinical cohort examined in the present study, only 16% of the adolescents had used alcohol
and 6% illicit drugs prior to age 15. Thus, we judged that ASB prior to age 15 indexed an
early onset of ASB in Sweden at this time period. Furthermore, evidence suggests that ASB
onsets later in girls than in boys (Silverthorn & Frick, 1999). By using age 15, we expected
to capture ASB in girls.
We hypothesized that (a) the more severe the ASB before age 15, the higher the odds of
adverse outcomes up to age 50; (b) the more severe the ASB before age 15, the greater
the number of adverse outcomes; and (c) the associations between the severity of ASB
before age 15 and the adverse outcomes would persist over time. For each hypothesis, tests
were conducted to assess whether the association between the severity of ASB before age
15 and the adverse outcomes varied by sex.
METHOD
PARTICIPANTS

Files were screened to identify all of the individuals who had been seen between January 1,
1968, and December 31, 1971, at the only clinic for adolescent substance misuse in the
greater Stockholm area. Age at intake ranged from 9 to 20 years. Initially, 2,088 individuals were identified: 96 were excluded because of incorrect personal identification numbers
(a unique number assigned to each Swedish citizen and resident) or lost files, 28 individuals
had left Sweden, and 17 had died before follow-up started at age 21. Deaths were due to poisoning, suicide, or accidents. The 17 males who had died before age 21, as compared to those
who were alive, obtained higher scores for ASB before age 15 (N = 1,610; Kruskal-Wallis
2 = 5.28, df = 1, p < .05). This association could not be examined in females, as only 4 had
died before age 21. The final cohort included 324 women and 1,623 men.
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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 161

Of the cohort, 5.8% of the women and 7.7% of the men had been born outside of Sweden.
Just over 40% of the parents were engaged in nonmanual occupations. At intake, the mean
age of the females was 16.8 years (SD = 1.83) and of the males 17.8 years (SD = 1.70).
Reasons for referral ranged from being drunk in a public place to persistent use of illicit
drugs. Among the females, 25.3% received in-patient treatment, 27% received out-patient
treatment, 46.4% only detoxification, and 1.3% received no treatment. Among the males,
9.1% received in-patient treatment, 29.6% received out-patient treatment, 58.7% only
detoxification, and 2.6% received no treatment. Among the participants, 28.4% of the
women and 18.9% of the men were under compulsory treatment.
PROCEDURE

Once the Ethics Committee of Karolinska Institute had granted permission for the
study, the old clinic files were screened to extract personal identification numbers. A
request was sent to the national registers that described the study, presented a copy of the
ethics approval and the list of personal identification numbers, and requested collaboration.
Each of the national registers forwarded data to Statistics Sweden. Information on participants up to age 20 was extracted from files and sent to Statistics Sweden. Once all data were
on hand, Statistics Sweden merged the files, deidentified the data, assigned each participant
a study identification number, and sent the data file to the research team. Adult outcomes
were documented until December 31, 2002, providing a follow-up from age 21 to 50.
Information on participants up to age 20. The files included information about the
cohort members when they consulted the clinic, as well as information on all health and
social service contacts and police records from birth to age 20. A manual was written to
guide data extraction. Six research assistants were trained to extract information using the
manual, and procedures for data extraction were examined on a regular basis to ensure
interrater agreement. Throughout the data collection, two research assistants rated 10% of
the files independently in order to calculate interrater agreement. Variables with Cohens
kappa below 0.6 (Cohen, 1960) were dropped from all analyses.
Parents socioeconomic status (SES) was defined according to the classification system
used by Statistics Sweden (1982) and included six categories: unskilled workers, skilled
workers, assistant nonmanual employees, intermediate nonmanual employees, high-level
nonmanual employees, and self-employed professionals. The parent with the highest SES
was coded. Low parent SES was defined as unskilled workers.
Severity of ASB before age 15. ASB and substance misuse commonly co-occur (Armstrong
& Costello, 2002), and it has been suggested that ASB and substance misuse are elements
within the externalizing spectrum (Krueger et al., 2002; Krueger, Markon, Patrick, Benning,
& Kramer, 2007). In this study, ASB before age 15 was defined to include a broad spectrum
of externalizing behaviorsillicit drug use, alcohol use, conduct problems, aggressive
behavior, and criminalityeach rated none (0), moderate (1), or high (2) based on file information. Items indexing illicit drug use and alcohol use included assessments of frequency
and severity of misuse. Conduct problems were defined as in the DSM-IV (American
Psychiatric Association, 1994). Aggressive behavior included bullying, fighting, and physical
and sexual abuse. Criminality included official reports of nonviolent and violent crimes. The
scores for the five types of ASB were summed to index ASB before age 15.
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Percentage of cohort members

162 Criminal Justice and Behavior

70
60
50
40

Males

30

Females

20
10
0
0

10

Severity of antisocial behavior before age 15

Figure 1: Frequencies of the Severity of Antisocial Behavior Before Age 15 Among Males and Females

A weighted mean of the intraclass correlation coefficient (ICC) for the different raters was
calculated, and interrater agreement was high (ICC = 0.88). Internal consistency of the ratings of the five types of ASB was estimated using Cronbachs alpha (Cronbach, 1951) and
reached .68. Females had on average (M = 1.28, SD = 1.93) higher scores than did males
(M = 1.08, SD = 1.82), but the sex difference was not statistically significant, t(1,945) = 1.85,
p = .06, two-tailed. As presented in Figure 1, many of the cohort members obtained ratings
of none on each of the five items of ASB prior to age 15. Consequently, the ratings
of ASB are highly skewed, and the standard deviations around the means are large. Many of
the cohort members began engaging in ASB after age 15. For example, the mean age of
alcohol onset was 16.2 years (SD = 2.09) and 17 years (SD = 2.02) among the women and
men, respectively. The mean age of illicit drug use was 14.9 years (SD = 2.27) and 15.1
years (SD = 2.46) among the women and men, respectively.
Adult outcomes. Information on adult outcomes was extracted from national registers.
Swedish registers are updated annually and have been shown to be valid (Mortensen,
Allebeck, & Munk-Jrgensen, 1996).
Information on date and cause of death was extracted from the death register, which has
been maintained by the Swedish National Board of Health and Welfare since 1961.
Information on all hospitalizations was provided by the Swedish hospital discharge register maintained by the Swedish National Board of Health and Welfare. From 1972 to 1986,
all admissions in the county were registered, including admissions in the municipality
where the clinic was situated, and from 1987 to 2002 all admissions to any hospital in
Sweden were recorded.
Physical illness related to substance misuse was defined as admission to an inpatient ward
with a discharge diagnosis of a disease related to alcohol or drug use (Cook & Clark, 2005;
Mathers, Lopez, & Murray, 2006; Room, Babor, & Rehm, 2005; Single, Rehm, Robson,
& Truong, 2000) as defined in the Global Burden of Disease Study (Mathers et al., 2006).
Diagnoses included sexually transmitted diseases, neoplasms, cardiovascular diseases,
digestive diseases, and unintentional injuries. In addition, HIV/AIDS and Hepatitis B and C
were included.

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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 163

Mental illness was defined as admission to an inpatient ward with a discharge diagnosis of
schizophrenia; schizotypal disorders; delusional disorders; mood disorders; neurotic, stressrelated, and somatoform disorders; eating disorders; or personality disorders.
Self-inflicted harm was defined as an admission to inpatient care with a discharge diagnosis of intentional injuries.
Substance misuse was defined as (a) an admission to inpatient treatment with a discharge
diagnosis of substance dependence syndrome or harmful use; and/or (b) an admission to
inpatient treatment for alcohol- or drug-induced conditions; and/or (c) criminal convictions
related to substance misuse, including public drunkenness, intoxication on the job, driving
while intoxicated, supplying illicit substances, possession of illegal substances, personal
misuse of illegal substances, manufacturing illegal substances, recklessness with narcotics,
narcotics for nonmedical use, smuggling, unlawful import and export of illegal substances,
and crimes against the law on prohibition of certain doping substances.
Information on criminal convictions was extracted from official criminal records, which
have been maintained by Statistics Sweden since 1973.
Violent crimes were defined to include attempted or completed homicide or manslaughter, criminal negligence causing death, assault resulting in death, assault and aggravated assault, assault on an official, arson and aggravated arson, robbery and aggravated
robbery, kidnapping, stalking, harassment, unlawful threats, rape and aggravated rape,
sexual assault, sexual molestation, sexual abuse of minors, incest, procuring, and child
pornography crimes. Nonviolent crimes were defined to include all other offenses in the
penal code with the exception of substance-related crimes.
Poverty was defined as receiving social welfare payments due to low income, and information was available only from 1990 on from Statistics Sweden.
STATISTICAL ANALYSES

The associations between ASB prior to age 15 and the eight adverse outcomes were
analyzed separately for six 5-year periods and for the entire 30-year follow-up period from
age 21 to 50. Within each 5-year period, each outcome was coded as present or absent.
Participants who had lived abroad for longer than 6 months were excluded from the age
period when they were absent from Sweden. Individuals were included in the analyses up
until the 5-year period when they died.
Logistic regression models were calculated in order to examine the associations between
ratings of ASB prior to age 15 and each outcome. Crude odds ratios and 95% confidence
intervals for the 30-year follow-up period and for each 5-year period are presented. Odds
ratios adjusted for parental SES, sex, and Sex ASB were calculated. In a subsequent step,
the effect of substance misuse in adulthood on the odds of the other adverse outcomes was
examined. Odds ratios were recalculated, controlling for the presence of substance misuse
in the current or any preceding period, after adjusting for parental SES, sex, and Sex
ASB. To examine whether there was a dose-response relationship between ASB and the
outcomes, the total score for ASB before age 15 was divided into three levels: low ASB
(0-2 points), medium ASB (3-5 points), and severe ASB (6-10 points). Crude odds ratios
and 95% confidence intervals for the 30-year follow-up period were calculated.
Generalized linear models assuming a negative binomial distribution were used to assess
the associations between the severity of ASB and the number of adverse outcomes. The
two-way interaction of sex and score for ASB was tested for significance.
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164 Criminal Justice and Behavior

To examine changes over time in the association of ASB and each adult outcome, generalized linear models were applied to fit a repeated measures logistic regression, with
age period, sex, and severity of ASB as predictors, including interactions. These models
provided odds ratios estimating the change at each age period, the change in the effect
that ASB had on each outcome at age period, and gender differences.
RESULTS
Hypothesis 1: The more severe the ASB before age 15, the higher the odds of adverse outcomes
up to age 50.

Crude odds ratios estimating the associations between the severity of ASB prior to age
15 and each outcome for the entire 30-year follow-up period and for each of the 5-year
periods are presented in Table 1. Each unit increase in the severity of ASB prior to age 15
was associated with increased odds of death, hospitalization for physical illnesses related
to substance misuse, hospitalization for mental illness, hospitalization for self-inflicted
harm, substance misuse, criminal convictions for violent and nonviolent crimes, and poverty for the entire 30-year period and for the majority of the 5-year periods.
Odds ratios were adjusted in order to estimate the extent to which parents SES, sex,
and the interaction of Sex ASB explained the associations between ASB prior to age
15 and the adult outcomes. Low parent SES was significantly associated with only one
outcomedeathover the 30-year follow-up period and at three 5-year age periods.
Sex was significantly associated with some outcomes; women, as compared to men, had
higher odds of being hospitalized for a physical illness related to substance misuse, selfinflicted harm, and poverty for the entire follow-up period and during five of the 5-year
age periods. Conversely, men had higher odds of being convicted for a violent crime and
for a nonviolent crime during the follow-up period and during eight of the 5-year periods.
Men also had higher odds of substance misuse problems from age 26 to 30. After taking
account of ASB before age 15, the analyses showed no major differences in outcomes among
males and females. The Sex ASB interaction term was not significant for any of the eight
outcomes over 30 years, and was significant for only three outcomes assessed in all of the
5-year periods. Mental illness was the only outcome that was not significantly associated with
ASB prior to age 15 after adjusting for SES, sex, and Sex ASB.
To understand if the adverse outcomes in adulthood were associated with continued
substance misuse, the associations between ASB prior to age 15 and the eight outcomes
through adulthood were estimated, adjusting for parents SES, sex, Sex ASB and, in addition, substance misuse in adulthood in either the current age period or a previous one. As
presented in Table 1, after controlling for current or prior substance misuse, the odds ratios
decreased and remained significant for 33 of the 5-year age periods for all the outcomes
except hospitalization for mental illness. After adjusting for substance misuse in adulthood,
parents SES continued to be significantly associated with death and mental illness but not
with self-inflicted harm. Sex was significantly associated with some outcomes; women, as
compared to men, had higher odds of being hospitalized for a physical illness related to
substance misuse, self-inflicted harm, mental illness, or poverty for the whole follow-up
period and for five of the 5-year age periods. Conversely, men had higher odds of being
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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 165


Table 1:Logistic Regression Analyses of the Associations of Antisocial Behavior (ASB) Before Age 15
and Eight Adverse Outcomes in Adulthood







Number of
Participants




Prevalence
Rates (#)

Death
Age 21-25
1,945
1.8%

Age 26-30
1,905
3.1%

1,831
1.7%
Age 31-35

Age 36-40
1,788
3.0%

Age 41-45
1,709
4.3%

(35)
(60)
(31)
(54)
(73)

Age 46-50
908
3.1% (28)

Age 21-50
1,945
14.4% (281)

Medium vs. low ASB

High vs. low ASB


Hospitalization for
physical illnesses
related to
substance misuse
Age 21-25
1,218
15.0%

Age 26-30
1,816
16.5%

Age 31-35
1,776
14.7%

Age 36-40
1,714
13.8%

Age 41-45
1,619
15.6%

(183)
(300)
(261)
(237)
(252)

Age 46-50
902
17.8%

Age 21-50
1,873
47.4%


Medium vs. low ASB

High vs. low ASB

Hospitalization for
mental illness
Age 21-25
828
6.4%

Age 26-30
1,816
5.7%

Age 31-35
1,776
4.6%

(161)
(887)

(53)
(103)
(82)




Crude OR
(CI)


OR
(CI) Adjusted for
SES, Sex,
and Sex ASB

OR (CI) Adjusted
for SES, Sex,
and Sex ASB
and Substance
Misuse After Age 21

1.18*
(1.02-1.35)
1.21***
(1.09-1.34)
1.17*
(1.01-1.37)
1.10
(0.97-1.25)
1.15*
(1.03-1.28)
1.32***
(1.12-1.56)
1.18***
(1.11-1.25)
1.58*
(1.10-2.26)
2.37***
(1.47-3.82)

1.20*
(1.03-1.40)
1.25***
(1.10-1.41)
1.10
(0.91-1.33)
1.11
(0.96-1.29)
1.17*b
(1.04-1.31)
1.30*
(1.08-1.57)
1.19***b
(1.11-1.27)
1.60*b
(1.06-2.42)
2.55***b
(1.50-4.34)

1.20*
(1.02-1.42)
0.98
(0.82-1.19)
0.97
(0.84-1.13)
1.06b
(0.94 -1.19)
1.16
(0.96-1.39)
1.09*b
(1.01-1.17)
1.03b
(0.63-1.67)
1.51b
(0.84-2.74)

1.14***
(1.07-1.22)
1.09*
(1.02-1.16)
1.09*
(1.02-1.17)
1.18***
(1.10-1.26)
1.17***
(1.09-1.25)
1.13*
(1.02-1.26)
1.13***
(1.08-1.19)
1.40*
(1.05-1.86)
1.91**
(1.24-2.94)

1.15**
(1.05-1.25)
1.04
(0.96-1.13)
1.09*c
(1.00-1.18)
1.15***
(1.06-1.25)
1.17***c
(1.08-1.26)
1.12
(0.99-1.27)
1.12***c
(1.06-1.19)
1.26
(0.90-1.77)
1.82*
(1.10-3.00)

1.07
(0.98-1.19)
0.96
(0.88-1.03)
1.01c
(0.94-1.10)
1.10*
(1.01-1.18)
1.10*c
(1.01-1.18)
1.03
(0.91-1.16)
1.12***c
(1.06-1.18)
0.91
(0.64-1.31)
1.07
(0.63-1.81)

0.99
(0.87-1.13)
1.14**
(1.04-1.25)
1.15**
(1.04-1.27)

0.83
(0.65-1.06)
1.04d
(0.91-1.17)
1.03d
(0.89-1.18)

0.80
(0.64-1.00)
0.99d
(0.88-1.12)
0.97d
(0.85-1.12)

(continued)

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166 Criminal Justice and Behavior


Table 1: (continued)







Number of
Participants




Prevalence
Rates (#)

Age 36-40
1,714
5.1%

Age 41-45
1,619
4.0%

Age 46-50
902
4.2%

1,862
11.2%
Age 21-50

Medium vs. low ASB

High vs. low ASB

Hospitalization
for self-harm
Age 21-25
1,218
3.3%

(88)
(65)
(38)
(209)

(40)

Age 26-30

1,816

2.9% (53)

Age 31-35
1,776
1.9% (33)

Age 36-40
1,714
2.4% (41)

Age 41-45
1,619
1.1% (18)

Age 46-50
902
0.8% (7)

Age 21-50
1,873
8% (149)

Medium vs. low ASB

High vs. low ASB

Substance misuse
Age 21-25
828
26.0% (215)

Age 26-30
1,816
23.1% (419)

Age 31-35
1,776
20.7% (367)

Age 36-40
1,714
17.9% (307)

Age 41-45
1,619
15.8% (256)

Age 46-50
902
11.8% (106)

Age 21-50
1,862
41.7% (777)

Medium vs. low ASB




Crude OR
(CI)


OR
(CI) Adjusted for
SES, Sex,
and Sex ASB

OR (CI) Adjusted
for SES, Sex,
and Sex ASB
and Substance
Misuse After Age 21

1.15**
(1.05-1.27)
1.09
(0.96-1.23)
1.02
(0.81-1.28)
1.09*
(1.01-1.17)
1.44
(0.95-2.17)
1.28
(0.68-2.39)

1.06d
(0.92-1.21)
1.01b
(0.85-1.21)
0.96
(0.74-1.25)
1.03
(0.94-1.13)
1.06
(0.61-1.82)
0.97
(0.43-2.17)

1.02d
(0.90-1.16)
0.97b
(0.83-1.14)
0.94
(0.73-1.21)
0.99c
(0.91-1.08)
0.82
(0.47-1.42)
0.63
(0.28-1.43)

1.22***
(1.08-1.38)
1.35***
(1.21-1.49)
1.30***
(1.14-1.48)
1.31***
(1.17-1.48)
1.36***
(1.15-1.61)
1.35
(0.98-1.86)
1.30***
(1.21-1.39)
2.32***
(1.48-3.63)
5.81***
(3.51-9.63)

1.22*c
(1.03-1.45)
1.39***c
(1.22-1.59)
1.12
(0.90-1.39)
1.30***b
(1.12-1.50)
1.26
(0.98-1.62)
1.44*
(1.02-2.03)
1.28***c
(1.18-1.40)
2.15*
(1.19-3.86)
5.66***
(3.02-10.59)

1.09c
(0.90-1.32)
1.22**c
(1.07-1.39)
1.04
(0.86-1.27)
1.21*
(1.05-1.39)
1.15
(0.91-1.44)
1.28
(0.91-1.79)
1.19***c
(1.10-1.30)
1.53
(0.84-2.80)
3.23***
(1.69-6.16)

1.34***
(1.25-1.44)
1.32***
(1.25-1.40)
1.32***
(1.25-1.40)
1.29***
(1.22-1.37)
1.32***
(1.24-1.40)
1.15*
(1.02-1.30)
1.38***
(1.31-1.47)
2.56***
(1.91-3.44)

1.37***
(1.25-1.49)
1.34***c
(1.25-1.43)
1.32***
(1.24-1.42)
1.32***
(1.23-1.42)
1.33***
(1.23-1.44)
1.18*
(1.04-1.35)
1.42***
(1.32-1.53)
2.86***
(2.01-4.08)

1.27***
(1.15-1.41)
1.17***
(1.09-1.26)
1.15***
(1.07-1.24)
1.17***
(1.08-1.26)
0.99
(0.87-1.13)
e

(continued)

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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 167


Table 1: (continued)







Number of
Participants




Prevalence
Rates (#)

High vs. low ASB



Criminal convictions
for violent crimes
Age 21-25
828
15.7%

1,816
12.1%
Age 26-30

Age 31-35
1,776
9.4%

Age 36-40
1,714
7.5%

Age 41-45
1,619
5.8%

Age 46-50
902
4.6%

Age 21-50
1,862
24.8%

Medium vs.
low ASB
High vs. low ASB

Criminal convictions
for nonviolent crimes
Age 21-25
828
40.7%

Age 26-30
1,816
32.0%

Age 31-35
1,776
22.2%

Age 36-40
1,714
18.1%

Age 41-45
1,619
17.1%

Age 46-50
902
11.2%

Age 21-50
1,862
52.1%

Medium vs.
low ASB
High vs. low ASB

Poverty
Age 36-40
315
39.4%

Age 41-45
1,441
32.3%

Age 46-50
902
25.1%

(130)
(220)
(167)
(129)
(94)
(42)
(461)

(337)
(582)
(394)
(310)
(277)
(101)
(970)

(124)
(466)
(226)




Crude OR
(CI)


OR
(CI) Adjusted for
SES, Sex,
and Sex ASB

OR (CI) Adjusted
for SES, Sex,
and Sex ASB
and Substance
Misuse After Age 21

8.70***
(4.95-15.27)

8.09***
(4.19-15.62)

1.28***
(1.19-1.38)
1.30***
(1.22-1.38)
1.30***
(1.21-1.39)
1.35***
(1.26-1.46)
1.33***
(1.22-1.45)
1.20*
(1.02-1.42)
1.37***
(1.29-1.44)
2.91***
(2.16-3.93)
6.32***
(4.07-9.81)

1.28***c
(1.17-1.40)
1.31***c
(1.22-1.41)
1.30***c
(1.21-1.41)
1.35***c
(1.24-1.47)
1.35***c
(1.22-1.48)
1.21*
(1.00-1-45)
1.39***c
(1.30-1.50)
3.16***
(2.23-4.48)
6.42***
(3.81-10.84)

1.17***c
(1.07-1.29)
1.18***c
(1.09-1.27)
1.17***c
(1.08-1.26)
1.24***c
(1.14-1.35)
1.20***c
(1.09-1.31)
1.07
(0.90-1.27)
1.26***c
(1.18-1.35)
2.31***
(1.57-3.40)
3.49***
(1.99-6.13)

1.31***
(1.22-1.40)
1.30***
(1.23-1.38)
1.32***
(1.24-1.39)
1.35***
(1.28-1.44)
1.27***
(1.20-1.36)
1.25***
(1.11-1.40)
1.36***
(1.28-1.45)
2.72***
(1.99-3.72)
5.56***
(3.17-9.77)

1.32***c
(1.21-1.45)
1.33***c
(1.25-1.43)
1.34***c
(1.25-1.43)
1.37***
(1.28-1.47)
1.27***
(1.18-1.37)
1.28***
(1.13-1.46)
1.41***c
(1.31-1.53)
3.17***
(2.13-4.71)
5.45***
(2.75-10.78)

1.21***c
(1.10-1.33)
1.19***c
(1.11-1.28)
1.18***c
(1.10-1.27)
1.22***
(1.14-1.32)
1.15***
(1.07-1.24)
1.11
(0.98-1.26)
1.25***c
(1.16-1.36)
2.28***
(1.47-3.54)
2.51*
(1.20-5.25)

1.25***
(1.14-1.38)
1.26***
(1.19-1.34)
1.28***
(1.16-1.42)

1.29***
(1.14-1.45)
1.29***c
(1.20-1.39)
1.29***
(1.15-1.44)

1.12
(0.99-1.28)
1.16***c
(1.08-1.25)
1.15*
(1.03-1.28)
(continued)

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168 Criminal Justice and Behavior


Table 1: (continued)







Number of
Participants




Prevalence
Rates (#)




Crude OR
(CI)


OR
(CI) Adjusted for
SES, Sex,
and Sex ASB

OR (CI) Adjusted
for SES, Sex,
and Sex ASB
and Substance
Misuse After Age 21

Age 36-50
1,656
36.1% (598)

Medium vs. low ASB

High vs. low ASB

1.33***
(1.25-1.41)
3.29***
(2.39-4.52)
3.78***
(2.32-6.14)

1.36***c
(1.27-1.47)
3.45***
(2.36-5.05)
4.92***
(2.72-8.89)

1.22***c
(1.13-1.31)
2.48***
(1.62-3.78)
2.25*
(1.19-4.26)

Note. OR = odds ratio; CI = 95% confidence interval.


a. Individuals were included in the analyses up until the 5-year period when they died.
b. Parents socioeconomic status (SES) significantly associated with outcome at p < .05.
c. Sex significantly associated with outcome at p < .05.
d. Sex ASB interaction significantly associated with outcome at p < .05.
e. Substance misuse was controlled for in current and prior age periods and could therefore not be controlled for
in this age period.
*p < .05. **p < .01. ***p < .001.

convicted for both violent and nonviolent crimes during the whole follow-up period and
during eight of the 5-year age periods. However, few sex differences were detected after
taking account of ASB before age 15. The Sex ASB interaction term was not significant
for any of the eight outcomes over 30 years and was significant for only three 5-year age
periods. This suggests that the effect of ASB prior to age 15 on the adverse outcomes was
similar among males and females.
Odds ratios were estimated for the associations between different levels of ASB before
age 15 and each outcome for the entire 30-year follow-up period. Results show that individuals who exhibited medium levels of ASB before age 15, as compared to those who
exhibited low levels of ASB, presented significantly increased crude odds (from 1.40, 1.051.86, to 3.29, 2.39-4.52) of all adverse outcomes except for hospitalization for mental illness. Individuals who exhibited high levels of ASB before age 15, as compared to those
who exhibited low levels of ASB before age 15, presented significantly increased crude
odds (from 1.91, 1.24-2.94, to 8.70, 4.95-15.27) of all outcomes in adulthood except for
hospitalization for mental illness. After controlling for SES, sex, and Sex ASB, individuals with medium and high levels of ASB before age 15 presented increased odds of all
outcomes except for hospitalization for mental illness. After adjusting for substance misuse
in adulthood, associations remained significant for self-inflicted harm, convictions for violent and nonviolent crimes, and poverty.
Hypothesis 2: The more severe the ASB before age 15, the greater the number of different
adverse outcomes.

As presented in Figure 2, generalized linear models showed that each unit increase in
the severity of ASB prior to age 15 increased the number of adverse outcomes by 0.37
(p < .001; 95% CI 0.27-0.48) for men and 0.31 (95% CI 0.12-0.51) for women. The interaction term Sex ASB prior to age 15 was not significant, indicating no differential association among men and women.
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Number of adverse outcomes

Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 169

6
5
4
Males

Females

2
1
0

0
1
2
3
4
5
6
7
8
9 10
Ratings of antisocial behavior before age 15

Figure 2: Generalized Linear Models of the Associations Between Antisocial Behavior Before Age 15 and
Total Number of Adverse Outcomes Age 21 to 50 Among Males and Females

Hypothesis 3: The associations between the severity of ASB before age 15 and the adverse outcomes would persist over time.

Table 2 presents odds ratios estimating changes in the prevalence of outcomes over the
30-year follow-up period, controlling for age period, the interaction between age period and
severity of ASB prior to age 15, and the interaction between age period and severity of ASB
and sex. Results indicate that even though the prevalence of the outcomes decreased over
time, the associations between the severity of ASB prior to age 15 and the eight adverse
outcomes in adulthood did not differ across the six 5-year age periods or among women and
men. These analyses demonstrate that the effect of ASB before age 15 on the adverse outcomes did not decrease with time but remained stable throughout the entire 30-year followup period among both women and men.
DISCUSSION

In a cohort of 1,947 men and women who consulted a clinic for substance misuse as
adolescents, ASB before age 15 conferred increased risk for death, hospitalization for
physical illnesses related to substance misuse, self-inflicted harm, substance misuse, convictions for violent and nonviolent crimes, and poverty during the subsequent 30 years.
Results are consistent with prior research in suggesting that ASB with onset by early adolescence increases the risk of adversity in early adulthood (Fergusson & Woodward, 2000;
Kim-Cohen et al., 2003; Moffitt et al., 2002). The results extend previous findings by showing that the severity of ASB is associated with a broad array of adult outcomes indexing
serious health problems, criminal convictions, and poverty through three decades of adult
life similarly among males and females.
Hospitalization for mental illness after controlling for SES, sex, and Sex ASB was the
only outcome not associated with ASB before age 15, a finding that differs from observations in the Dunedin birth cohort (Kim-Cohen et al., 2003; Odgers et al., 2007). The divergent results are not easily explained but may be due to differences in samplesa birth cohort

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170 Criminal Justice and Behavior


Table 2:Generalized Linear Models of Changes in the Associations of Antisocial Behavior Before Age
15 and Eight Adverse Outcomes in Adulthood Over Time

OR

Death
Age period
1.14***
Age Period Antisocial Behavior Before Age 15
1.00
Age Period Antisocial Behavior Before Age 15 Sex
0.94
Hospitalization for physical illnesses related to substance misuse
Age period
1.02
Age Period Antisocial Behavior Before Age 15
1.01
Age Period Antisocial Behavior Before Age 15 Sex
1.01
Hospitalization for mental illness
Age period
0.93*
Age Period Antisocial Behavior Before Age 15
1.00
Age Period Antisocial Behavior Before Age 15 Sex
1.00
Hospitalization for self-harm
Age period
0.79***
Age Period Antisocial Behavior Before Age 15
1.02
Age Period Antisocial Behavior Before Age 15 Sex
0.96
Substance misuse
Age period
0.87***
Age Period Antisocial Behavior Before Age 15
0.99
Age Period Antisocial Behavior Before Age 15 Sex
0.99
Criminal convictions for violent crimes
Age period
0.80
Age Period Antisocial Behavior Before Age 15
1.01
Age Period Antisocial Behavior Before Age 15 Sex
0.96
Criminal convictions for nonviolent crimes
Age period
0.76***
Age Period Antisocial Behavior Before Age 15
1.00
Age Period Antisocial Behavior Before Age 15 Sex
1.01
Poverty
Age period
0.75***
Age Period Antisocial Behavior Before Age 15
1.00
Age Period Antisocial Behavior Before Age 15 Sex
1.03

CI
1.06-1.23
0.97-1.04
0.84-1.04
0.98-1.06
0.99-1.03
0.96-1.06
0.88-0.98
0.98-1.03
0.95-1.06
0.72-0.87
0.98-1.05
0.88-1.04
0.84-0.90
0.98-1.01
0.94-1.03
0.76-0.84
0.99-1.03
0.89-1.05
0.73-0.78
0.98-1.01
0.98-1.06
0.68-0.83
0.95-1.06
0.90-1.18

Note. OR = odds ratio; CI = 95% confidence interval.


*p < .05. ***p < .001.

and a clinic sample of individuals who as adolescents consulted a clinic for substance misuse
problemsand/or to differences in the measurement of mental illness. Whereas the current
study used health records and thereby identified only severe mental illnesses that had led to
hospitalization, the Dunedin study included diagnostic interviews with cohort members,
which may have detected untreated and/or less severe mental health problems.
The total number of adverse outcomes experienced by the participants increased as a
function of the severity of ASB before age 15. The findings are consistent with previous
research that related childhood and adolescent onset ASB to multiple adversities in early
adulthood among males (Moffitt et al., 2002). The findings are also consistent with the
limited number of studies on females (Fergusson, Horwood, & Ridder, 2005; Pajer, 1998).
These findings extend prior knowledge by demonstrating that individuals who displayed
ASB in early adolescence accumulate multiple problems that persist to age 50. The presence of comorbid health and psychosocial problems may promote persistence of ASB and
limit desistance and rehabilitation.
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Samuelson et al. / ADVERSE OUTCOMES TO AGE 50 171

The associations between ASB and the adverse outcomes remained stable from age 21 to
age 50. These results confirm and extend previous knowledge by showing that ASB before
age 15 continued to have a negative impact on the lives of the cohort members up to age 50.
Overall, these results highlight the importance of providing effective interventions in childhood and adolescence to reduce ASB.
Low parent SES was only associated with one outcomedeathover the 30-year
follow-up. This finding may be due to the extensive social safety net that existed in Sweden
at the time the cohort members were teenagers and young adults.
No differences were detected in the association of ASB prior to age 15 and outcomes
from age 21 to 50 among women and men. The associations persisted from age 21 to 50,
and the severity of ASB was positively associated with the number of adverse outcomes
equally among women and men. These findings confirm previous results as well as the
theory thatalthough ASB is less common among girls than among boysthe outcomes
are similar (Moffitt et al., 2001). Precisely because the prevalence of conduct problems is
lower among girls than among boys (Hay, 2007), health professionals have less experience
in detecting, assessing, and treating girls. As girls have often been the victims of abuse
(Hodgins et al., 2007), the tendency may be to treat them as victims and to fail to address
their ASB. The findings from this study suggest that girls ASB should be targeted for
intervention in order to prevent future adversity.
Importantly, the associations between ASB prior to age 15 and elevated risks for death,
hospitalizations for physical illnesses related to substance misuse, self-harm, violent and
nonviolent criminal convictions, and poverty were not explained by substance misuse in
adulthood. The results suggest, but do not prove, that the beginnings of these multiple
problems might have been present in adolescence. Recent studies of both community and
clinical samples of adolescents with substance misuse problems report that most present
mental disorders had onset prior to substance misuse (Armstrong & Costello, 2002). This
has also been found to be true of adolescents who in 2004 consulted the same clinic where
the cohort members in the present study were treated (Hodgins et al., 2007). Information
noted in clinical files from 1968 to 1971 was inadequate, however, to detect the presence
of comorbid mental disorders. In fact, mental disorders other than substance misuse were
not assessed, and consequently no treatment was provided for them. Thus, it may have been
that the cohort members with ASB prior to age 15 also had problems in other domains, that
these problems remained unidentified and untreated, and consequently that the negative life
trajectories that they were following were not interrupted but grew worse during the subsequent 30 years.
The present study is characterized by several strengths. The follow-up period was 30
years. The cohort was relatively large and included both males and females, allowing for the
study of gender differences. Attrition was minimal, including only the few individuals who
had emigrated from Sweden. The severity of ASB before age 15 varied greatly. Although
this was a clinical cohort, reasons for referral to the clinic ranged from individuals who had
been found drunk in a public place once to individuals with severe substance misuse problems. Outcome was defined broadly to include an array of problems, and each outcome was
documented from national registers that have been shown to be complete and reliable
(Mortensen et al., 1996).
The current investigation also has several limitations that should be taken into account
when interpreting the results. Although documenting long-term outcomes is advantageous,
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172 Criminal Justice and Behavior

it meant studying individuals who sought professional help more than 30 years ago. We
compared the individuals in the present study to those who consulted the same clinic in
2004. The most important difference was the increase in the percentage of girls, from
16.7% in the cohort studied to 55% in 2004. By examining ASB prior to age 15, associations with negative outcomes may have been underestimated, as most other studies have
examined the outcomes of conduct problems that had onset at younger ages. The severity
of ASB was low, especially when compared to current clinical samples of adolescents with
substance misuse problems attending the same clinic (Hodgins et al., 2007), yet it was
associated with elevated risk of multiple adverse outcomes over 30 years. In the late 1960s,
mental health professionals in Sweden were reluctant to assess ASB among adolescents.
The ratings of ASB likely underestimated conduct problems. Another limitation was the
restrictive definitions of the adult adverse outcomes, including, for example, only hospitalizations for physical illnesses related to substance misuse, and serious mental illnesses, and
official criminal convictions. Thus, other physical and mental illnesses were not measured,
nor were illegal activities that did not lead to a conviction in criminal court. Generalization
of the findings is limited to clinical samples of individuals who as adolescents sought help
for substance misuse.
The findings revealed that ASB with onset prior to age 15 was associated with a broad
array of negative outcomes through adulthood. Although ASB is relatively common and
even normative in adolescence (Moffitt, 1993), it is not necessarily a transient problem that
disappears as individuals age. It can have life-long negative consequences in multiple
domains and should therefore be targeted for intervention. These results suggest that adolescents displaying ASB require assessment and treatment for a wide range of difficulties
in an effort to shift them onto a socially adaptive life trajectory. The results of this study
also demonstrate that ASB in adolescence is associated with negative outcomes in adulthood equally among females as among males.
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Yasmina Molero Samuelson earned her degree in criminology at Stockholm University and is currently pursuing her doctorate at the Department of Clinical Neuroscience at Karolinska Institute. Her major research interest focuses on the longitudinal
development of antisocial behavior among women and men.
Sheilagh Hodgins is a professor at the Institute of Psychiatry, Kings College London. She conducts a large program of
research investigating the proximal and distal determinants of antisocial and violent behavior. She leads the study
Consequences of Antisocial Behaviour in Adolescence, which is funded by the Stockholm City Council.
Agne Larsson is a research analyst at the Research Centre for Adolescent Psycho-Social Health. He earned his masters
degree in statistics from the University of Linkping. His research interests include methods for analyzing longitudinal data.
Peter Larm is a PhD student in the Department of Clinical Neuroscience at Karolinska Institute. He earned his degree in
Social Work from Ume University. His research focuses on risk and protective factors for substance misuse in adolescence.
Anders Tengstrm received his PhD from Karolinska Institute in 2000. His primary research and clinical interests are program evaluation and interventions to improve the quality of life of adolescents with psychosocial problems, such as substance
abuse, antisocial lifestyles, and psychiatric problems.

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