Male Life-Course-Persistent Antisocial Behavior:  The Most Important Pediatric Mental Health Problem

In recognition of the public health importance of mental disorders, the most widely circulated medical journal in the world, JAMA, is devoting a theme issue to this topic.¹ In concert with this recognition, this commentary will contend that male life-course-persistent (LCP) antisocial behavior is arguably the most important pediatric mental health problem for several reasons. First, LCP antisocial behavior, which refers to the childhood onset of severe conduct problems that emerge from early neurodevelopmental (eg, attention-deficit/hyperactivity disorder) and family adversity risk factors, is the most widely accepted model for delineating pathways in the development of conduct problems.² Second, the social cost of LCP antisocial behavior is great as it is almost always a prognosticator of poor adult adjustment.² For example, the landmark Dunedin 30-year longitudinal study of 1000 children from ages 3 to 32 years reported that individuals with LCP antisocial behavior had an array of serious problems in many domains, such as (1) mental health (eg, suicide, substance abuse), (2) physical health (eg, compromised cardiovascular and respiratory functioning), (3) economic situation (eg, chronic unemployment, severe financial problems), and (4) criminality and violence toward others (eg, partner and child abuse).³ These outcomes are even more likely for the subgroup of youth with LCP antisocial behavior who have callous and unemotional traits, which predict psychopathy in adulthood.⁴ Individuals with LCP antisocial behavior, especially those with callous and unemotional traits, are the “few, persistent, and pathological”² who come from 7% to 10% of the families in any community and who across their life spans commit more than 50% of crimes in the United States.^2,5 Third, the financial cost is large, with each chronically violent individual costing society an average of 2 million dollars.⁶ Fourth, the sex ratio is substantial as males are astonishingly 10 to 14 times more likely than females to develop LCP antisocial behavior, thus making it an almost exclusively male phenomenon.² This substantial sex difference is due in great part to the greater male vulnerability to a host of neurodevelopmental risk factors that in interaction with family and environmental adversity exponentially increase the probability of violent behavior.^2,7 In sum, it would seem difficult to exaggerate the importance of the pediatric mental health problem of male LCP antisocial behavior.