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Precursors and diverse pathways to personality disorder in children and adolescents

Published online by Cambridge University Press:  07 July 2009

Dante Cicchetti  and
Nicki R. Crick
Dante Cicchetti*
Affiliation:
University of Minnesota
Nicki R. Crick*
Affiliation:
University of Minnesota
*
Address correspondence to Dante Cicchetti or Nicki R. Crick, Institute of Child Development, University of Minnesota, 51 East River Road, Minneapolis, MN 55455.
Address correspondence to Dante Cicchetti or Nicki R. Crick, Institute of Child Development, University of Minnesota, 51 East River Road, Minneapolis, MN 55455.
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Abstract

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A major goal of these two Special Issues, of which this issue is Part 1, is to examine the precursors and diverse pathways to the development of personality disorders in childhood, adolescence, and adulthood. Because personality disorders do not appear de novo in late adolescence and during the period of emerging adulthood, the investigation of the precursors and pathways to personality disorder during childhood and adolescence is essential to the formulation of life span developmental models of personality disorder. Childhood symptoms of personality pathology may not be phenotypically similar or identical to symptoms of personality disorder manifested in adulthood. Although phenotypic discontinuity may characterize the relation between childhood and late adolescent/emerging adulthood personality pathology, there may be continuity in the underlying meaning of the varying symptoms present in childhood, adolescence, and adulthood.

The historical belief was that personality disorders should not be diagnosed in children because their personalities were not fully integrated. Another major concern with diagnosing personality disorders in children relates to the possible stigmatization that could result (Hinshaw & Cicchetti, Reference Hinshaw and Cicchetti2000). Because personality pathology has often been viewed as being unmodifiable and recalcitrant to intervention, it was thought that diagnosing a child with a personality disorder could lead to a lifelong categorization of dysfunction. Research on normal personality development, as well as longitudinal investigations of personality pathology, reveal a much more dynamic portrayal of these processes than was previously thought (Caspi, Roberts, & Shiner, Reference Caspi, Roberts and Shiner2005; Caspi & Shiner, Reference Caspi, Shiner and Eisenberg2006; Clark, Reference Clark2009; Dweck, Reference Dweck2008; Rutter, Kim-Cohen, & Maughan, Reference Rutter, Kim-Cohen and Maughan2006). In contrast to viewpoints that personality pathology is pervasive, persistent, and pathological, findings emanating from longitudinal studies of individuals with personality disorder suggest that one need not be pessimistic about their future functioning outcomes. It will be important to ascertain whether prospective longitudinal studies of the development of personality pathology from childhood to adulthood yield similar conclusions. Adherence to a dynamic life span developmental perspective on personality disorder highlights the importance of conducting such investigations.

A growing consensus in the field is that there is a great need to incorporate developmental issues into conceptualizing personality disorders across the life span (Tackett, Balsis, Oltmanns, & Krueger, Reference Tackett, Balsis, Oltmanns and Krueger2009 [this issue]). Shortly after the publication of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), a number of authors emphasized the criticality of imparting an integrative life span developmental perspective on personality disorder into DSM-V (De Clercq & De Fruyt, Reference De Clercq and De Fruyt2007; Widiger & Clark, Reference Widiger and Clark2000; Widiger, De Clercq, & De Fruyt, Reference Widiger, De Clercq and De Fruyt2009 [this issue]; Widiger, Simonsen, Krueger, Livesley, & Verheul, Reference Widiger, Simonsen, Krueger, Livesley and Verheul2005). Such an approach would entail knowledge of the diverse childhood antecedents to personality disorders (Crick, Murray-Close, Woods, & Han, Reference Crick, Murray-Close, Woods, Han, Freeman and Reinecke2007; Rogosch & Cicchetti, Reference Rogosch and Cicchetti2004, Reference Rogosch and Cicchetti2005). Unfortunately, to date, there has been a paucity of research on childhood precursors and pathways to personality disorders (Crick, Murray-Close, & Woods, Reference Crick, Murray-Close and Woods2005). This state of affairs is hardly surprising given that most of the traditional nosological systems of psychopathology do not recognize personality pathology prior to the age of 18 (American Psychiatric Association, 1994), thereby hindering the design and implementation of longitudinal studies investigating possible childhood precursors to personality disorder. To achieve a thorough comprehension of the developmental antecedents and pathways to personality disorder across the life span, we believe that an interdisciplinary, multiple levels of analysis approach holds much promise (Lenzenweger & Cicchetti, Reference Lenzenweger and Cicchetti2005). With increased research on Gene × Environment interactions and neuroimaging, such a multilevel understanding of emergent personality and personality pathology becomes likely.

Before assigning personality disorder diagnoses to children, it may be more prudent to await the results of longitudinal investigations of the emergence of personality pathology across the life span. What is the developmental course like in children who have what appears to be a personality disorder? Could some personality disorders be more transitory, whereas others may be more lifelong, or at least recurrent? These are challenging distinctions that will be faced by scientists and practitioners alike.

The ongoing incorporation of developmental psychopathology principles into the conceptualization and investigation of personality pathology would be extremely helpful in elucidating the antecedents of personality disorder throughout the life span (Cicchetti, Reference Cicchetti1993; Geiger & Crick, Reference Geiger, Crick, Ingram and Price2001; Lenzenweger & Cicchetti, Reference Lenzenweger and Cicchetti2005; Sroufe, Reference Sroufe1997). For example, the systems theory concepts of equifinality and multifinality (Cicchetti & Rogosch, Reference Cicchetti and Rogosch1996) underscore that there are diverse pathways to, and varied outcomes from, different forms of personality pathology. Likewise, developmental psychopathologists assert that the study of normality and psychopathology are mutually influential. Thus, investigations of the development of normal personality and personality disorder should proceed in tandem (Shiner, Reference Shiner2009 [this issue]). Undoubtedly, insights into these pathways will emanate from research on normal personality development in childhood and adolescence, as well as from investigations of personality aberrations (Shiner, Reference Shiner2009 [this issue]).

Developmental psychopathologists are as interested in individuals at high risk for the development of personality pathology who do not manifest it over time as they are in individuals who develop an actual disorder (Luthar, Cicchetti, & Becker, Reference Luthar, Cicchetti and Becker2000; Masten, Reference Masten2001). Understanding how children overcome significant biological and psychological stressors and proceed on an adaptive developmental course is an area that holds great promise for informing the ontogenesis and epigenesis of personality pathology and prevention and intervention efforts (Cicchetti & Curtis, Reference Cicchetti and Curtis2007). If personality disorders are present in children, then it will be crucial to ascertain which treatment strategies will be most efficacious. Additionally, if prospective longitudinal studies reveal precursors of emergent personality disorders, then preventive interventions to deflect these children from their pathological developmental trajectories will need to be developed.

Alternative proposals for conceptualizing personality disorders in DSM-V are presently being proffered. Because of the significance of the topic, we have devoted two Special Issues to studies investigating precursors and diverse pathways to personality disorder in children and adolescents. Another goal in these Special Issues is to encourage theoreticians and researchers who do not typically focus on personality disorders (Axis II) to stretch their thinking in ways that would inform our understanding of personality pathology. In particular, we were interested in targeting researchers whose area of expertise is the development of Axis I disorders that are comorbid with personality disorders (e.g., depression) and researchers whose work is primarily focused on normal personality development instead of clinical disorders. We were also interested in including conceptual frameworks of researchers and theorists who investigate personality disorders but who typically focus on adults. We wanted them to get beyond their comfort zones and apply their expertise to children and adolescents.

We believe that these Special Issues will focus much needed attention on the etiology of personality disorders, a much neglected topic in research, yet an extremely serious, widespread problem for society. These Special Issues should direct attention to the many practical concerns involved in considering the development of personality disorders, such as the problems of labeling youth with these often stigmatizing diagnoses (e.g., insurance issues) weighed against the consequences of waiting until adulthood to identify the suffering experienced by youth who are dealing with these disorders. We hope that the articles contained within these Special Issues will stimulate creative research initiatives directed toward an increased understanding of diverse etiological pathways that may eventuate in personality disorders. Equally important, increased knowledge and, ultimately, its exportation to clinical arenas may decrease the burden of mental illness and the stigmatization associated with personality disorders.

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