Psychological Assessment of Participants
Children / Adolescents
All child underwent a psychological personality test, the Freiburg Personality Inventory (FPI) conducted by trained psychologists 27. FPI was conducted to identify the subjects with CD. The FPI has shown to be a valuable tool for the early identification of AST. The FPI is comprised of 98 items in the form of a questionnaire. Each item on the FPI is related to one of the seven inventory scales measuring the risk/tendency for a certain personality trait:
FPI 1. Socially Desirable Response
Replies in a manner that will be viewed favorably by others
FPI 2. Breaking the Code of Practice
Breaks the norms and rules of behavior and the values established by society
FPI 3. Addictive behavior
The readiness for addictive behaviour
FPI 4. Self-destructive behaviour
The tendency to engage in certain kinds of self-destructive acts such as both social and literal suicide i.e. self harm
FPI 5. Aggression and violence
The tendency to express violence and aggression
FPI 6. Volitional control of emotional reactions
The tendency to lack cognitive appraisal of a given situation i.e. emotional reaction without awareness
FPI 7. Delinquent Behavior
The readiness to engage in delinquent behavior.
The FPI was chosen because of its high reliability and internal consistency (Cronbach's alpha) 2829
The combination of FPIs scores were compared between control subjects and CD subjects. Raw values were first normalized relative to FPI and later transformed to a standard score scale 3031. The subjects with scores within a normal range in all FPIs were denoted as “control” subjects 32.
Otherwise, the subject was considered “at-risk” for CD. To avoid highly skewed responses in the CD group, two groups were assigned for those at risk: low CD who had abnormal scores in three or less items, and those with high CD who had four or more items.
To avoid stigmatization of the children, youth, and/or their parents, each parent was given a verbal explanation of terms such as “CD”, “low and high scores in a given psychological test”, or “questionnaires” prior to the study. Moreover, if the subject was identified as a person with, CD in the future both the subject and the parent will be offered psychotherapeutic sessions (free of charge). The training program will be comprised of elements of cognitive-behavioral 33 and Rogerian therapies34 in combination with art-therapy 35.
All subjects and their mothers underwent a semi-structured individual clinical interview by a trained psychiatrist, psychologist and neurologist. The interview was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-R; American Psychiatric Association, 2000). The interview enabled a multi-axial assessmentwhich facilitated a comprehensive and systematic evaluation of the various risk/predictive and comorbid factors
Magnetic Resonance Imaging
Brain MRI scans were performed on a 1.5 Tesla (Philips-Intera) MRI. The MRI protocol, i.e. sequences and scanning duration, was optimized for the studied age groups. The following standard protocols were used to acquire both T1 and T2 weighted images in the axial and sagittal planes: T2 TSE in axial plane, T2 FLAIR-MV in axial plain, T1 SE in sagittal plane, T2 TSE SPIR-MV in coronal plain and T2 TSE SPIR-MV in coronal plain. The whole brain was checked for anatomical abnormalities. The regions related to antisocial behaviour 1516) was identified as target regions.
T2 TSE in axial plane: Twenty-two images, 6 mm slice thickness, with 1 mm gap were acquired; TE - 110 ms, TR – 4889.6 ms, FOV - 230/230 mm, matrix-384/304. The signal intensity can indicate intraparenchimal abnormalities associated with necrosis, cyst formation, vasogenic and cytotoxic oedema, inflammation, etc. The major pitfall of this protocol is that high-intensity signal areas associated with brain tissue abnormalities, adjacent to ventricles and/or subarchnoidal space can be missed due to cerebrospinal fluid (CSF) signal intensity. The same areas also present a signal hyperintensity on T2 images. To avoid possible artifacts, T2 FLAIR sequencing was run as well.
T2 FLAIR-MV in axial plain: Forty-five images, 3 mm slice thickness with 1 mm gap were acquired; TE - 140 ms, TR - 11000 ms, FOV - 219/219 mm, matrix-200/50. This sequence attenuates CSF signal and therefore provides better contrast at the interface of brain with CSF, which improves the likelihood of detecting small white-matter lesions. The MV technique was used to correct motion artifacts.
T1 SE in sagittal plane: Twenty-two images, 5 mm slice thickness with 1 mm gap were acquired; TE - 15 ms, TR – 596.2 ms, FOV - 210/210 mm, matrix - 236/188. T2 sequences can provide resolution for detection of intraparenchimal damage. Nevertheless, the increased signal intensity due to oedema on T2 images might obscure a lesion. Therefore, T1 provides better anatomical detection of an underlying lesion. It also provides high contrast between gray and white matter and is well suited for the detection of cortical lesion.
The whole brain was checked for anatomical abnormalities. The regions related to antisocial behaviour789 was identified as target regions (see below)
The MRI protocol contained two more sequences that also improved the image quality of midline subcortical structures (e.g., hippocampus), detection of any possible tumors (without contrast agents) and abnormal tissue related to possible acute, vasogenic alterations
T2 TSE SPIR-MV in coronal plain: Twenty-eight images, 4 mm slice thickness with a 1 mm gap; TE - 120 ms, TR - 4000 ms, FOV - 199/199 mm, matrix - 332/30;
DWI in axial plain: Forty-four images, 5 mm slice thickness with a 1 mm gap; TE - 74 ms, TR – 3206.6 ms, b-values of 500 or 1000; FOV - 229/229 mm, matrix-112/89.
The following areas were identified as target regions: frontal lobe 15163738, temporal lobe 38, parietal lobe/angular gyrus and cingulate cortex 39, hippocampus 4041, amygdala 42, and corpus callosum 43. The abnormalities in the above mentioned structures have been reported to disrupt moral thinking and feeling, produce poor emotional decision making, behavioral planning, attentional shifts, memory disabilities, and problems in reading and arithmetic. Abnormalities in these areas can predispose and give rise to antisocial tendencies (rule-breaking) and/or behaviour 4445