Antisocial personality disorder and related factors of adolescents in multi-ethnic areas of China: A cross-sectional study

doi:10.21203/rs.3.rs-1961376/v1

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Antisocial personality disorder and related factors of adolescents in multi-ethnic areas of China: A cross-sectional study

https://doi.org/10.21203/rs.3.rs-1961376/v1

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Background Antisocial personality disorder (ASPD) has a high incidence and does serious harm to society and families. Although it has received widespread attention, there is no research on the relationship between ASPD and ethnic groups. Therefore, our goal is to study the prevalence, potential risk factors and ethnic correlation of ASPD among adolescents in multi-ethnic areas of China.

Methods We collected a sample of 2571 adolescents in China using a cross-sectional study. SPSS22.0 software was used with chi-square test for univariate analysis, logistics regression for multivariate regression analysis, to explore the distribution of ASPD and the relationship between social demographic factors.

Results The positive rate of ASPD screening among adolescents in multi-ethnic areas in China is 24.2% (95%CI:22.5~25.8). Univariate chi-square test showed that gender, age, educational background, nationality, subjective family economic situation, single-child family, father's education level and mother's education level were related to the positive rate of ASPD screening, and the difference was statistically significant. Further logistics regression analysis showed that male (OR=3.541,95%CI: 2.915-4.301), Lisu nationality (OR=1.750,95%CI: 1.259-2.433) and single-child family (OR=,95%CI: 1.028-1.776) were independent risk factors for ASPD. Age ≥ 19 (OR=0.394,95%CI：0.219~0.712) and educational background of senior high school (OR=0.451,95%CI：0.311~1.106) are protective factors of ASPD.

Conclusions High positive rate of ASPD screening among adolescents in multi-ethnic areas of China. Gender, age, educational background, nationality, subjective family economic situation, single-child family, father's education level and mother's education level are the influencing factors of ASPD. Male, Lisu nationality and single-child family were independent risk factors for positive ASPD screening, while age ≥ 19 years old and high school education were protective factors for ASPD.

antisocial personality disorder

nationality

adolescents

related factors

cross-sectional study

Antisocial personality disorder (ASPD) is characterized by widespread neglect of the feelings of others, usually accompanied by violations of the rights of others through negligence or public action ^[1]. The results of previous epidemiological investigations show that the prevalence rate of ASPD among adults in the community sample is 3.3% to 19% ^[2-4], 0.78% in the elderly aged ≥65 years ^[5], and 30.6%-47% in prison samples ^[6-7]. Aggressive behavior is the general behavior pattern of the disease^[8], which may be harmful to oneself or others and is illegal ^[9]. It is difficult for ASPD patients to comply with social norms and laws, so it is difficult for them to maintain stable work and interpersonal relationships, and they are often expelled by social environments, such as family, friends and work, resulting in high unemployment and divorce rates ^[1]. In addition, most ASPD patients may have multiple mental disorders such as post-traumatic stress disorder, severe depression, anxiety disorder, addictive behavior, panic disorder, social phobia, special phobia and bipolar disorder, and the incidence of suicidal behavior and attempted suicide is much higher than the normal people ^{[1-3,5,10,11]}. Such a high prevalence rate and the destructiveness of ASPD make patients become a serious social problem.

Some people believe that the disease is caused by the interaction of genetic environmental, biological, psychological and psychosocial factors ^[8]. Currently, several studies have systematically examined the risk factors for ASPD. ASPD is related to age, marital status, family income, education level and place of residence ^[5,6,8,12]. However, these studies mainly analyzed communities, hospitals and prison populations. Sample differences may lead to different results, which may make previous research results not widely applicable to Chinese teenagers. Due to historical reasons, a country can have different nationalities. China is a country composed of 56 ethnic groups. However, there are few studies that include the important factor of nationality in the study. Therefore, our goal is to study the prevalence, potential risk factors and ethnic correlation of ASPD among adolescents in multi-ethnic areas of China.

Object of study

The study population is composed of students from ordinary middle schools, vocational middle schools, senior high schools and universities in Yunnan Province. Exclusion criteria: (a) suffering from severe physical illness; (b) previously diagnosed mental disorders; (c) those who refused to participate in the survey.

Methods

Instruments

General information questionnaire

The questionnaire includes the factor of gender, age, grade, nationality, single-child family, family structure, family economic level, family location, father's education level and mother's education level.

Personality Diagnostic Questionnaire Fourth Edition Plus（PDQ-4+)

PDQ-4+^[13] prepared by Dr. Hyler of the United States, the Chinese version of PDQ-4+ used in this study contains 107 items to evaluate 12 types of personality disorders in the DSM-IV system. The answer to the project is "yes" or "no", with a score of 1 or 0. The positive result of ASPD subscale screening was defined as score ≥ 3. In this study, the Cronbach's α of PDQ-4+ scale was 0.932.

Quality control

The study adopted the method of convenient sampling. In December 2021, students from 9 schools in Lijiang City, Dali Bai Autonomous Prefecture and Nujiang Lisu Autonomous Prefecture in Yunnan Province were investigated with general data questionnaire and PDQ-4+. The informed consent of all participants was obtained in this study, and the researchers adhered to the principles of the Helsinki Declaration throughout the study.

The questionnaire issuing personnel were trained to use unified instructions to guide students to fill in the questionnaire, distributed and recovered on the spot, and the quality of the original data was controlled. The questionnaires lacking basic information, obvious logic errors and random answers were considered as abnormal questionnaires and excluded. After recovered the questionnaire, the data was inputted into EpiData3.1 for saving, with two researchers check data together to reduce the input error.

Statistical analysis

The data were analyzed by SPSS22.0 (IBM^®) statistical software. The chi-square test was used to compare the positive rate of screening among different gender, age, education, nationality, subjective family economic situation, single-child family, family structure, father's education level and mother's education level and ASPD. Logistics regression analysis was used to study the influencing factors of positive ASPD screening. P < 0.05 was defined as statistically significant.

Sample feature

A total of 3006 questionnaires were collected, of which 2571 were valid, with an effective recovery rate of 85.53%. Among them, there were 940 males (36.6%) and 1631 females (63.4%), The age ranged from 13 to 24 years old, the average age was 16.92±1.43 years old.

Positive rate of screening for antisocial personality disorder

In this study, the positive rate of ASPD screening among adolescents in multi-ethnic areas of China was 24.2% (95%CI: 22.5 to 25.8).

Univariate analysis of antisocial personality disorder

The data of positive ASPD screening and negative screening were compared. Single factor chi-square test showed that gender, age, education, nationality, subjective family economic situation, single-child family, father's education level and mother's education level were significantly related to ASPD screening positive between the two groups (Table1).

Table 1 Univariate analysis of ASPD（N=2571）

Variables	Category	Total（N,%）	ASPD
Variables	Category	Total（N,%）	Positive	Negative	χ^２	P
Gender	Male	940	377	563	205.828	0.000
	Female	1631	244	1387
Age	≤15	318	121	197	59.358	0.000
	16	657	152	505
	17	915	212	703
	18	371	98	273
	≥19	310	38	272
Education background	Junior high school	272	108	164	50.500	0.000
	Senior high school	2029	474	1555
	University/college	270	39	231
Nationality	Han	921	175	746	30.007	0.000
	Bai	625	186	439
	Yi	511	118	393
	Lisu	337	100	237
	Others	177	42	135
Subjective family economic situation	Poor	444	136	308	17.114	0.000
	Medium	2070	465	1605
	Affluence	57	20	37
Residence	Rural	2421	575	1846	3.688	0.055
	Urban	150	46	104
Single-child status	Yes	377	116	261	10.553	0.001
	No	2194	505	1689
Family structure	Raised by parents	2253	530	1722	5.520	0.133
	Single-parent family	207	56	151
	Foster families	18	7	11
	Remarried family	93	28	65
Father's educational level	Primary school and below	914	203	711	10.141	0.017
	Junior middle school	1328	321	1007
	Senior high school	266	73	193
	University and above	63	24	39
Mother's educational level	Primary school and below	1222	271	951	12.550	0.006
	Junior middle school	1104	270	834
	Senior high school	211	70	141
	University and above	34	10	24

Multivariate analysis of antisocial personality disorder

Taking adolescents with or without positive ASPD screening as dependent variables and general demographic data of P < 0.15 in univariate analysis as independent variables, binary logistic regression analysis was carried out. Take the variable with the least assignment as the dumb variable, the independent variable assignment is shown in Table 2. The results showed that male participants were 3.541 times more likely to be positive for PD screening than women (OR=3.541,95%CI: 2.915-4.301). Compared with Han nationality, Lisu participants were 1.750 times more likely to be positive for ASPD screening (OR=1.750,95%CI: 1.259 to 2.433). Compared with non-single-child family, single-child family were 1.351 times more likely to be positive for ASPD screening (OR=1.351,95%CI: 1.028-1.776). Age ≥ 19（OR=0.394,95%CI：0.219~0.712）and senior high school educational background（OR=0.451,95%CI：0.311~1.106）are protective factors for positive ASPD screening (Table 3).

Table 2 Variable assignment table of multiple logistics regression analysis

Variable name	Assignment
Gender	Female=0, Male=1
Age	≤15=1, 16=2, 17=3, 18=4, ≥ 19=5
Education background	Junior high school=1, Senior high school=2, University/college=3
Nationality	Han=1, Bai=2, Yi=3, Lisu=4, Others=5
Subjective family economic situation	Poor=1, Medium=2, Affluence=3
Residence	Rural=1, Urban=2
Single-child status	No=0, Yes=1
Family structure	Raised by parents=1, Single-parent family=2, Foster families=3, Remarried family=4
Father's educational level	Primary school and below=1，Junior middle school=2，Senior high school=3, University and above =4
Mother's educational level	Primary school and below=1，Junior middle school=2，Senior high school=3, University and above =4

Table 3 Multivariate logistics regression analysis of antisocial personality disorder (n=2571)

Variables	Category	ASPD
		β	OR	95%CI	P
Gender	Male	Ref
	Female	1.264	3.541	2.915~4.301	0.000
Age					0.005
	≤15	Ref
	16	-0.117	0.890	0.576~1.375	0.599
	17	-0.037	0.963	0.623~1.490	0.867
	18	0.037	1.037	0.649~1.659	0.878
	≥19	-0.930	0.394	0.219~0.712	0.002
Education background					0.002
	Junior high school	Ref
	Senior high school	-0.797	0.451	0.290~0.701	0.000
	University/college	-0.534	0.586	0.311~1.106	0.099
Nationality					0.013
	Han	Ref
	Bai	0.272	1.312	0.989~1.742	0.060
	Yi	0.143	1.153	0.866~1.537	0.329
	Lisu	0.560	1.750	1.259~2.433	0.001
	Others	0.377	1.458	0.957~2.221	0.079
Subjective family economic situation					0.073
	Poor	Ref
	Medium	-0.258	0.752	0.587~0.962	0.024
	Affluence	-0.129	0.879	0.463~1.668	0.694
Residence	Rural	Ref
	Urban	0.198	1.219	0.784~1.893	0.379
Single-child status	Yes	0.301	1.351	1.028~1.776	0.031
	No	Ref
Family structure	Raised by parents				0.348
	Single-parent family	Ref
	Foster families	0.079	1.082	0.759~1.544	0.662
	Remarried family	0.819	2.267	0.815~6.309	0.117
		0.224	1.251	0.765~2.046	0.371
Father's educational level					0.546
	Primary school and below	Ref
	Junior middle school	-0.068	0.934	0.741~1.178	0.566
	Senior high school	-0.012	0.988	0.688~1.418	0.947
	University and above	0.418	1.519	0.756~3.051	0.240
Mother's educational level					0.078
	Primary school and below	Ref
	Junior middle school	0.124	1.132	0.904~1.418	0.279
	Senior high school	0.437	1.547	1.063~2.253	0.023
	University and above	-0.410	0.663	0.252~1.745	0.406

NOTE：Ref: reference

This study shows that the positive rate of ASPD screening among adolescents in multi-ethnic areas of China is 24.2%(95%CI:22.5 ~ 25.8). The results were much higher than those in community samples of psychiatric outpatients in Shanghai, China, psychiatric outpatients in Southwest Ethiopia, residents in Chengdu, China and community sample of Montreal men, where the incidence of ASPD was 0.6% ^[12], 7.2% ^[14], 5.91% ^[15] and 16% ^[4], respectively. The incidence of inmates is lower than that of the Dessie Correctional Centre Prison in Ethiopia (30.6%) ^[6]. The above differences may be due to differences in sample selection. All the samples in the above study came from hospitals, communities and prisons, while this study was conducted in schools in ethnic minority areas in China. A recent Meta analysis shows that psychological interventions such as Contingency Management + Standard Maintenance, Schema Therapy and Dialectical Behavior Therapy and the like may change antisocial behavior in ASPD, but the quality of the evidence is very poor [9]. At the same time, they also summarized the effect of drug intervention on ASPD. Unfortunately, this study is not sufficient to draw any conclusions about the use of drug interventions in the treatment of ASPD ^[16]. Therefore, the intervention and treatment of ASPD remains a major challenge.

Gender is an independent influencing factor of positive ASPD screening. The results of this study show that the gender difference in diagnosing ASPD performs males is 3.55 times higher than females, which is basically consistent with the result that the prevalence of ASPD among psychiatric outpatients in southwestern Ethiopia that is 3 times higher than females ^[14]. The risk of violence and ASPD in males is 3–5 times higher than that in females. However, the antisocial behavior patterns of patients with ASPD vary from gender to gender, and men with ASPD are more likely to participate in illegal violence, while women with ASPD are more likely to commit non-violent antisocial behavior ^[18]. It may be that men who are in adolescence are impulsive, irritable and advocate force to solve problems, so they are more prone to violent attacks.

The nationality of Lisu is also an independent affecting factor of the occurrence of ASPD. The Lisu is one of the 56 nationality minorities in China, mainly distributed in Yunnan, Tibet and the border area of Kachin in Myanmar, while the rest are scattered in other parts of Yunnan, northeast India and the border area between Thailand and Myanmar. In the past, the Lisu villages had not yet formed a unified and authoritative organ of authority, which often led to armed struggle when disputes were caused by marriage, land usage right, debt, theft and the like that huge amounts of young and middle-aged men in the village would take part in. It may be because of this traditional national culture and geographical location that Lisu teenagers are more prone to use violence. However, people with ASPD are prone to lifelong violence ^[19]. Therefore, the future research should take the characteristics and differences of nationalities into consideration, so as to explore the influence of nationalities on the occurrence and formation of ASPD.

Age is the protective factor of ASPD. A recent longitudinal study shows that the average level of ASPD characteristics decreases moderately over time from late adolescence to adulthood, indicating that younger people are more likely to develop ASPD. What is disturbing is that the antisocial personality of some patients will gradually increase with age, from immoral to illegal acts such as robbery, theft and drug abuse ^[18]. It also shows the importance of timely intervention of ASPD. Education is also a protective factor of ASPD. In China, there is often a certain age limit for enrollment, for example, the age for admission to primary school must be ≥ 6 years old. This requirement also ensures that in the schools in this sample survey, students in the same grade are about the same age. The results of this study show that, compared with junior high school education, high school and college education are protective factors for positive ASPD screening, but college education is not statistically significant. Previous studies have also shown that the incidence of ASPD is the highest with education below senior high school ^[2], and there is a negative correlation between education level and the diagnosis of ASPD ^[21]. Therefore, age ≥ 19 years old and high school education are protective factors of ASPD.

If a couple has only one child, the family structure is called the single-child family, and this child is called single-child. The single-child family is an independent risk factor for ASPD. The results of Yan Tan et al ^[22] in personality disorder screening among all new employees in 12 machinery factories in China showed that the score of single-child employees was significantly higher than that of non-single-child employees in antisocial personality disorder subtypes. This is basically consistent with the results of this study. Perhaps it is because the single-child family alone enjoys the care from the whole family that they are easily overprotected by their parents. However, the lack of parents' daily and emotional care and care or parents' excessive protection from an early age are the main social factors for the formation and development of antisocial personality ^[23]. It can be seen that family factors play an extremely important role in the formation and development of personality disorder.

The results of univariate analysis showed that the subjective family economic situation was the influencing factor of ASPD. It is basically consistent with the research results of Muhammed Seid et al that monthly income is a predictor of ASPD ^[6]. It is very impolite to talk about or ask about other people's financial situation openly in the context of Chinese culture, and most of the children do not know the specific income of their families. So, when we designed the questionnaire, we used the subjective family financial situation as an option to represent the family's income, rather than the specific value. The educational level of father and mother is the influencing factor of antisocial personality disorder, which is consistent with the results of the study conducted in Finland ^[24]. The educational level of father and mother determines the educational atmosphere of the family to a great extent, and the environment in which children grow up greatly affects the formation of personality ^[22].

First of all, this study is a cross-sectional study, which cannot represent whether there is a direct relationship between adolescent and adult ASPD. Therefore, it is suggested that a longitudinal study should be conducted in the future. In addition, ASPD is not caused by a single factor, this study only studies the general demographic factors. In the future, we can add genetic environment, biological, psychological and social factors to explore the influencing factors of ASPD. Finally, this study only recruits in one province, and the inclusion of ethnic groups is limited. It is suggested that wider research should be carried out in the future to include the role of more ethnic groups in the formation and development of ASPD.

The positive rate of ASPD screening among adolescents in multi-ethnic areas in China is high. Gender, age, educational background, nationality, subjective family economic situation, single-child family, father's education level and mother's education level are the influencing factors of ASPD. Male, Lisu nationality and single-child family were independent influencing factors of positive ASPD screening, while age ≥ 19 years old and high school education were protective factors of ASPD. In the future, it is suggested to include more influencing factors to study the impact on ASPD.

ASPD

Antisocial personality disorder

SPSS

Statistical Packaging for Social Science

odds ratio

Confidence.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethical Review Board of Dali University. Participants were fully aware of the purpose and potential benefits of the study. This information is collected after obtaining the informed consent of each participant, participating in the study is voluntary, and has the right to withdraw from the study at any time. The names and personal information of the participants were closely protected throughout the study. All methods are carried out in accordance with the relevant guidelines and regulations.

For participants under the age of 16, after obtaining their informed consent, we then telephoned for the informed consent of their parents and/or legal guardians, and informed consent has obtained from all parents and/or guardians of children under 16 years of age.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. Email: [email protected]

Competing interests

The authors declare that they have no conflicts of interest.

Funding

This research project is supported by the second batch of innovation team of Dali University, "Health Care Research and Innovation team of Special groups in the Western Minority areas of Dali University"(Project number：XYPY2020303)

Authors’ contributions

Qiao Zhou, Yu Wan and Yanfen Fu designed and supervised research progerss, collected, analyzed and interpreted data; Jianhua Wang, Liying Yang, Fang Shen, Qinmin Ni, Qiu Tan, Liting Dong, Jing Yang, Hong Peng, Shixiao Zhang, Jibiao Huang and Xueyan Gao assisted in designing, collecting, analyzing and interpreting data; and Qiao Zhou, Yu Wan and Yanfen Fu wrote the manuscript. All authors contributed to data analysis, drafting and critical revision of papers, and agreed to be responsible for all aspects of the work. All authors reviewed the manuscript.

Acknowledgements

We would like to thank the staff of the Education Bureau of Lijiang City, Dali Bai Autonomous Prefecture, and Nujiang Lisu Autonomous Prefecture for their support and assistance throughout the study process.

Authors' information

Qiao Zhou, Email: [email protected]

Yu Wan, Email: [email protected]

Jian Hua, Email: [email protected]

Liying Yang, Email: [email protected]

Fang Shen, Email: [email protected]

Qinmin ni, Email: [email protected]

Qiu Tan, Email: [email protected]

Liting Dong, Email: [email protected]

Jing Yang, Email: [email protected]

Hong Peng, Email: [email protected]

Shixiao Zhang, Email: [email protected]

Jibiao Huang, Email: [email protected]

Xueyan Gao, Email: [email protected]

Yanfen Fu, Email: [email protected]

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No competing interests reported.

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Antisocial personality disorder and related factors of adolescents in multi-ethnic areas of China: A cross-sectional study

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