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Obstetric Complications, Parenting, and Risk of Criminal Behavior
Sheilagh Hodgins, PhD;
Lynn Kratzer, PhD;
Thomas F. McNeil, PhD
Arch Gen Psychiatry. 2001;58:746-752.
ABSTRACT
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Background The results of studies that have examined the relationship between prenatal
and perinatal complications and adult criminality and violence are contradictory.
Supporting evidence for this relationship comes from studies of samples drawn
from a single cohort. The present study was designed to examine the associations
between prenatal and perinatal complications and criminality, defining more
precisely than past investigations subject characteristics and the types of
offenses.
Methods The cohort includes the 15 117 persons born in Stockholm, Sweden,
in 1953 and followed up to age 30 years. Information was extracted from obstetric
files, health, social, work, and criminal records. Obstetric complications
were defined as deviations from normal development occuring at any point from
conception through the neonatal period. Inadequate parenting was indexed by
social intervention.
Results Inadequate parenting was experienced by 19.1% of the men and 18.1% of
the women, and was shown to increase the risk of offending (men, 1.39 times
[95% confidence interval {CI}, 1.28-1.50]; women, 2.09 [95% CI, 1.70-2.56])
and of violent offending (men, 2.02 times [95% CI, 1.67-2.44]; women, 2.09
[95% CI, 1.70-2.56]). Obstetric complications in the absence of family problems
did not increase the risk of offending. A combination of pregnancy complications
and inadequate parenting affected 3.1% of the men and 4.0% of the women, and
increased the risk of offending (1.64 times [95% CI, 1.43-1.89]; 1.79 times
[95% CI, 1.16-2.75], respectively) and violent offending (2.86 times [95%
CI, 2.09-3.91]; 1.81 times [95% CI, 0.57-5.79]).
Conclusions A combination of pregnancy complications and inadequate parenting increased
the risk of violent and nonviolent offending only slightly more than inadequate
parenting alone. However, inadequate parenting was experienced by 5 times
more cohort members than was the combination of inadequate parenting and pregnancy
complications.
INTRODUCTION
THE RESULTS of studies that have examined the relationship between obstetric
complications (OCs) and adult criminality and violence are contradictory.
Obstetric complications are defined as the broad class of deviations from
the expected, normal course of events, including child development during
pregnancy, labor/delivery, and the early neonatal period.1
Prospective investigations of the prevalence of OCs experienced by members
of a cohort with criminal records compared with those with no criminal record,
found no differences2, 3 or provided
very weak or questionable evidence of differences.4, 5, 6
Similarly, retrospective studies have found no differences in the prevalence
of OCs experienced by female adolescent offenders and female nonoffenders.7, 8 In contrast, studies of samples from
a single birth cohort provide evidence that birth complications and difficulty
in the neonatal period are related to impulsivity, and, in combination with
some type of family adversity (parental mental disorder, maternal rejection),
to aggressive behavior and violent criminality.4, 9, 10, 11, 12
Furthermore, this evidence suggests that the association between a combination
of OCs and adversity and violent crime may only apply to men who presented
a stable pattern of conduct problems from childhood onward.12
The contradictory findings are likely the result of the methodological
features of the investigations. The relevant studies have all used varying
definitions and sources of information about OCs and psychosocial adversity.
While many investigations have consistently reported that low socioeconomic
status and inadequate parenting are associated with the development of criminality,13, 14 the interaction of these family variables
with OCs has not been examined. Several studies failed to conduct analyses
separately for men and women, even though men are at a higher risk for both
offending and for brain insults during the early stages of life. None of the
studies have excluded persons with mental retardation and with major mental
disorders, who are at higher risk for both offending15, 16, 17
and for OCs18, 19, 20, 21
than those in the general population. Finally, the available findings may
be contradictory because persistent offenders, those who have had conduct
problems since childhood and who commit most of the crimes,22, 23
have not been distinguished from other types of offenders. Much evidence has
accumulated from investigations conducted in several different countries,
confirming similar prevalence rates and characteristics specific to this type
of offender.24, 25, 26
Etiological factors, which act early in life, are suspected to play a role.27 Hereditary factors have been identified,28, 29 and the results of 2 investigations
support the hypothesis of an involvement of OCs. An adoption study indicates
that prenatal exposure to alcohol interacts with a hereditary vulnerability,
contributing to the development of conduct problems and aggressive behavior,30 and sons of mothers who were malnourished during
the first and second trimesters of pregnancy have been found to have an increased
risk of antisocial personality disorder.31
Given the paucity and lack of precision of the available information
on the role of OCs in the development of offending and its potential importance
in developing prevention programs, the present study was undertaken. We examined
a birth cohort followed up from early pregnancy to age 30 years. Our goal
was to examine the associations between OCs and violent and nonviolent criminality,
to examine the type and timing of the associated OCs rated using a standardized
and validated scale, and to more narrowly define psychosocial adversity as
low socioeconomic status and inadequate parenting. Further, to achieve our
goal, we reduced the heterogeneity of the sample by excluding subgroups of
persons known to be at high risk both for offending and for OCs and conducted
analyses separately for groups at differential risks for offending behavior
and for OCs (ie, men, women, and early-start persistent offenders).
SUBJECTS AND METHODS
SUBJECTS
The cohort is composed of all 15 117 persons born in Stockholm
in 1953 and residing there in 1963.32 Of them,
94% were still alive and living in Sweden at age 30 years. Excluded from the
present analyses are those individuals who were institutionalized before beginning
school, those who were mentally retarded,17
and those who were admitted to a psychiatric ward with disorders other than
substance use disorders.15 This article is
based on data from 7101 men and 6751 women.
Subjects with at least 1 conviction for a criminal offense by age 30
years were classified as offenders; those with at least 1 violent offense,
as violent offenders; and those who were convicted for an offense both before
and after the age of 18 years and who committed at least 1 crime during each
of 3 or more age periods (before age 15 years, 15-17 years, 18-20 years, and
21-30 years)24 were defined as persistent early
starters.
MEASURES
Criminal convictions were documented from the records of the Swedish
National Police in 1983. Violent offenses were defined as crimes involving
the use or threat of physical violence (ie, assault, rape, robbery, unlawful
threat, and molestation).
Information on any abnormality of the mother or the fetus was extracted
from the files of midwives, obstetricians, and hospitals during the early
1970s. This information was coded using the McNeil-Sjöström Scale
for Obstetric Complications33 by one of us
(T.F.M.). The severity of each complication is rated on a 6-point scale reflecting
the ordinal degrees of inferred potential harm to the baby: severity level
1 indicates not harmful or relevant (eg, maternal heartburn, maternal fatigue);
severity level 2, not likely harmful or relevant (eg, maternal nose bleed,
maternal headache, maternal ischias [pain due to compression of the spinal
cord and specifically of the ischiadic nerve]); severity level 3, potentially
but not clearly harmful or relevant (eg, maternal febrile cystitis, maternal
sinus infection, induction of labor); severity level 4, potentially clearly
harmful or relevant (eg, mild preeclampsia, breech delivery); severity level
5, potentially clearly greatly harmful or relevant (eg, severe preeclampsia,
fetal asphyxia); and severity level 6, very great harm to or deviation in
offspring (eg, eclampsia, severe neonatal distress, offspring hypoxic-ischemic
cerebral injury). The scale is a reliable and valid research instrument for
measuring somatic complications and conditions occurring during pregnancy
(PC), labor-delivery (LDC), and the neonatal period (NNC).34
For each period and for each subject, 2 scores were calculated: (1) the number
of different OCs above a severity level of 3; and (2) the sum of the severity
scores for OCs with a severity score above 3. The McNeil-Sjöström
Scale has been used with considerable empirical success in identifying the
complications associated with schizophrenia,35
and it is more sensitive to OCs than other scales.36
Socioeconomic status (SES) of a subject's family of origin was indexed
using Swedish norms.32 Parents' occupations
at the time of the subject's birth were used to assign individuals a score
ranging from 5 (unskilled workers) to 1 (upper or upper-middle socioeconomic
status). Inadequate parenting was documented from the reports of the Child
Welfare Committee, which at that time in Sweden had a broad mandate to ensure
children's well-being. Each subject's file was initially divided into 3 sections:
from birth to 6 years, from age 7 to 12 years, and from age 13 to 18 years.
Scores were then assigned for each of the 3 age periods. Decisions made by
the Child Welfare Committee to intervene because of inadequate or inappropriate
parenting were assigned a score of 1 if the subject was left with his or her
parents and a score of 2 if the subject was removed from the family home.
These scores were added to those assigned to placements. If the subject was
placed in a foster home, a score between 1 and 6 was assigned depending on
the length of the placement. If the subject was placed in an institution,
a score between 2 and 12 was assigned depending on the length of the placement.37
ANALYSES
All analyses were conducted separately for men and women. Differences
in OCs, SES, and parenting were compared between: (1) offenders and nonoffenders,
(2) violent offenders and nonoffenders, and (3) early starters and nonoffenders.
Descriptive statistics are presented in Table 1 and Table 2.
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Table 1. Percentages of Male Nonoffenders, Offenders, Violent Offenders,
and Early-Start Offenders With Each Characteristic*
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Table 2. Percentages of Female Nonoffenders, Offenders, Violent Offenders,
and Early-Start Offenders With Each Characteristic*
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In the first step of the analyses, t tests
were used to compare the mean number of PCs, LDCs, and NNCs; the mean severity
level of OCs at each reproductive period; and the mean scores for SES and
parenting. These analyses measure group differences on each of the mentioned
variables and presume that the groups of subjects are relatively homogeneous
with respect to the variable being measured. In order to verify the extent
to which group differences applied to all subjects within a group,  2 tests were conducted to compare the prevalence of each measure within
each group of subjects. An  value of P<.01
was used to adjust for the large number of tests that were conducted. Because
the number of crimes committed by subjects varied widely, nonparametric statistics
were used to compare mean numbers of nonviolent and violent crimes.
In the second step of the analyses, logistic regressions were conducted
to examine interactions between OCs and psychosocial adversity. Separate logistic
regressions were carried out for 3 different dependent variables: (1)
criminal/noncriminal, (2) violent criminal/noncriminal, and (3)early starter
criminal/noncriminal.
The predictor variables entered into the logistic regressions were the following:
OCs (PCs, LDCs, or NNCs); SES; parenting; OCs (PCs, LDCs, or NNCs) x
SES; and OCs (PCs, LDCs, or NNCs) x parenting. Thus, separate logistic
regressions were conducted for OCs that occurred during 3 different periods
of development.
One possible outcome of having entered 2 interactions simultaneously
into models is that if the 2 interactions were strongly correlated, then the
effect of one interaction may have cancelled the effect of the other in the
model. Thus, we conducted a second set of logistic regressions in which a
single interaction (eg, PCs x family problems), along with OCs, SES,
and family problems, were entered into the model. This second set of analyses
was conducted only with interactions that had a significant probability of
less than .05 in the first set of analyses. We adopted these liberal criteria
in conducting this second set of analyses because there were so few significant
interactions in the first set. It is important to note that the 2 significant
interactions in the first set of the analyses were still significant in the
second set, and that no additional interactions were significant in the second
set.
Thus, in the logistic regressions, the dependent variable was dichotomized
(noncriminal/criminal, noncriminal/violent criminal, noncriminal/early-start
criminal), and for many of the analyses, the independent variables were dichotomized
(PCs: 0 vs 1 or more; LDCs: 0 vs 1 or more; NNCs: 0 vs 1 or more; SES: high
status 1-3 vs low status 4 and 5; inadequate parenting: no intervention vs
intervention). It has recently been shown that dichotomization of variables
facilitated the study of risk factors for delinquency, encouraged a focus
on individuals, and most importantly, showed no signs of producing misleading
conclusions.38
RESULTS
MEN
The mean number and mean severity ratings of PCs, LDCs, and NNCs did
not differ for offenders compared with nonoffenders, or for violent offenders
compared with nonoffenders. Severity ratings are presented as means ±
SDs. Early starters, compared with nonoffenders, had fewer LDCs (early starters:
0.62 ± 0.73; nonoffenders: 0.73 ± 0.79; t436.27 = -2.57, P<.01)
and also had a lower mean severity rating for LDCs (early starters: 2.27 ±
2.70; nonoffenders: 2.70 ± 3.03; t442.42 = -2.83, P<.005). There were no differences
between any of the groups in the proportions of subjects who had experienced
PCs, LDCs, and NNCs.
Compared with nonoffenders (SES: 2.94 ± 1.39; parenting: -0.32
± 0.47), men who committed an offense had been raised in families of
lower SES (offenders: 3.35 ± 1.34, t6852 = 11.66, P<.001; violent offenders:
3.58 ± 1.30, t5103 = 9.85, P<.001; early starters: 3.67 ± 1.22, t522.22 = 11.62, P<.001) and
had experienced more severely inadequate parenting (offenders: 0.06 ±
0.55, t3827.55 = 6.69, P<.001; violent offenders: 0.14 ± 0.70, t4966 = 7.35, P<.001; early
starters: 0.15 ± 0.68, t446.59
= 5.27, P<.001).
Compared with nonoffenders (43.2%), a larger proportion of offenders
(56.5%; 21,6854 = 106.27, P<.001),
violent offenders (63.6%; 21,5105 = 75.18, P<.001), and early starters (68.0%; 21,5057 = 95.43, P<.001) had been raised
in families of low SES. Additionally, compared with the nonoffenders (16.0%),
a larger proportion offenders (25.3%; 21,7107 =
88.23, P<.001), violent offenders (31.8%; 21,5281 = 81.86, P<.001), and
early starters (32.4%; 21,5197 = 76.04, P<.001) experienced inadequate parenting (Table 1).
Logistic regressions indicated that the interaction between PCs and
parenting was significant in predicting criminality (Wald 21 = 5.73, P<.02) and violent criminality
(Wald 21 = 5.34, P<.02). Table 3 presents the results of comparisons
of men who had experienced only inadequate parenting (19.1%), men who had
experienced only PCs (18.7%), men who had experienced both inadequate parenting
and PCs (3.1%), and men who had experienced neither inadequate parenting nor
PCs (59.1%). As can be observed, inadequate parenting increased the risk of
both offending in general and violent offending, though slightly less than
did the combination of inadequate parenting and PCs.
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Table 3. Odds Ratios for Offending and for Violent Offending*
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There were significant differences in the mean number of crimes (Kruskal-Wallis df = 3,126.08; P<.001) and
mean number of violent crimes (Kruskal-Wallis df
= 3,65.34; P<.001) of the 4 aforementioned groups.
Because these 1-way nonparametric analyses of variance (comparing men who
experienced both PCs and inadequate parenting, only PCs, only inadequate parenting,
and neither for both total number of crimes and total number of violent crimes)
were statistically significant, Mann-Whitney U tests
were used to compare group means. The number of PCs are reported as means
± SDs. The men who had experienced both PCs and inadequate parenting
committed, on average, more crimes (8.22 ± 27.27) and more violent
crimes (0.47 ± 1.70) than the men with no PCs and adequate parenting
(crimes: 2.70 ± 14.10, P<.001; violent
crimes: 0.18 ± 1.18, P<.001), and than
those who had experienced only PCs (crimes: 2.26 ± 8.97, P<.001; violent crimes: 0.14 ± 0.80, P<.001). Those who had experienced both PCs and inadequate parenting
had committed, on average, more crimes than those who had experienced only
inadequate parenting (crimes: 5.73 ± 20.03, P
= .01) and similar numbers of violent crimes (violent crimes: 0.33 ±
1.43, P was not significant).
The types of complications experienced by the men with PCs and inadequate
parenting were examined. The most frequent complications were preeclampsia-related
conditions, affecting 82% of the men with PCs and inadequate parenting. The
prevalence rates of the 6 most frequent complications (toxemia plus other
complications, toxemia alone, anesthesia, Rhesus immunization, twin, other)
were compared for the offenders and the non-offenders. No differences were
found.
Neither inadequate parenting, PCs, nor both factors predicted early-start
criminality as tested in a logistic regression analysis.
WOMEN
The mean numbers and mean severity ratings of PCs, LDCs, and NNCs did
not differ for offenders compared with nonoffenders, violent offenders compared
with nonoffenders, and early-start offenders compared with nonoffenders. There
was only 1 significant difference between any of the groups in comparisons
of the proportions of the different subject groups with OCs. More of the nonoffenders
(18.0%) than the offenders had neonatal complications (21,5435 = 8.50, P<.004).
Compared with nonoffenders (SES: 3.04 ± 1.38), all groups of
female offenders had been raised in families of lower SES (offenders: 3.41
± 1.36, t6538 = 5.39, P<.001; violent offenders: 3.63 ± 1.33, t6166 = 3.32, P<.001; early-start
offenders: 3.82 ± 1.28, t6132 =
2.97, P<.003). Additionally, offenders (0.17 ±
0.99), compared with nonoffenders (-0.03 ± 0.37), had experienced
inadequate parenting (t425.33 = 4.22, P<.001).
Compared with nonoffenders (46.9%), a larger proportion of offenders
(59.0%; 21,6751 = 6.46, P<.01)
and early-start offenders (67.9%; 21,6327 = 23.05, P<.001) had been raised in families of low SES. Additionally,
compared with the nonoffenders (16.9%), a larger proportion of offenders (31.3%; 21,6751 = 59.34, P<.001) and
early-start offenders (50.0%; 21,6327 = 23.05, P<.001) had experienced inadequate parenting.
The logistic regressions indicated no significant interactions between
PCs, LDCs, NNCs, and SES, or inadequate parenting in association with offending,
violent offending, and early-start offending. This may be because of the small
number of female offenders and the even smaller numbers in the various comparisons. Table 3 presents general comparisons of
the risks of offending and of violent offending among the women who had experienced
only inadequate parenting (18.1%), among those who had experienced only PCs
(17.0%), and among those who had experienced both inadequate parenting and
PCs (4.0%), compared with those who had experienced neither inadequate parenting
nor PCs (60.9%). As is true for the men, inadequate parenting increased the
risk of offending and of violent offending only slightly less than did the
combination of inadequate parenting and PCs. Among the women in the early-start
group, only 37% had not experienced either PCs or inadequate parenting, 50%
had experienced inadequate parenting, 10% of them also experienced PCs, and
another 13% had experienced PCs but not inadequate parenting.
COMMENT
Among both men and women, no relationship was identified between PCs,
LDCs, and NNCs occurring in the absence of inadequate parenting and violent
and nonviolent offending. Early-start offenders were characterized by fewer
and less severe LDCs than nonoffenders. The associations between both low
SES and inadequate parenting and offending, violent offending, and early-start
offending were found, as in many previous investigations, to be powerful.13, 14
Pregnancy complications combined with inadequate parenting in the early
years of life slightly increased the risk of offending, and it more than doubled
the risk of violent offending. The combination of PCs and inadequate parenting
affected only 3% of the men and 4% of the women, and it increased the risk
of crime and of violent crime only slightly more than did inadequate parenting
alone. This is important because inadequate parenting was much more common,
affecting another 16% of the men and 18% of the women (who did not experience
PCs). To illustrate the significance of this finding for preventing crime,
consider the following numbers: of all the men born in Stockholm in 1953,
1135 experienced inadequate parenting and did not experience PCs. Of these
1135 men, 483 (42.6%) were convicted of an offense. By contrast, 218 of the
male cohort members experienced both inadequate parenting and PCs, and 110
(50.5%) of them were convicted of criminal offenses. In other words, 4 times
(n = 483) more male offenders experienced inadequate parenting than inadequate
parenting combined with PCs (n = 110). However, while few men had experienced
both PCs and inadequate parenting, of those who did, half became offenders
and 16% became violent offenders who committed many offenses.
The finding that inadequate parenting in combination with OCs increased
the risk of offending concurs generally with studies of samples from the Danish
Perinatal Project. However, results differ in 3 important ways. In the present
study, (1) the complications associated with offending occurred during the
pregnancy and not at birth or in the neonatal period; (2) complications were
associated with offending in general and not only with violent offending;
and (3) the association between OCs and inadequate parenting and offending
was not observed for early-start offenders. One possible explanation for these
differences in the findings is the exclusion of the mentally retarded and
mentally ill from the sample examined in the present investigation. Such persons
are at increased risk for offending,15 at an
even higher risk for violent offending15, 16
and homicide39 than the general population,
and are suceptible for OCs, particularly at birth and during the neonatal
period.35 If samples inadvertently included
disproportionate numbers of mentally retarded and/or mentally ill subjects,
an association between a combination of OCs and family adversity and offending
that applies only to them may have been interpreted as characteristic of male
offenders in general. This would be especially true in a country like Denmark,
where the violent crime rate is relatively low, and the proportions of mentally
retarded and mentally ill subjects among the offenders are relatively high.
This speculation is supported by the finding that most of the offenders in
the present cohort who developed major mental disorders had experienced complications
during the neonatal period.40
A disproportionately high number of men who became persistent offenders
and who had begun to offend at a young age had experienced fewer LDCs than
average. Three possible explanations for this finding warrant further study.
First, based on twin and adoption studies,27, 28, 29, 30
it would be expected that some elevated proportion of the mothers of early-start
offenders would themselves present a history of antisocial behavior, which
is associated with low anxiety, fear, and arousal. These maternal characteristics
could be associated with a reduction of LDCs. A second possible explanation
relates to recent findings on body size. In the present investigation and
in the longitudinal investigation of a New Zealand cohort, it has been found
that this type of early-start male offender is heavier than average at birth.23 Finally, body size at age 3 years has been found
to be associated with aggressive behavior at age 11 years,41
body mass index at various ages has been found to be associated with aggressive
behavior,42 and weight during the first 12
months of life has been associated with violent offending in adulthood.43 Boys who are larger than their peers during early
childhood may learn to be aggressive as a result of persistent provocation,42 or alternately, the various measures of body size
used in these different investigations may be tapping a metabolic syndrome
which is related to brain functioning and to impulsivity or reduced behavioral
disinhibition.
The present investigation is characterized by a number of strengths
that increase confidence in the validity and generalizability of the results.
This was a large, unselected birth cohort born and raised in a society that
provided good health care and social services to all of its citizens.44 Information from the obstetric records was extracted
by persons blind to the objectives of the present study, and they were coded
using a standardized and validated rating scale. Information on criminality
was complete. Subjects were followed up from pregnancy to age 30 years with
almost no attrition. Finally, the specificity of risk factors for criminal
behavior of men and women without mental retardation or mental illness were
examined.
Like all investigations, however, ours has weaknesses. Four are of importance
for interpreting the results: (1) Even though an level of .01 was
used to limit type I error due to multiple comparisons, this procedure would
not protect against all such errors. Consequently, the findings should be
interpreted cautiously until they are replicated. (2) No information was available
on the behaviors of the mothers during the pregnancy, such as smoking, which
has been found to increase the risk of violent criminality in the offspring.45, 46 (3) Official criminal records were
used to index behavior. Again, this would lessen the strength of all associations
except those related to serious violence, such as murder, that would almost
always lead to criminal charges. (4) The follow-up period was not long enough
to allow exclusion of all persons who would develop major mental disorders.
The results of the present investigation suggest that future studies
on factors related to the development of offending will more surely advance
knowledge if they focus on homogeneous groups of offenders and take account
of both information recorded in obstetric files in addition to mothers' reports
of behaviors during each reproductive period that may harm their children.
AUTHOR INFORMATION
Accepted for publication March 23, 2001.
This investigation was completed with funds from the Social Sciences
and Humanities Research Council of Canada, Ottawa, Ontario (Dr Hodgins).
The authors extend their grateful appreciation to Michal Abramovich,
PhD, of McGill University, Montréal, Québec, who patiently advised
us on the statistical analyses.
From the Department of Psychology, Université de Montréal,
Montréal, Québec (Dr Hodgins), and the Division of Forensic
Psychiatry, Karolinska Institute, Stockholm, Sweden (Dr Hodgins); the Department
of Psychology, Concordia University, Montréal (Dr Kratzer); and the
Section of Epidemiology, Department of Community Medicine, University of Lund,
Malmö, Sweden (Dr McNeil).
Corresponding author and reprints: Shellagh Hodgins, PhD, Department
of Psychology, Université de Montréal, CP 6128, Succ. Centre
Ville, Montréal, Québec, Canada H3C 3J7 (e-mail: shellagh.hodgins{at}umontreal.ca).
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